Journal of Midwifery & Women’s Health www.jmwh.

org
Clinical Rounds

Caring for Women Experiencing Breast

Engorgement: A Case Report
CEU
Ashley Gresh1 , CNM, MSN, MA , Kelley Robinson1,2 , CNM, MSN, Clifton P. Thornton1,3 , MSN,
RN, CNMT, CPNP, Corinne Plesko1 , BSN, RN

Breast engorgement is an uncomfortable and sometimes painful component of the postpartum period. The effective treatment of breast engorge-
ment may provide an avenue for clinicians to improve postpartum care for women and promote breastfeeding. This case report presents one
woman’s experience with breast engorgement in the early postpartum period. The etiology, evidence-based practices for treatment, clinical impli-
cations, and recommendations for practice are reviewed. The importance of interprofessional care to minimize conflicting information a lactating
woman receives is highlighted. Interprofessional teamwork can optimize care to resolve breast engorgement and facilitate a woman achieving her
breastfeeding goals.
J Midwifery Womens Health 2019;00:1–6  c 2019 by the American College of Nurse-Midwives.

Keywords: breastfeeding, breast engorgement, lactation, lactogenesis, postpartum, midwifery, interprofessional communication

CASE REPORT
A.M. was a 32-year-old woman, gravida 1, para 1, who
gave birth at a birth center and was discharged home 6
hours after birth. A.M. had an uncomplicated, healthy
pregnancy that culminated in the rapid labor and normal
spontaneous vaginal birth of a vigorous, full-term male
newborn. The newborn was placed skin-to-skin imme-
diately after birth, and breastfeeding was initiated at the
birth center. The attending midwife noted a tongue tie
during the preliminary newborn examination and did not
recommend intervention at that time. A.M. had inverted
nipples but reported her newborn latched well the first
day; however, over the next few days, her breasts became
engorged, making newborn latch difficult.
A.M. reported many problems with breastfeeding start-
ing the first day postpartum while at her home. On the first
day home, A.M. called the midwives’ office and reported
that her breasts were filling quickly, stating they felt “super
hard and painful.” A nurse triaged A.M.’s call and discour-
aged pumping to avoid increasing engorgement, recom-
mended applying ice, wearing a well-fitting bra, and hand
expressing while taking multiple warm showers daily. A.M.
found it difficult to maintain this regimen while caring for
a newborn. A referral was given for a lactation consultant
during the initial call. The lactation consultant was con-
tacted, and she advised A.M. to hang her breasts in a tub
1
Johns Hopkins University School of Nursing, Baltimore,
Maryland
2
Baltimore Medical Systems, Baltimore, Maryland
3 INTRODUCTION
Herman & Walter Samuelson Children’s Hospital, Baltimore,
Maryland
Correspondence
Ashley Gresh
Email: Ashley.gresh@jhu.edu
ORCID
Ashley Gresh https://orcid.org/0000-0002-7181-8219
and hand express in the warm water, pump as much as pos-
sible, and apply ice packs to her breasts. The suggestions left
A.M. unsure of the best approach for relief after receiving
conflicting advice. At the first pediatric visit on postpartum
day 1, the pediatric team confirmed a newborn tongue tie,
for which an in-office frenectomy was performed.
By day 3 postpartum, A.M. was still engorged, and her
breasts were taut, lumpy, hard, and increasingly painful to
touch, with worsening newborn latch. A.M. returned to the
pediatrician to find that her newborn had lost 11% of his
birth weight. With increasing concern for newborn well-
being, she was advised to formula supplement. The pedi-
atrician gave A.M. a nipple shield to assist with latch, but
A.M. had concerns about using it because of previous ad-
vice from the lactation consultant to avoid a nipple shield.
A.M. called the midwives’ practice again, and the nurse
advised her to use belladonna and arnica by mouth and
continue warm compresses, hot showers, pumping, and
nursing as much as possible. A friend suggested she apply
cabbage leaves to the breasts, which A.M. also tried.
On postpartum days 4 and 5, the newborn was able to
latch with difficulty, but A.M.’s breasts were still painfully
engorged. A.M. contacted another lactation consultant,
who came for a home visit and advised her to stop every-
thing and nurse every 3 hours (with breast massage), pump
until breasts feel empty, and apply ice after each feeding.
She encouraged A.M. to wean pumping after 24 hours. This
treatment was effective for A.M., and her breast engorge-
ment resolved approximately 24 hours after the lactation
consultant’s home visit.
Recent studies suggest that many women (83.2%) who give
birth in the United States initiate breastfeeding following
birth, but less than 50% of infants are exclusively breast-
fed at 3 months of age.1 The reasons for breastfeeding ces-
sation in the early postpartum period are complex and
multifactorial; difficulties with lactation, including breast

