Welcome to Breast Engorgement, OMG!

Not all lactating breasts become huge bowling balls when milk comes in. For some moms, the signs are subtle. But for those who suffer from profound engorgement, what can be done to relieve this misery?!

These twins had difficulty deeply attaching to their mother's swollen breasts.

Many moms, especially first-timers, will become uncomfortably swollen and firm when the milk volume in their breasts increases, typically around days 2-5. Gone are the soft, pliable breasts that you were sandwiching and pulling your baby onto with a RAM. (rapid arm movement) Those were your training breasts, OK? Now you've got the real deal, and you had no idea they could feel this heavy. Engorged breasts can be hard as a rock and painful, too. Colostrum is being replaced by mature milk, lots of it, and your breasts are coping with their new function. You may notice the color of milk is changing from yellow/clear, to white. Your babe on the breast is swallowing more frequently, sometimes even choking on the let-down! (that's typical) If you're pumping, you're able to collect milk easily, and the amounts are finally increasing, which is very welcome. If you're trying to latch a baby onto your new set of breasts, you may be frustrated. Baby might be screaming at your breast that's dripping milk onto his face and you're left wondering why he can't eagerly latch like he was doing at the last feeding. This situation can result in baby AND mom crying!

What's going on?

Your baby vacated the womb and what happened next initiated the process of making mature milk: your placenta detached. This triggered big hormonal changes that result in colostrum turning into mature milk, which you will notice around 2-5 days later. The arrival of mature milk is often met with relief and wonder. You may also notice your breasts feel warm and you're a bit nauseated. Although commonly referred to as "milk coming in" that's a bit misleading, since the colostrum that you had at delivery, was also a type of milk. A new movement refers to this phase as "milk transitioning," which is more accurate. Milk composition is always updating inside your breasts, but this change is the most drastic, for sure. From baby's perspective, the uptick in volume and the ease in which it flows, is a big adjustment. And the feel of the breast could be totally new, from baby's perspective. The enlargement and firmness of your tissue make it really difficult for baby to maintain a grasp of the nipple, which is often flattened out by swelling of the areola. Could you latch onto a bowling ball with a tiny nub of a nipple on it? It is literally and figuratively harder for baby to accomplish this, and achieving that deep latch is next to impossible.

Management

This baby is calm and was able to latch because his mom wedged her breast tissue for him.

There are many things that will help. Lets start with the simplest intervention, and that's offering the breast often, at the first HINT of a feeding cue, before your baby is insistent upon eating. This is usually well before the three hour mark. Three hours is a long time for your engorged breasts to "wait" to be drained, and at this point they may feel ready to burst. A shorter interval will make the feeding more successful because the breasts are less full and therefore easier to sandwich, with mom's thumb and fingers parallel to baby's lips. When your baby doesn't even know he's hungry yet, he will be more calm and patient, willing to attempt latching multiple times, without getting frantic.

But let's say you both fell asleep, and baby awoke starving, and your breasts are monstrously swollen and hard. Deep pressure softening is a simple technique, performed with two fingers, that pushes fluid away from the base of your nipple. Then it's softer and baby can get his mouth around it, and sustain his latch. There's a blog post all about DPS here.

Another easy way to soften your swollen breast and help baby latch is to remove some milk by hand expression. This simple action saved me the day after I got home from the hospital. I hadn't practiced it in the hospital, so a nurse described it to me over the phone. I was amazed that it worked, and I could turn on the faucet myself! Here is a video for those who aren't confident with this technique; you may want to fast forward to 5" 30 seconds, for step-by-step instructions. Removing some milk will not only soften your breasts and make them more graspable for baby, but you can also offer the milk that you remove by spoon, to calm baby if he is frantic or hangry.

Gentle massage while baby is nursing, helps to move milk that is potentially stuck behind swollen tissue. The massage has to be light though, without firm pressure, because swollen breasts are vulnerable to damage and bruising. When using massage, you want to start at the base of your breast and move forward toward your nipple. If you have one hand steering baby's head and the other supporting your breast, how do you massage? Grow a third arm! Or ask your partner. Sometimes a good breastfeeding support pillow props baby well enough that you can sneak your arm away and use it to massage. This technique will also increase the amount of milk that your baby removes from the breast, and that's usually a good thing!

