Common Problems Encountered by Breastfeeding Women

Engorgement

Postpartum Breast Engorgement
The amount of postpartum breast engorgement women experience is highly variable. Some women can scarcely tell that their milk has come in, while others have extraordinary breast swelling, firmness, and discomfort. The amount of engorgement probably is influenced by the frequency of milk removal, the number of milk glands present, the rate at which hormones fall after delivery, and other individual differences.

Breastfeeding Problems Related to Engorgement
Over fifty years ago, a noted British physician, Dr. Harold Waller, published an insightful article in the medical literature describing the contribution of severe breast engorgement to various breastfeeding problems. He estimated that about 20 percent of first-time mothers experienced very dramatic breast engorgement and had difficulty establishing milk flow. It was his belief that this excessive engorgement, if not relieved promptly, soon led to the problems outlined below and was the chief explanation for early failure of breastfeeding. My own observations match Dr. Waller's conclusions, and I wholeheartedly concur with his hypothesis. In my opinion, severe or unrelieved engorgement in the first postpartum week represents the greatest single physical cause of unsuccessful breastfeeding. Severe engorgement, if not promptly relieved, can contribute to each of the following difficulties:

Breast swelling and firmness can make the nipple and surrounding areola more difficult (certainly not easier!) to grasp. As a result, an infant may latch on incorrectly, taking only the tip of the nipple, thereby obtaining little milk and causing nipple discomfort. Babies who have learned to attach correctly in the first day or two when the nipple and areola are soft and pliable will be better prepared to nurse effectively should excessive engorgement occur later. In the past, when new mothers routinely remained hospitalized for several days after delivery, abundant milk production began prior to discharge, and nurses were available to help women position their babies correctly if engorgement was present. Today, however, most women find themselves at home when their milk comes in, and are left to muddle through the experience without benefit of guidance from health professionals. An early follow-up visit within two days of hospital discharge can help identify infants having latching troubles due to severe engorgement.

Swelling of the skin of the nipple and areola during engorgement makes the nipple more susceptible to trauma during attempts to breastfeed and contributes to soreness. The resulting damage-often with cracking, bruising, or abrasions on the nipple-leads to nipple soreness, ranging from mild to severe, that can interfere with nursing. Thus, uncomfortable breast engorgement and painful nipples often go hand in hand, creating what one mother referred to as the "double whammy" blow to breastfeeding.

Excessive engorgement leads to residual milk and elevated pressure in the milk ducts that causes diminished milk produc-tion. When the pressure of severe engorgement interferes with milk flow, residual milk in the breasts can decrease further milk production. Thus, a woman can go very quickly from too much to too little milk. Bottle-feeding mothers represent a commonplace ex-ample of how quickly unrelieved engorgement can cause decreased milk supply. Bottle-feeding mothers attest that extreme breast firmness and fullness subside substantially within about forty-eight hours, as the milk-producing glands cease to function. Thus, the period of engorgement is a critical time in the initiation of breastfeeding, often the make-it-or-break-it period. If milk flow is easily established and the breasts are drained regularly, then full milk production continues. However, if the pressure in tense, tight breasts cannot be relieved and little milk is removed, a woman's body will react as if she is bottle-feeding. Within a few short days, a woman with unrelieved breast engorgement can suffer diminished milk supply. It can take days, or even weeks, of dedicated effort to restore milk production to its full capacity after only a few days of early difficulties. Sometimes the effect can be permanent. Unrelieved breast engorgement is more than a temporary nuisance or an uncomfortable inconvenience. It is a very real threat to the success of breastfeeding because it is so harmful to milk supply.

