When a breast becomes overfull it is said to be “engorged”. Engorgement is very common in the early weeks after birth when there will be extra blood and tissue fluid within the breast as well as the milk supply coming in. A breast may also become engorged with milk at any time, e.g. if a baby sleeps longer than usual and misses feeds or if a baby isn’t draining the breasts properly due to a poor latch (the way baby attaches to the breast) or a blocked milk duct. Or sometimes if tight clothing has been pressing on the breast.
Relieving engorged breasts
At the first sign of discomfort, it is important to express some of the milk from the breasts until they feel comfortable again. This can be done by hand expressing, using a breast pump, or ideally by your baby breastfeeding well to drain the breasts. By expressing to comfort, or feeding her baby frequently, a mother will avoid having very sore and tender breasts, and reduce the risk of painful mastitis symptoms or developing an abscess. Ideas for engorgement relief are described further in Engorged Breasts and include a combination of breast drainage, massage, cold therapy, and suitable anti-inflammatory medication.
Milk not letting down
Sometimes engorgement can be so severe that a mother can’t seem to get her milk to let down at all, her breasts will feel hard, lumpy and very painful. The mother may describe them as being “blocked” or that “the milk is stuck” and she just can’t express any milk. Her baby, who would normally be the ideal trigger for a let down, may also be refusing to latch, or be unable to latch because the nipple or breast may have changed shape. In these situations even a very good pump may not always help—because it may make the congestion or swelling (oedema) worse by pulling more tissue fluid and blood into the engorged area.
When an area of the breast is severely engorged, it can prevent everything behind it from flowing forward, much like a traffic jam might prevent traffic moving throughout a town centre. Another analogy compares severe breast engorgement to stepping on a hose full of water (obstructing the flow).
When milk won’t flow, milk will go
Severe engorgement of this type is a high risk factor for mastitis and for the mother’s milk supply to be reduced. A special protein that regulates supply called feedback inhibitor of lactation (FIL) builds up in an engorged breast to reduce milk production, and unrelieved engorgement can damage milk making cells 1. In view of the risk to her milk supply, not to mention the discomfort, how can a mother get engorgement relief if she can’t get any milk out?
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Tips for engorgement relief when milk won’t flow
Breast massage and hand expression
A gentle breast massage can really help to get milk flowing and prepare the breasts to release milk (“the let-down”). Breast massage should not be painful and finger tip pressure need only be as light as you would use when applying a cream or ointment to your skin. The massage video below from Maya Bolman of Breastfeeding Medicine of Northeast Ohio shows gentle rolling, kneading and tapping techniques to get the breasts ready for expression and shows a gentle breast massage technique to alternate with hand expressing. For further tips and videos to help with hand expressing see Hand Expressing Breast Milk.
Anecdotally some mothers have found using a wide tooth comb to gently stroke an engorged breast can help circulation and drainage. Marsha Walker likens this to the Asian practice of gua-sha therapy 2.
Lymphatic breast drainage
A mother who has been on an intravenous (IV) drip is more likely to experience swelling and engorgement caused by water retention in her breasts 3. If this is the case, the breast massaging technique featured in the video above will help move the extra fluid out of the breast via the lymphatic system (a drainage system for tissue fluid in the body). Mothers may like to semi recline for the massage so that gravity can help to drain the fluids via the lymphatic system alongside gentle massage towards the armpits.
Reverse pressure softening
A version of breast massage, known as reverse pressure softening can help bring out a nipple flattened by engorgement by redistributing the fluid behind the nipple. This can help a baby who is struggling to latch to a full breast and can also begin to release the “traffic jam” behind the nipple. See Engorgement Help: Reverse Pressure Softening by Jean Cotterman, for the technique. Using a combination of reverse pressure softening and general breast massage may be most helpful.
Commercial breast shells can provide gentle pressure to a swollen areola instead of fingers to achieve reverse pressure softening and expose the nipple 4.
Cold is your friend
Cooling the breasts whether by using crushed ice or frozen vegetables in a damp cloth against the engorged areas or placing a chilled cabbage leaf in the bra causes blood vessels to constrict (get smaller). This reduces blood flow to the area, and reduces swelling which helps with lymphatic drainage of tissue fluid in the breast. Applying cold therapy has not been shown to cause any problems for let down or milk transfer and it helps with pain 5 6.
Warmth in moderation only
Warmth applied to the breasts prior to hand expressing or pumping can help trigger a let down. Some mothers have found success suspending their breasts in warm water by leaning over a sink or bowl and letting gravity, warmth, and gentle massage help. Letting warm water run down your back in a shower may also help get milk flowing. However, be very wary of popular advice to apply excess heat to a swollen breast; this will cause blood vessels to dilate bringing extra blood rushing to the area which is likely to make the engorgement even worse. Marsha Walker IBCLC explains:
Heat application in the form of hot compresses, hot showers, or hot soaks is poorly researched and has usually been more of a comfort measure to activate the milk ejection reflex, rather than a treatment for oedema. Some mothers complain that heat exacerbates the engorgement, causes throbbing and an increased feeling of fullness.