An updated intervention for extreme engorgement is ice and anti-inflammatories. This replaces outdated advice of "heat before, ice after." Heating pads on engorged breasts can increase the congestion, and may not be helpful. "Ice after" is still recommended, though. When baby is finished nursing, assuming he can latch, ice can be applied to the breasts if they still feel uncomfortably full. This reduces inflammation, and that's a lot of what's going on inside your breast. Engorged breasts aren't just giant jugs of milk, they are swollen tissue. Anti-inflammatory medication like ibuprofen can also help, for those who can safely take ibuprofen. Sometimes the breasts are so swollen that milk is trapped and not flowing well. This is almost an emergency, because if milk can't be expressed frequently from each breast, like at least every three hours, then your body will get the message to halt production. Really work at getting the faucets turned on if your milk isn't flowing. When your breasts are frequently giving up milk, your production is activated, and you'll find yourself with a good supply.

If none of that works and your baby can't latch well enough to get a meal, then you may want to pump your breasts enough to soften them. Hopefully your pump can turn on the faucets! A double electric pump is recommended to protect supply if baby can't latch, but sometimes just an active milk collector, like a Haakaa or Boon Trove, applied to your breast, will get some milk running. When milk is removed, the breast may soften enough that baby can latch, and that's all you really need to accomplish. This could be a one time intervention. You want to avoid pumping the breasts at each feeding, and removing large quantities of milk that are destined for the freezer. This will result in an oversupply. Occasionally a mom will double pump after a feeding, to relieve discomfort. Doing that once is OK if you're truly miserable and other tactics don't alleviate the pressure, but doing it routinely will make the situation worse. If baby is latching well and taking all the milk they need to gain weight, then you largely want to avoid the pump in the early days of breastfeeding.

This baby might calm with a few sucks from the bottle, and then transfer over to the breast.

Using some of the above techniques, you may be able to accumulate some milk in a bottle, and once you do, you can try the bait and switch method of getting your baby to latch. If baby is crying at your breast, hungry, unable to stay latched, give him a swig from a bottle. Let him drink for a couple of minutes until he seems relaxed and establishes a good rhythm of sucking and swallowing. Then pull the bottle out and quickly offer the breast, wedging the breast tissue parallel to his lips, so he can get a big bite of it. He may then get onto the breast and finish his meal directly from you. Success!

This mom has applied a nipple shield and is getting ready to latch her baby.

If your baby consistently can't latch and is taking bottles of your milk at every feeding, then you might consider a nipple shield. See my blog post about nipple shields if you are going this route. A nipple shield is a great tool for a non-latching baby. In some cases it's like a tapper for a keg. You put it on, and suddenly your baby can latch and drink and has access to all that milk in the breast that you were pumping out and feeding by bottle. Luckily the shield can be used short-term; once the engorgement phase is over, baby can be coaxed back onto your bare breast. Using a shield necessitates pumping after breastfeeding, however, especially when you first introduce the shield. If you don't pump afterward, you may find your supply crashing. Read more in my blog post!

How long does this last?

I hope some of these techniques are helpful. Keep in mind that engorgement is a temporary phase: usually the worst is over in 48 hours. Your breasts do not stay this huge and hard as they continue to make milk. In fact, at about 2-3 weeks, when much of the extra fluid and blood volume from pregnancy and delivery are gone because you've peed or sweated them out, your breasts may suddenly feel familiar again. Don't let this change make you insecure that your milk went away....if baby has continued feeding often, then it is very doubtful that your supply dipped. Keep in mind that your breasts aren't just storage facilities, they are factories, capable of making and delivering milk almost instantly in response to suckling. The engorgement that you dealt with in the early weeks is mostly a thing of the past, even as you maintain your ability to make plenty of milk.