Posted by: Admin | January 24, 2012

Engorgement & the Breastfeeding Mother


Most women who give birth have an encounter with engorgement. Even mothers who do not breastfeed can experience it. Simply said, engorgement is the swelling of the breasts. It can be moderate and not cause much discomfort, or it can be severe and trigger a chain of unpleasant events. Usually it can be prevented, and we need to remember that prevention is always best!

Generally an immediate post-delivery engorgement, commonly called “the milk coming in,” involves two different processes: 1) a swelling of the lactating tissues which receive the demand to produce more milk and 2) an increase in blood flow required to produce that milk. When the baby is at the breast often, latches on correctly and sucks efficiently, milk is removed regularly from the breast and only a slight swelling is noticed. However, when the baby is not at the breast often enough, when his latch is shallow or when his sucking movements do not obtain enough milk, the milk produced will stagnate. The breast will then enter a cycle that can get pretty severe. If it is not caught soon enough, the breast can get so hard that the baby will not be able to latch on! Sometimes, the IV fluids the mother received during labor trigger the swelling of the tissues.

What happens is quite simple: the milk flowing forward, backflows into the breast, and causes pressure to the surrounding tissues. Those tissues are already engorged with more blood and fluid than usual. You get the picture? The lymph nodes that usually do a good job in draining all the excess fluid caused by inflammation are also blocked from the swelling. When the milk stagnates, it hinders the blood and lymphatic fluid flow, and then it aggravates the engorgement. Everything just jams in there!

So what can we do?

First, prevention!

1. As mentioned before, the baby has to breastfeed often, but sometimes babies are sleepy. It is important to check and make sure they breastfeed from 8 to 12 times per 24 hours. No rigid schedule. Babies do not like to be woken up every 2, 3 or 4 hours. You will see that they are too sleepy to breastfeed when woken up at specific times. They do much better when they awaken on their own. Slight movements, such as sucking of the lips or hands, are signs that the baby is waking up and ready to breastfeed.

2. Babies need to be positioned correctly to be able to latch on well. Their whole body needs to be turned towards their mother (ear, shoulder and hip aligned) and they need to be held really close. The baby needs to open his mouth wide and for those who think the baby’s mouth is too small, look at how wide he opens it when he yawns! Never let your baby latch onto the breast if his mouth is not open wide enough! Your baby will learn to do it well if you ask him to do it! If the mouth is not open wide enough, the baby will close his gums on the nipple.  Instead, though, he should close his gums as far up as possible on the areola.

3-If your baby is very sleepy or if, for any reason, you feel your breast stays engorged after a breastfeed, do not be afraid to express milk manually or to use a breastpump to soften them up. This imbalance in the baby’s demand and the milk produced usually only lasts a few weeks.

4-If your breasts are painful, you can use ibuprofen (Motrin, Advil) to reduce the inflammation the swelling causes. It can also have a healing effect; it will help the pain and the swelling.

 

Once the engorgement is there

If the breasts are still soft to the touch

When the breasts are still soft to the touch and the milk flows easily, some warm compresses or a hot bath or shower can be used to get the milk to flow better. You can use gentle massages and manual expression. There is also a new technique called Reverse Pressure Softening (RPS). This will help to soften the areola so the baby will latch on well. See the link below for a video clip of the technique and the other link will send you to the scientific article that explains how it works. Remember that it takes only a small change in the texture of the areola to make it difficult for the baby to latch correctly.

You might not notice any difference, but your baby will!

Scientific article :  http://jhl.sagepub.com/content/20/2/227.abstract

If the breasts are hard to the touch

You need to avoid putting heat on your breasts if they are very hard to the touch or have hard spots and if they are red and feel hot. The most comfortable and healing thing you can do to help is to treat them as you would a sprained ankle: with cold. A sprain causes swelling in the tissues that block the fluid circulation. This is exactly what is happening in a severe engorgement.