1526-9523/09/$36.00 doi:10.1111/jmwh.13011 
c 2019 by the American College of Nurse-Midwives 1
engorgement, have been found as reasons for early cessation
of breastfeeding.2 Two-thirds of women report experiencing
some form of breast engorgement after giving birth.3 In an
analysis of the Infant Feeding Practices Study II (N = 2572),
60% of women stopped breastfeeding earlier than they had
initially intended.3 The participants identified several reasons
for discontinuing breastfeeding; women who stopped breast-
feeding before they intended reported a higher incidence of
breast engorgement (10.9% vs 5.7%, respectively; P = .002),
and this study found that engorgement was associated with a
higher odds of discontinuing breastfeeding (odds ratio, 1.97;
95% CI, 1.22-3.52).2
Stage II of lactogenesis typically occurs 2 to 4 days post-
partum. Most often women leave the birth center or hospital
setting before their breasts become engorged;4 therefore, it is
important to educate women and their families about the pro-
cess of lactogenesis and to guide them using evidence-based
practice for managing engorgement.
ETIOLOGY AND CLINICAL MANIFESTATION OF
BREAST ENGORGEMENT
Engorgement can occur at various times throughout the post-
partum period and is classified as primary or secondary
engorgement.5,6 Primary engorgement occurs during stage
II of lactogenesis, which generally occurs between the sec-
ond and fourth day following birth. Primary engorgement
includes interstitial breast edema, increased vascularity, and
congestion; initiation of milk production usually lasts approx-
imately 24 to 48 hours.5,7–9 Secondary breast engorgement is
the result of an imbalance between milk production and ex-
traction. This article addresses treatments for primary breast
engorgement.5
Women with breast engorgement report a sense of heav-
iness as the breasts fill, leading to tenderness and distension.
The skin is often warm, veins become prominent, and skin
becomes taut. During this stage, the nipples may become firm
or flattened, making it difficult for the newborn to latch.6,9
Because of the increased metabolic rate associated with milk
production, mild elevated temperatures up to 38°C (100.4°F)
may occur despite breast engorgement not involving an in-
flammatory or infectious process.4,9,10 During this phase of
lactogenesis, women should be able to continue to breastfeed
comfortably and efficiently, as the sensation of breast full-
ness can be uncomfortable but is rarely severe and is a self-
limiting condition.4 Engorgement can be peripheral, in the
body of the breast, or involve the areola, and both breasts are
affected.5
Severe engorgement is a pathologic condition and can
result from mismanagement of milk stasis. With severe en-
gorgement, the breasts become hard, red, hot, shiny, and very
painful.9 Severe engorgement can occur with delayed initia-
tion of feedings, use of breast milk supplements, infrequent
feedings, history of breast surgery that affected outflow tracts,
or removing the newborn from the breast prior to completely
emptying the breast.4,5 If the newborn is unable to latch, the
woman’s pain increases, and breast and nipple tissue may be-
come so taut that trauma to the tissue can occur as the new-
born vigorously tries to withdraw milk from the breast.4 Se-
vere engorgement is less common among individuals who are
2 Volume 00, No. 0, xxxx 2019
taught to breastfeed frequently in the first 48 hours of a new-
born’s life.3
DIFFERENTIAL DIAGNOSIS OF PRIMARY BREAST
ENGORGEMENT
Prior to treating engorgement, it is important to differenti-
ate breast engorgement from other causes of swelling such
as mastitis or gigantomastia. Often preceded by breast en-
gorgement, mastitis is characterized by an infection in the
breast tissue leading to inflammation.6 The presence of fever,
erythema, purulent drainage, and induration may suggest
mastitis.11 Gigantomastia is an excessive growth of breast tis-
sue and presents with increased size of the areola and breasts
and may require medication or surgical intervention.12,13
PREVENTION AND TREATMENT OF PRIMARY
BREAST ENGORGEMENT
Primary breast engorgement is a self-limiting condition,
which makes research on effective prevention and treatment
modalities difficult.4 Although there are some scales of breast
engorgement in use, there is no standardized tool for evalua-
tion and diagnosis. Treatment primarily focuses on facilitating
