I've found that as Riordan's text says there are different degrees of
engorgement.  For instance two sisters who gave birth within 4 months of  each other
both experienced more severe engorgement even with early and  frequent
attachment of their babies.

While many mothers I've worked with have done fine just pumping (or hand
expressing) enough to soften the areola and the breast slightly, some  mothers
have needed to pump once thoroughly when the milk becomes more  copious and the
baby has that wonderful feeding followed by a longer sleep  period, and then
are fine after that.

I conjecture that the more thorough emptying might allow the tight  junctions
to be set sooner, whereas the continuing fullness and incomplete  emptying
might be keeping pressure on the cells and the spaces between them  open,
allowing milk leakage into the surrounding tissue and therefore  continued
engorgement.



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