almost everything we thought we knew about postpartum engorgement changed

Most who have had severe postpartum engorgement have a lot to say about it! They describe breasts that feel as heavy and hard as bowling balls. The milk doesn’t flow, it hurts to breastfeed. And so on. Thanks to the latest research, published in 2022, what we now know is that early postpartum engorgement lies along what is being regarded as part of the “mastitis spectrum”. This spectrum, or range, of conditions results from the narrowing of milk ducts, congestion of the glandular tissue involved in milk production and generalized edema in the breast tissue. If not treated, these can essentially lead to a variety of breast infections further along the mastitis spectrum. And, surprisingly to most people, the science shows we were wrong about “plugged milk ducts”. Nothing is “clogged up” per se, but rather inflammation and ductal narrowing are to blame. Ducts in the breast are innumerable and interlacing according to our latest studies. Thus, it’s not physiologically or anatomically possible for a single duct to become obstructed with a “milk plug”. Lactating parents can feel a relief of a so-called “plug” following breastfeeding because it decreases the fullness of the glandular tissue in the breast.

We can assist lactating parents to be proactive and preventive during early postpartum engorgement (which is still considered a normal biological response) as a strategy to avoid most of the mastitis spectrum. We used to advise pumping the breasts or aggressively massaging them to “move the milk” because it was thought that stagnant milk would result in infection. The new research shows that this actually causes more trauma to the breast tissue. Instead, ice and decreased removal of breast milk will decrease the narrowing of the milk ducts and the breast edema. One approach with respect to family education is to explain to parents that the basic management of early postpartum engorgement is similar to how they’d treat a swollen ankle. Ice and ibuprofen will decrease swelling and control the pain. In the breasts, as the swelling decreases, the milk ducts will have more room to “open up” again. Once they’re not as narrowed, the milk will flow more readily. Ice can be applied every hour or more frequently if desired according to the Academy of Breastfeeding Medicine. In my experience, the commercial icepacks don’t really get cold enough to optimally address engorgement. For moms who are inpatient or visiting their baby in ICN (Intensive Care Nursery) or TCN (Transitional Care Nursery), providing crushed ice in 4-5 clear plastic Ziploc sized bags or in large disposable gloves works great. At home, I suggest parents try using four to five unopened bags of small veggies like peas or corn, for example, and wrap them in a thin baby blanket to make a full breast ice pack. The blanket is merely for comfort and keeps the plastic off the skin.

They may have to extend the ice packs up towards the axilla too. Remember that the breast tissue is tear drop shaped with the “point” of the tear drop (called the Tail of Spence) extending into the axillary region. Along with the ice, the Academy recommends 800 mg of ibuprofen every 8 hours but as always, they should check with their provider first. The research also found that heat for some people can be somewhat effective. They’ll need to be careful, though, that the heat does not cause more problems. Excessive heat applications (or even a long hot steamy shower!) during early postpartum engorgement can lead to increased edema in the breast tissue leading to ductal narrowing and so on.