LuAnn, I think what is important on management of engorgement is that not  
all women produce milk equally.  There are some women who are just more  prone 
to engorgement and not because they skipped feedings or their baby is not  
getting enough.  
As lactation professionals we really need to assess each case on its own  
merits and not rubber stamp either the management or the cause.  I know  this 
frustrates people from the nurses, doctors, parents and LCs but there  really 
isn't simple answers.  
We can certainly make generalizations which should cover most cases but  than 
need to be opened minded and flexible when symptoms fall out of the normal  
curve.  
So, if a mother continues to have engorgement it needs to be addressed or  
she will have a negative feedback inside her breast that could lead to decrease  
supply.  Moms need to be given treatments that relieve their symptoms while  
taking a very through history.  Having a mom pump down to soft when  engorged 
should not start something that cannot be controlled.  Engorgement  makes for 
difficulty latching and hand expressing.  If mom can soften a  breast enough 
for the baby to latch, the baby may help the mother with the  rest.  
There are moms who need to down regulate their supply because that is how  
their bodies work not because they over used breast pumps or expressing.  I  
think we should be very careful not to jump on the pump as the reason to this  
problem.  The facts just don't support it.
Take this case by case and listen very carefully to what the mother is  
saying.
Ann Perry, RN IBCLC
Boston, MA
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