Severe and unrelieved breast engorgement can make it difficult for the baby to obtain sufficient milk with nursing. Several factors can limit a baby's milk intake during excessive engorgement. Not only is correct latch-on made more difficult when the breasts are swollen and firm, but excessive pressure can impair milk flow. A mother may struggle at feeding times to get her baby to latch on and suckle well, while the hungry baby cries in frustration at not being able to properly position her mouth on the tense areola. Or, a baby seemingly may nurse often enough, yet remain underfed because she is unable to effectively extract milk during nursing attempts. As the days go by, a baby may lose an excessive amount of weight, becoming less able to nurse effectively, at the same time that milk production rapidly is declining. This is a dangerous combination that all too often follows severe, unrelieved breast engorgement.

Treatment of Engorgement
Feeding Schedule
Whether or not engorgement can be prevented by frequent feedings, I definitely agree that it is improved by frequent, effective nursing. By the time milk comes in around the third day, a baby should be nursing every two to three hours, at least eight to ten times in twenty-four hours. It's not uncommon for a baby to have one longer sleep interval (hopefully at night!). Ordinarily, I would allow a newborn one five-hour stretch without feeding in a twenty-four-hour period, but if your breasts are engorged, I wouldn't let this single longer interval exceed about 31/2 hours. I recommend you not allow your baby to use a pacifier in the early weeks of breastfeeding, and this is especially true during engorgement. It does no good for your baby to suck non-nutritively on a pacifier when your full breasts need to be drained. Even if your baby just nursed forty minutes ago, if she exhibits any feeding cues, put her back to your breast. It's entirely possible that her last feeding was not very effective and that she obtained little milk. Now she wants to try again-and she should! Going by the clock ("Gee, she shouldn't be due to feed yet") is likely to prevent your breasts from getting the stimulation and emptying they need and your baby from getting all the milk she requires.

Correct Positioning at the Breast
Going through the motions of frequent feedings does little good if the baby is positioned incorrectly to nurse. In fact, it can make things worse by causing sore nipples that interfere with subsequent feedings. You may have to use a breast pump (see below) or hand expression to take off some milk before latching your baby on. Expressing some milk first will soften the nipple-areola area and make it easier for your baby to grasp. Also, starting some milk dripping from your nipple will help entice your baby to latch on. Cupping your breast in the C-hold, with your fingers well behind the areola, you may need to gently compress your thumb and forefinger to make the nipple and surrounding areola easier to grasp. Make sure your baby takes a large mouthful of breast. Her lips should be flanged out, not curled in.

Cold and Heat
Simple measures like cold and heat application can help relieve breast discomfort and improve milk flow. Cold therapy increasingly is being recognized for its value in reducing inflammation and pain. Traditional ice packs, cool compresses, or commercial cold packs-even bags of frozen vegetables!-can be applied to the engorged breasts for fifteen to twenty minutes at a time to reduce blood congestion and tissue swelling. This will diminish internal pressure in the breast and help milk move through the ducts to the nipple openings.

Many women attest that their breasts start dripping milk when they stand under a warm shower. This observation has led to the widespread recommendation to apply moist heat to engorged breasts, particularly before feedings to increase circulation to the breast and bring the hormone oxytocin to help trigger milk let-down. Wrapping the breasts in warm, wet washcloths or towels for ten to twenty minutes not only feels good but also can start milk dripping. Commercial hot packs are available from a breast pump manufacturer. These packs can be reused by warming them in the microwave. Be careful not to burn the already stretched, damaged breast tissues, especially in the sensitive nipple area. Try both heat and cold applications to find which brings you most relief from discomfort and which helps best to improve your milk flow and decrease breast congestion. You can alternate these therapies in a way that is most effective for you.

Cabbage Leaves
For centuries, cabbage has been used in many countries as a folk remedy for a wide variety of ailments. All kinds of medicinal applications have been suggested for cabbage, including eating it raw or lightly cooked, drinking fresh cabbage juice, or applying a raw cabbage leaf poultice. In recent years, a number of lactation experts have suggested that wrapping engorged breasts in cabbage leaves brings rapid, effective relief of discomfort and facilitates milk flow. Many women attest to the benefits of this treatment, but scientific proof is still lacking to confirm whether such therapy truly is effective for breast engorgement. The home remedy is used as follows:

