Hill and Humenick published two excellent articles on engorgement in JHL a
few yrs ago.  I don't have the articles at home, so can't give the issues
and dates, but they are very important to read and review as they are among
the very few clinically based discussions of the subject.  You'd think there
would be tons of articles on this, but alas not so.  Anyway, they describe 4
distinct patterns of engorgement identified in their study and speculate
there may be other patterns.  One possible pattern experienced by a fair
number of women is severe and prolonged engorgement despite normal
management efforts.  I have ceased predicting to mothers how long
engorgement may last, because my own clinical experience matches Hill and
Humenick's observations:  it will vary.  I have seen mothers who had home
births and nursed immed. with appropriate latch, who had dramatic and
uncomfortable engorgement for as long as two weeks in spite of round the
clock nursing. As Hill and Humenick suggest, this pattern of engorgement
should be viewed as a bit of a red flag for risk of lactation failure,
because it is unpleasant.  The other red-flag pattern is the mother who
experiences no major breast changes post-partum, and who can't really
identify the day when the milk "came in."

As Molly Pessl says in the editorial in the latest JHL, we shouldn't be
seduced by  our own mythology.  It is not necessarily so that good
management can prevent all engorgement. Appropriate management of
engorgement is critical due to autocrine control of milk synthesis esp
during the calibration period.  So we need to have a clinical basis for
discussing engorgement.  For instance, there is still no clinically based
consensus on whether heat or cold is preferable in the management of
engorgement.
Barbara

Barbara Wilson-Clay, BS, IBCLC
Private Practice, Austin, Texas
Owner, Lactnews On-Line Conference Page
http://moontower.com/bwc/lactnews.html