Toby,
My favorite measure of engorgement is a functional one - how far can mom
(gently) pull her nipple away from her breast?  I find it needs to be btwn 1/2
and 1 inch in order for baby to be able to form a teat and latch properly.
Engorgement (edema) takes up the slack in the breast tissue, so that the skin
is stretched and shiny, and the nipple cannot protract...often misdiagnosed in
hospitals here as "flat nipples".  Differential diagnosis is engorgement vs
inelastic skin, the shininess from stretching will not be apparent with
inelastic tissue, nor will the breast feel hot and heavy.  I also have noticed
that nipple fissures are more common when mom is engorged and tries to nurse
without softening the areola, suspect that the nipple skin bursts due to
excessive pressure (lack of slack in skin and malpositioning in front of the
infant's mouth.)  Of course that could be the chicken, and the egg a faulty
suck or mismanagement that caused the engorgement in the first place!  Don't
you love this field!
        I also agree with you that problems seem to occur in groups.  Even my
kids ped finds this to be so.  I call it the "problem of the month" phenomena.
 I will see mostly ankyloglossia, then mostly tongue retraction, then mostly
low tone babies....I sometimes start to wonder if I am simply
"overdiagnosing", then the presenting problem suddenly changes.  Go figure.
My dad was a NY city cop, and they swore that the types of calls they received
varied with the phases of the moon...
Catherine Watson Genna, IBCLC  NYC  [log in to unmask]