1. Thoroughly rinsed and dried, refrigerated or room-temperature, crisp, green cabbage leaves are prepared by stripping out the large vein before applying the leaves over the engorged breast or breasts. The leaves can either be worn inside the bra or as compresses covered by a cool towel. Holes can be cut in the leaves, if necessary, to allow the nipples to be kept dry. The cabbage leaf compresses are left in place for about twenty minutes, or until they have wilted, at which time they can be replaced by fresh leaves. Most women report significant relief within eight hours. Continued application up to eighteen hours has been recommended for mothers who needed to wean abruptly or for severely engorged bottle-feeding mothers who wanted to dry up completely.
2. The applications should be discontinued as soon as the desired result is obtained; overtreatment is claimed to reduce milk supply. Practitioners who use cabbage leaves report that women usually require only one or two applications to establish good milk flow.

Breast Pump
Many women are reluctant to pump or express milk during engorgement for fear that they might stimulate too much milk and exacerbate the condition. But engorgement is more a problem of poor milk flow than excessive milk production. Removing milk is essential to reducing the pressure in the breasts and the backup of milk that eventually can decrease milk supply. Improving the ease of milk flow from the breasts makes it easier for the baby to obtain milk when nursing. Because the situation so often is compounded by infant difficulties in breastfeeding, a breast pump can be enormously helpful in managing engorgement. A wide array of pumps is available, ranging from inexpensive hand pumps to hospital-grade electric pumps. I strongly recommend that you obtain a hospital-grade rental electric pump with a dual collection kit that can empty both breasts simultaneously if your breasts become severely engorged. Because unrelieved engorgement can be so distressing and its prompt resolution is so critical to continued success, you will want to have the most comfortable, convenient, and effective means of emptying your breasts. If your baby is not nursing well or if your breasts remain uncomfortably full after breastfeeding, pump after feedings to express any remaining milk and reduce breast firmness. Ten to fifteen minutes of pumping with an electric pump is usually sufficient at one session. Longer pump-ing times can damage nipples and swollen breast tissues. For severe engorgement, some women obtain better results by pumping one breast at a time, instead of both breasts. Use your free hand to gently massage your breast while pumping. Steady pressure applied to areas of firmness often starts milk flowing, at least briefly. When milk flow stops, switch to the opposite breast. Massage and pump on the second side as long as you are getting results. Then switch again when milk flow stops. After fifteen to twenty minutes of total effort, wait an hour or two before trying again.

Relaxation
Do your best to relax and visualize your milk flowing. Being anxious and uptight is only likely to inhibit your milk ejection reflex. Play calming music or practice relaxation techniques such as Lamaze breathing. Ask your partner to give you a neck massage or back rub. Extend your arms above your head and slowly bring them down to your sides. Repeat this "flying angel" exercise several times. Many women find it helps their milk to let-down.

Synthetic Oxytocin Nasal Spray
The hormone your body makes to trigger your milk ejection reflex and start your milk flowing is known as oxytocin. A synthetic form of this hormone was formerly marketed as a nasal spray known as Syntocinon (Sandoz Laboratories). The drug was prescribed for breastfeeding women to help trigger their let-down reflex and promote milk flow when the milk ejection reflex was thought to be inhibited. Synthetic oxytocin was sometimes prescribed for mothers of premature infants and employed mothers who needed help conditioning their milk ejection reflex when using a breast pump. The medication was also recommended to help relieve severe breast engorgement by triggering the milk ejection reflex and stimulating milk flow. Unfortunately, Syntocinon is no longer being marketed. However, a compounding pharmacist can prepare an equivalent drug with a physician's prescription. A compounding pharmacist is a pharmacist who makes custom-tailored medications from scratch. The International Academy of Compounding Pharmacists offers a referral service for patients to help them locate a compounding pharmacist within a fifty-mile radius of their zip code (see Resource List, page 451). If other measures to relieve engorgement haven't helped, ask your doctor whether synthetic oxytocin nasal spray might be worth trying in your case.