Engorgement causes inflammation so suitable anti-inflammatory medication can help with pain and symptoms. Several pain killers are compatible with breastfeeding. The Academy of Breastfeeding Medicine Protocol #20 Engorgement reports on the success of an anti-inflammatory enzyme drug serrapeptase 7 and other enzyme therapy.
Try a different pump or check pumping equipment
If you want to try a breast pump but cannot get milk flowing with your regular pump, consider whether your pump is working properly, whether the flanges are a good fit or whether you could afford a better model. See How to Increase Milk Supply When Pumping for more information on choosing a pump or where to hire a good hospital grade pump. Bear in mind that pumping a severely engorged breast on too high a setting, or pumping in the early days after birth—may be counterproductive for reasons mentioned above, at least until the milk is flowing again.
More ideas for engorgement relief
“Juice Jar” breast pump
Kelly Bonyata describes how to use a one litre glass jar or bottle (with a 5cm or larger opening) to create a vacuum around the breast to both stimulate a let down and help draw out a flattened nipple. Her method:
- Fill the glass container with very hot water to heat the glass, be careful not to burn yourself (wrap it in a towel).
- Empty out the water and cool the mouth of the bottle with a cold cloth to skin temperature.
- Place the breast in the cooled mouth of the jar, check there is a good air tight seal.
- As the air inside the jar slowly cools, a vacuum will be created that releases milk from the breast.
Called the “Juice Jar” breast pump it is described more fully in Engorgement by Kelly Bonyata. A commercial device that works on a similar principle using a vacuum effect is the Haakaa Silicon Breast Pump, for more information about this pump see This Year’s Big Thing… by Shel Banks IBCLC.
Oxytocin nasal spray
If you are still unable to get milk to let down after trying the techniques above, synthetic oxytocin as a nasal spray is available on prescription in some countries, and may be helpful 8. Breastfeeding authors West and Marasco have this to say about dosage:
The usual dosage is one spray (three drops) in each nostril two to three minutes before breastfeeding or pumping. The use of synthetic oxytocin to aid milk ejection is usually temporary and rarely required for longer than a week.
Breastfeeding specialists do not always agree whether cabbage is an evidenced based or useful cure for engorgement. If nothing else, a chilled cabbage leaf in the bra will be a “cold friend” to your breasts. A 2017 study concluded cabbage leaves were better than cold gel packs at reducing engorgement9. If you decide to try them, Dr Jack Newman, a Canadian paediatrician, writes:
Take a green cabbage, remove the outer leaves and discard them. Then take a few of the inner leaves and place them on the breast after feeding, inside your bra. The curved shape helps them fit nicely. Some suggest crushing the leaves with a rolling pin to help them fit the shape of the breast. Actually, there is no agreed upon protocol for using cabbage leaves. Some lactation specialists suggest using them after each feeding and keeping them on for 20 minutes or so. Some suggest keeping them on until they wilt, or until you need to feed your baby. Some suggest using them only three or four times a day. Experiment and see what works for you.
In Making More Milk the authors describe herbs that can help facilitate milk ejection (let down). They point out that they may work by increasing milk supply (galactagogues) rather than helping the actual let down, therefore they could be problematic for the mother who is struggling to find engorgement relief while milk won’t flow. Use any herbs with caution and check with your health professional.
[Galactagogue herbs with a reputation for helping with let-down] include anise, black cohosh, blackseed, chasteberry, dill, fennel, hops, and red raspberry leaf.
Fenugreek seed poultice
Kelly Bonyata describes a fenugreek poultice traditionally thought to help with let down as follows:
Steep several ounces of fenugreek seeds in a cup or so of water. Let seeds cool, then mash them. Place on a clean cloth, warm, and use as a poultice or plaster on engorged or mastitic breasts to help with let-down and sore spots.
Medical causes for impaired let down
There can be medical causes for difficulty with let down. These include thyroid conditions and any damage to important nerves such as might happen during breast or brain surgery.
Problems with milk release (let down) appear to be a bigger issue than low milk supply where mothers have hyperthyroidism or hypothyroidism. If the milk can’t be removed then the special protein that regulates supply (FIL) will build up and reduce milk supply. In The Impact of Thyroid Dysfunction on Lactation, 2006, Lisa Marasco suggests that synthetic oxytocin spray, breast massage prior to feeding and breast compression may help propel milk from breast to baby.
If the fourth intercostal nerve (located by the nipple) has been damaged, for example by breast surgery (including breast implants or breast reduction), this can interfere with release of oxytocin and prolactin from the brain and affect the let down reflex (West and Marasco, 2009).
Further possible causes for difficulty with let down (with or without severe engorgement) include pain, grief and loss, previous sexual abuse, severe stress and birth trauma (Making More Milk Chapter 10).
Caffeine, smoking, alcohol, medications
If neurological function of key nerves involved in milk let down are impaired, or spinal vertebrae misaligned, some body work or manual therapy has helped some mothers with milk production and let down 10.
Working with a IBCLC lactation consultant can be invaluable for support to find the quickest route to thorough breast drainage and to avoid future engorgement episodes.