In a severe engorgement, the breasts feel full of milk, but nothing comes out. This is a pretty confusing situation. Also, in some cases, the breasts and areola are so hard that they hurt terribly. It might be intolerable to touch them. Manual expression and the use of a manual breastpump can be quite painful. The best pump to use at this point is a hospital-grade electric breastpump. Many clinics in the Cree territory have an electric breastpump to help out mothers in times like this. Elsewhere, hospitals have them and they can be rented at drugstores or support groups.

It is quite scary when nothing comes out, even with efforts to manually or mechanically express your milk. Here is a good trick. If you follow the following instructions well, you will get breastmilk to come out after a few tries:

1- Apply cold compresses for 20 minutes. Here are examples of things you can use:

-a Ziplock bag with frozen peas*

-a Ziplock bag filled with crushed ice*

-an gel ice pack*

*Important: Ice (or anything that is “ice” cold) needs to be wrapped in a clean thin towel to avoid the skin being burned by the cold

The following are cold but not icy cold, so they be applied directly onto the breasts:

-a washcloth dipped in ice cold water

-clean cabbage leaves applied to the breast and held by a tank top or a bra

2- Let rest for 10 minutes

3- Use a breastpump** for 5 minutes on each breast. If nothing comes out, stop.

4- Wait another 10 minutes.

5- Apply cold again for 20 minutes.

6- Use a breastpump** for 5 minutes on each breast. If nothing comes out, stop.

7- Redo the whole cycle until the milk starts to flow. It usually takes 4 o 5 cycles before the swelling reduces and the milk begins to flow well.

Be confident, it will work!!!

** A hospital-grade electric breastpump is the best you can use. Ask your local clinic. It is also possible to use a small electric or a manual breastpump, but it might be less comfortable. Manual expression is not recommended during a severe engorgement, as it might be painful to touch the breasts and areolas.

 

A note on the use of cabbage

Cabbage leaves are practical, comfortable and cheap. Some people assume the leaves have a special astringent (ability to draw in fluids) property, but their mechanism has yet to be determined. As of now, no research has proven that they improve engorgement. I like to believe it is simply the thickness of the leaves that entrap the cold. If you choose to use them, take away any hard parts from the leaves and wash them well. They will be invisible under your bra, but be sure to change them as they “cook” from the heat of your breasts and they can then give out a certain smell…lol.

References

Ayers, J. F. (2000). “The use of alternative therapies in the support of breastfeeding.” J Hum Lact 16(1): 52-6.

Berens, P. (2009). “ABM clinical protocol #20: Engorgement.” Breastfeed Med 4(2): 111-3.

Chapman, D. J. “Evaluating the evidence: is there an effective treatment for breast engorgement?” J Hum Lact 27(1): 82-3.

Chiu, J. Y., M. L. Gau, et al. “Effects of Gua-Sha therapy on breast engorgement: a randomized controlled trial.” J Nurs Res 18(1): 1-10.

Cotterman, K. J. (2004). “Reverse pressure softening: a simple tool to prepare areola for easier latching during engorgement.” J Hum Lact 20(2): 227-37.

Giugliani, E. R. (2004). “[Common problems during lactation and their management].” J Pediatr (Rio J) 80(5 Suppl): S147-54.

Glover, R. (1998). “The engorgement enigma.” Breastfeed Rev 6(2): 31-4.

Mangesi, L. and T. Dowswell “Treatments for breast engorgement during lactation.” Cochrane Database Syst Rev(9): CD006946.

Nikodem, V. C., D. Danziger, et al. (1993). “Do cabbage leaves prevent breast engorgement? A randomized, controlled study.” Birth 20(2): 61-4.

Renfrew, M. J., S. Lang, et al. (2000). “Feeding schedules in hospitals for newborn infants.” Cochrane Database Syst Rev(2): CD000090.

Roberts, K. L. (1995). “A comparison of chilled cabbage leaves and chilled gelpaks in reducing breast engorgement.” J Hum Lact 11(1): 17-20.

Roberts, K. L., M. Reiter, et al. (1998). “Effects of cabbage leaf extract on breast engorgement.” J Hum Lact 14(3): 231-6.

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