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 lactating breast may also become engorged with milk at any time, for example if a baby sleeps longer than usual between feeds or misses a feed or if a baby isn’t draining the breasts properly due to a poor latch (the way baby attaches to the breast). Other causes could include a blocked milk duct or sometimes tight clothing pressing on the breast can cause engorgement.
Relieving engorged breasts
At the first sign of discomfort, it is important to remove 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 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 (inflammation of the breast) or developing a breast abscess (pocket of infection in the breast).
Ideas for engorgement relief are described in Engorged Breasts and include a combination of breast drainage, massage, cold therapy, and suitable anti-inflammatory medication. But what if milk won’t flow and no amount of pumping seems to yield any milk to relieve the engorgement? This article offers ideas for relieving breast engorgement when milk won’t flow.
Milk not letting down
When a baby starts to breastfeed, milk is released from the breast in a neurohormonal reflex (involves nerves and hormones) known as the milk ejection reflex or “let-down”. However 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 breast 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). If the route to the nipple is blocked and milk cannot flow, the engorgement cannot be relieved.
When milk won’t flow, milk will go
Severe engorgement of this type is both a high risk factor for painful breast inflammation (mastitis) and for the mother’s milk supply to be reduced. This is because the pressure of milk within a full breast eventually slows further milk production. The mechanism for this is thought to involve a combination of physical pressure and chemical means:
- The increasing local pressure from the build up of milk may reduce blood flow to the breast and compress milk making glands causing a temporary shut down in milk production1
- Chemical messengers sometimes referred to as feedback inhibitors of lactation (FIL) may slow milk production. Research indicates the chemical messengers may be linked to levels of serotonin in the milk making tissue (Mohrbacher, 2020)
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?
Tips for engorgement relief when milk won’t flow
Find a breastfeeding specialist
Working with a breastfeeding specialist such as an IBCLC lactation consultant can be invaluable to help find the best way to thoroughly drain the breasts and to avoid future engorgement episodes.
Breast massage and hand expression
A gentle breast massage can really help to get milk flowing and prepare the breasts to release milk. 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. Alternating massage with hand expressing can help to gently clear the “traffic jam” behind the nipple or release blocked ducts within the breast. This will pave the way for milk to flow freely from deeper in the breast.
Sit up or lie down
A mother can sit up for the massage as in the video above or a mother may find that lying on her back and massaging her breast with circular movements (see video from 2:51) prior to hand expressing can be more effective.
Using a comb
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
Sometimes breast engorgement is not caused by breast milk and increased blood circulation alone. Other fluids can add to the pressure in the breast causing oedema or swelling particularly in the first week or two after birth. A mother who has been on an intravenous (IV) drip is more likely to experience swelling and engorgement caused by this type of water retention in her breasts during the first ten days after birth3. 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). A mother may like to semi recline or lie flat on her back 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. Using your fingers, the fluid in the compacted area can be gently moved away from the nipple sending it temporarily deeper into the breast. 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, general breast massage and hand expressing 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 by 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 pain5.
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 engorgement6. 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.
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 (Breastfeeding Network) are compatible with breastfeeding. The Academy of Breastfeeding Medicine Protocol #20 Engorgement (2016) mentions the possibility of enzyme therapy however it also points out that the research supporting this is more than 50 years old. One small study from 30 years ago indicated the anti-inflammatory enzyme drug serrapeptase was helpful with symptoms of breast engorgement.7
Review medications and lifestyle
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 One-Piece Silicone Breastpumps by Shel Banks IBCLC and How NOT to use a Hakaa by Johanna Sargeant 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 may be helpful and is available on prescription in some countries (Wambach and Spencer. 2020. p 381). Pharmacist Frank Nice explains:
When these methods fail, a nasal spray containing oxytocin may stimulate the letdown reflex in the mother. The dosage for use is one spray in one or both nostrils 2 to 3 minutes before nursing or pumping of breasts. There are compounding pharmacists in the United States who can and will compound an oxytocin nasal spray when the patient has a doctor’s prescription.
Marasco and West point out that if the oxytocin nasal spray doesn’t help within 48 hours it is time to re-evaluate using it.8
In Making More Milk: The Breastfeeding Guide to Increasing Your Milk Production the authors describe herbs that can help facilitate milk ejection (let-down). However as these may work by increasing milk supply (galactagogues) rather than helping the actual let-down, they could be problematic for the mother who is struggling to find engorgement relief while milk won’t flow. The authors mention that if stress is a factor inhibiting let-down then chamomile tea is known for its calming effects. Use any herbs with caution and always check with your health professional. (Marasco and West. 2020. p236)
Mohrbacher discusses how some cultures use hollyhock leaves and other herbal mixtures as a compress on the breast to treat engorgement and studies have shown favourable results when used alongside established care practices for engorgement (Mohrbacher. 2020).
Fenugreek seed poultice
Kelly Bonyata describes a fenugreek poultice traditionally thought to help with release of milk 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 the milk ejection reflex. 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 from the breast then the local control mechanisms in the breast will begin to reduce milk production. Medication to address the thyroid imbalance and assistance with milk release such as synthetic oxytocin spray, breast massage prior to feeding and breast compression may help propel milk from breast to baby9.
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, 2020).
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 (Marasco and West. 2020. Chapter 10).
Caffeine, smoking, alcohol, medications
If neurological function of key nerves involved in milk release are impaired, or spinal vertebrae misaligned, body work or manual therapy is reported to have helped some mothers with milk production and let-down 10.
Sometimes breast engorgement can be so severe that the breast seems to be “blocked’ and milk won’t flow. There are several techniques that can be useful to get breast milk flowing and release the pressure of breast milk in the breasts. It is important to relieve the engorgement to prevent mastitis and to avoid damage to the mother’s milk supply.
* Reproduced with permission of Pinter and Martin.