Protocol 20: Engorgement




Purpose


The purpose of this protocol is to evaluate the state of evidence as to the prevention, recognition, and management of breast engorgement to encourage successful breastfeeding. The effect of medications on breast engorgement and lactation suppression will also be reviewed.




Background


Engorgement has been defined as “the swelling and distention of the breasts, usually in the early days of initiation of lactation, caused by vascular dilation as well as the arrival of the early milk.” The concept put forward by Newton and Newton in 1951 suggested that alveolar distention from milk then led to compression of surrounding ducts, which subsequently led to secondary vascular and lymphatic compression. Some degree of breast fullness in the second stage of lactogenesis is considered normal and reassuring to the mother and health care provider.


Engorgement symptoms occur most commonly between Days 3 and 5, with more than two-thirds of women with tenderness on Day 5 but some as late as Days 9 to 10. Two-thirds of women experience at least moderate symptoms. More time spent breastfeeding in the first 48 hours is associated with less engorgement.


One difficulty when evaluating incidence and treatment options for this condition involves the spectrum of engorgement, from expected physiologic breast fullness through severely symptomatic engorgement. Additionally, more optimal lactation management and support in some institutions may reduce the frequency of significant symptoms compared to less supportive environments.




Assessment of Engorgement


Tools


No standardized reliable tool for assessing breast engorgement has been established. Various methods of subjectively rating engorgement have been utilized, such as visual descriptions, cup size, or hardness or firmness scales, but none has become clinically useful.


Predictors




  • 1.

    The relationship between parity and engorgement remains unclear because of little research. Onset of lactogenesis occurs sooner in multiparous compared to primiparous women, but engorgement has not been studied in this regard.


  • 2.

    Women undergoing cesarean delivery typically experienced peak engorgement 24 to 48 hours later than those who delivered vaginally. These women also initiated breastfeeding significantly later than did their vaginally delivered counterparts. This finding appears consistent with other research that has found that cesarean delivery may correlate with a higher likelihood of delayed onset of lactation.


  • 3.

    It is not uncommon for women who have undergone breast surgery to experience engorgement.


  • 4.

    The influence of length of labor, premature delivery, anesthetic options, and intravenous fluids remains unclear.





Differentiating Engorgement from Other Causes of Breast Swelling




  • 1.

    Mastitis . Engorgement may be associated with a slight elevation of maternal temperature, but significant fever, especially when associated with breast erythema and systemic symptoms such as myalgias, suggests the diagnosis of mastitis. Typically, mastitis affects only one breast with a segmental pattern of redness. Engorgement is usually diffuse, bilateral, and not associated with breast erythema.


  • 2.

    Gigantomastia . Gigantomastia is a diffuse, bilateral process that occurs very rarely and does not typically present in the postpartum period. The reported incidence is approximately 1:100,000, but some feel that it is more common with a rate as high as 1:8000. It is regarded as bilateral benign but progressive massive breast enlargement to an extent that tissue necrosis may occur and infection and sepsis may result. Histologic findings suggest marked lobular hypertrophy and ductal proliferation. No clear etiology for this condition has been elicited, although hormonal changes are likely involved.





Prevention and Treatment


Prevention


There has been a great deal of research into medical therapies to suppress lactation, but limited research into prevention and treatment strategies for lactating women who may develop engorgement. Focused education to mothers regarding breastfeeding position and attachment or prenatal nipple conditioning has shown no difference in subsequent incidence of engorgement. However, some breastfeeding techniques have been specifically associated with less engorgement, including emptying one breast at each feeding and alternating which breast is offered first. Limited evidence suggests breast massage after feeds performed for the first 4 days postpartum may reduce the extent of engorgement. Although commonly accepted as preventive of engorgement, frequent effective feeding patterns have not been studied.


Treatment


Adequate management of engorgement is important for successful long-term lactation. Although experiencing engorgement may be temporarily uncomfortable for mothers, it appears to be associated with a decrease in the likelihood of early weaning. At the same time, failure to effectively resolve prolonged symptomatic engorgement may additionally have a negative impact on continued adequate milk supply.


Both pharmacologic and nonpharmacologic therapies have been touted as beneficial for the treatment of engorgement. A systematic review of both randomized and “quasi-randomized” controlled studies assessing effectiveness of treatments for breast engorgement was done by Snowden et al. in 2001. This analysis identified eight trials including 424 women. Therapies reviewed that outperformed placebos in decreasing symptoms are described below:



  • 1.

    Serrapeptase® (Takeda Chemical Industries, Ltd., Osaka, Japan) (Danzen), an antiinflammatory enzyme agent, 10 mg three times daily, was compared to placebo three times daily for 3 days. The Danzen group reported marked improvement in 23% of women compared to only 3% in the placebo group. Overall, 86% of the treatment group reported statistically significant marked or moderate improvement compared to 60% for the placebo group. Although the results suggest that the antiinflammatory agent may be beneficial, the study has the significant limitation that few women in the study were breastfeeding their infants.


  • 2.

    Enzyme therapy using a protease complex enteric-coated tablet containing 20,000 units of bromelain and 2500 units of crystalline trypsin, another antiinflammatory agent, has been tested. Women with breast swelling or induration on Days 3 to 5 and pain were given either the protease complex or placebo tablets (approximately 5 tablets per day) for 3 days for a total of 16 tablets. The protease complex was found to be effective in 83% of cases compared to 33% of those receiving placebo.


  • 3.

    Reverse pressure softening technique uses gentle positive pressure to soften an area (1 to 2 in. or so) near the areola surrounding the base of the nipple. The goal is to temporarily move some swelling slightly backward and upward into the breast. Moving the edema away from the areola has been shown to improve the latch of the infant during engorgement. The physiologic basis for this technique is the presence of increased resistance in the subareolar tissues during engorgement.


  • 4.

    Snowden et al. concluded that there is no benefit for the following treatments as compared with placebo: cabbage leaves, cabbage leaf extract, oxytocin, cold packs, and ultrasound.



It may be that some treatments help the discomfort without relieving the actual engorgement. It should also be noted that many of the therapies listed above may not be available in certain countries.

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Jul 13, 2019 | Posted by in PEDIATRICS | Comments Off on Protocol 20: Engorgement
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