The idea of cold initially followed by warm later (how much later
varies-we used 24 hours) is what we've recommended to moms for
episiotomy, laceration, or just stretching perineal discomfort
following vaginal birth and with the rationale that was mentioned in
the earlier post.
My current understanding regarding warm vs cold for breast
fullness>engorgement in the early days is as follows:
1. Breast fullness is from 2 sources-milk fullness and swelling in
the tissues.
2. Either factor (or sometimes both) can lead to difficulty latching
and/or simply discomfort for the mom even though baby latches
effectively.
3. If the swelling is the primary problem, warmth may only increase
the circulation and swelling.
4. Many feel that warmth somehow helps increase milk flow (haven't
heard whether there is evidence of this or just hearsay).

Therefore, what I reccommend is:
1. ONLY if milk is leaking and it is easy to pump/express milk, a
little warmth first such as a warm washcloth or standing in the
shower and letting the warm water running over the breasts help more
leaking.  Then mom should be able to express enough to make the
breast "pliable" enough for baby to latch.
2. If it feels to the mom like milk should be pouring our, but it is
difficult or impossible to get much out, then the problem is more
likely that the swelling in the breasts is impinging on the ducts
and limiting flow.  I compare this to pinching a straw and trying to
drink through it.
3. In scenario #2 or if mom isn't sure which to use, I then
reccommend using cold for ten minutes or so and then pumping or
expressing.
4. Even if baby is able to latch effectively during these full days,
many moms report a general achy feeling in the breasts as part of
the process of the supply "kicking into high gear" (I avoid the term
"milk coming in" because it reinforces the notion that there's
nothing there for baby to et in the first days).  For those moms
whose breasts do ache, the ice packs used after nursing can help.

We suggest to moms that as soon as they get home (or maybe Dad could
do it sooner) to take a couple disposable diapers, soak them under
the faucet and pop them in the freezer.  They will make great ice
packs if she should need them.  They comform to the breast shape and
as they melt, water stays in so there's no leaking (of the water) to
contend with.  She can refreeze and reuse as often as necessary.  If
she is fairly large busted and has a toddler in diapers, I may
suggest using the larger ones.  (We do also mention cabbage.)  Mom's
really like this idea.  In fact, on 2 separate occasions the moms
happened to work in day care and thought that would be a great idea
to have some frozen diapers at the center to use for bumped heads,
etc.
I remember a lead article in Breastfeeding Abstracts a few years
back that discussed use of cold.  If I remember correctly, that
article stated there was no use for warmth in dealing with
engorgement.  I've had good response with the compromise approach
mentioned above.
Winnie Mading RNC, IBCLC

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