Someone reminded me  I wrote about this in Breastfeeding Matters decades ago. For what it's worth:
1. Engorgement

Extreme engorgement is now being seen as iatrogenic,[i] as it is rare when babies are fed ad libitum from birth. But some mothers will suffer a degree of engorgement even when fully demand feeding, as milk production can proceed faster than the baby’s ability to remove milk. An excess of milk in the breast, combined with the vascular and lymphatic congestion usual as the breast switches on to lactation, can create pressures that prevent milk outflow or lymphatic drainage. This leads to a degree of oedema needing assistance for prompt resolution. The most important thing to remember is that milk can flow out of the breast, while oedema must be resolved by getting lymph back into the circulation. The basic principles for the resolution of oedema can be adopted: rest, ice, compression and elevation. Treatments include the following:

· ‘Binders’. These would seem to work on the principle of persuading the breast to slow or stop milk production by mimicking the feedback pressure effect of total distension. They do cause pain to subside more rapidly when lactation is being suppressed.[ii] This, however, may not be a recommendation when lactation is to continue, as it may merely indicate greater efficiency at suppressing milk production. Before dismissing the idea of binders as unhelpful, we should listen to the reports of mothers who have found them to increase comfort when applied by skilled midwives willing to adjust them as often as needed: in all other cases of oedema, compression relieved as often as necessary is found to be useful. But unadjusted binders on breasts are as cruel as unadjusted plaster casts put on broken bones before the swelling has reached its maximum. Just as we break open casts that are too tight, we need to adjust binders to deal with breasts still increasing in size.

· Hand expression. this needs to be very gentle to avoid bruising an overdistended gland. Such expression has caused mastitis and bleeding when too vigorous. Nurses often have no idea how exquisitely painful engorged breasts can be. If it hurts, don’t do it! The hot jar technique discussed in the mastitis chapter can be used initially. So too can gentle massage and expression by the mother herself in a warm bath or under a warm shower.

· An electric breast pump can be used to ‘empty’ the breast at the end of the day, after the last feed. Following this, cold packs can be applied to help reduce the lymphatic congestion in the breasts, and often with this done, the breasts settle down as drainage is possible. Milk expressed can be frozen for later use.

·            Borrowing a hungry baby with more vigorous and efficient sucking techniques can

[i] Applebaum, op. cit., p. 218. For a good discussion of engorgement, see Neifert. M.R., “Routine Management of Breastfeeding” in Neville, M.C.& Neifert, M.R. op. cit., p. 283-4

[ii] Brooten, D.A. et al, “A comparison of four treatments to prevent and control pain and engorgement in non-nursing mothers”, Nurs. Res. (1983) 32, 4, 225-9.

Maureen Minchin
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