I determine whether to use heat or cold on the breast by how the breasts feel and what the mother thinks might help.
   If the breasts are abnormally "hot" I want to cool them down and reduce the edema that is causing the heat.  I tell moms that when the milk becomes more plentiful , usually 3-5 days postpartum, it is common for the breasts to feel warmer and fuller. When breasts  are hot and hard close evaluation of the baby at breast is a must.  I only use cold compresses (cold wet washcloths placed over a dry one) in the early engorgement period.
  It really make me crazy when I walk into a room and momis engorged, has been pumping like crazy, getting nothing, and no one thinks to change the planas this is obviously not working. 
  In the past year I have been getting great success with Reverse Pressure Softening. If baby can no longer latch on because the areolas are engorged I will have mom feel what the areolas feel like, then show her how to do RPS (displace the edema back into the breast, away from the areola, Moms are usually amazed at the difference to the areola. milk usually starts leaking too.  The baby then latches and starts transferring milk. - It's amazing to feel the breast actually cool down after a minute or two. 
  If you think about what a baby would do if not for RPS. They would continue trying, get only the nipple, mom would detach - due to pain and baby would continue until RPS is achieved by the baby. Mothers preforming some RPS before latching baby can aviod frustration. RPS works well with  fiberous areolas too.
  A pump during pathalogic engorgement usually makes matters worse by pulling the edema forward and decreasing milk flow. Also, babies are much better, and very cute, pumps when they are  able.
  Hand expression is a type of RPS
  Plugged ducts past the  early days - I recommend  nurse - massage, rest, sometimes heat. The plan needs to be individualized more.
  Thanks for letting me vent. Elena S. Coffey, Connecticut

 
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