excretion of milk from the breast and providing symptomatic
care.13 The Cochrane Collaboration published an updated re-
view of the scientific literature addressing interventions for
breast engorgement during lactation in 2016.13 For the pur-
pose of this case report, a review of peer-reviewed literature
was conducted in PubMed and CINAHL Plus to capture ad-
ditional publications on the topics since that time. A summary
of findings is provided in Table 1.
Medication
Medications used to treat primary breast engorgement in-
clude progesterone and agents that reduce inflammation. Pro-
gesterone inhibits the effects of prolactin and could thereby
theoretically slow milk production. The use of a topical pro-
gesterone gel applied to the breasts of 23 women with engorge-
ment resulted in only a 2.2% (SD, 2.2%) decrease in measured
breast firmness in one study.14 In a randomized controlled
trial (N = 70) conducted in 1989 in Singapore, the adminis-
tration of Serrapeptase, a dietary supplement thought to have
anti-inflammatory effects, was associated with “marked” im-
provement in 22.9% of women when compared with placebo
(P ⬍ .05).15 Additionally, 85.7% of women reported “moder-
ate to marked” improvement in symptoms while taking Ser-
rapeptase, compared with 60% who reported “moderate to
marked” improvement while receiving placebo (P ⬍ .05).15
However, this study was completed more than 30 years ago
and has not been validated in subsequent research.
Hot and Cold Treatments
Hot and cold treatments are often used for symptomatic re-
lief of acute pain, inflammation, and symptomatic treatment.
An experimental study conducted in Iran comparing acupres-
sure versus intermittent hot and cold compresses (N = 70) ap-
plied over 2 days found that both treatments were effective at
decreasing symptoms of engorgement (P ⬍ .001).16 Notably,
 Table 1. Current Approaches to Treatment of Breast Engorgement
Intervention Outcome Effectiveness Source
Progesterone gel No statistically significant difference in report of pain or No change Alekseev14
measurement in breast density or engorgement 2017
97.8% (SD, 2.2%) of preintervention pain (P = .08)
Serrapeptase Clinician assessment of engorgement symptoms and patient report Improvement Kee et al15
of discomfort decreased 1989
22.9% had marked improvement compared with 2.9% in placebo
group (P ⬍ .05)
Chinese breast Decreases subjective breast engorgement and discomfort Improvement Chiu et al22
scraping (P ⬍ .001) 2010
Acupressure Effectively relieved pain from engorgement, not as effective when Equivocal Ahmadi16
compared with warm and cold compress (P ⬍ .001) 2012
Acupuncture When compared with massage and warm compress, had no added No change Kvist et al32
benefit 2004;
Kvist et al,33
2007
Herbal mixture Statistically significant decrease in self-reported pain, greater Improvement Ketsuwan et al17
(as warm improvement when compared with warm compress alone 2018
compress) Pain scores decreased by 5.9 (SD, 1.8) in herbal mixture group
Cabbage leaves Cold cabbage leaves were equally effective to hot and cold Improvement Arora et al18
compresses in decreasing engorgement 2008
Pretreatment engorgement score was 5.17 with post-treatment
score of 3.02 (P ⬍ 0.001) and pain pretreatment was 6.4, reduced
to 3.45 (P ⬍ 0.001)
No differences between chilled or room temperature cabbage leaves Improvement Roberts et al19
Room temperature: 37% reduced pain; chilled leaves: 38% 1995
reduction
Chilled cabbage leaves decreased pain score by 1.8 out of 10 Improvement Roberts20
(P = .001), no difference when compared with cold packs 1995
Cream containing cabbage extract and placebo cream both reduced Equivocal Roberts et al21
pain by 1.2 out of 10 points without differences between groups 1998
Warm compress Decrease in self-reported pain after one application Improvement Ketsuwan et al17
Pain scores decreased by 3.1 (SD, 3.0) 2018
Warm packs and massage improved symptoms from baseline Improvement Chiu et al22
2010
Cold compress Improved pain compared with no intervention (P ⬍ .01) Improvement Wong et al34
2017
Pain scores decreased by 2.2 points out of 10 (P = .001), not Improvement Roberts20
different from chilled cabbage leaves 1995
Warm and cold Statistically significant improvement in discomfort from baseline Equivocal Arora et al18
compress but not significantly different compared with cold cabbage leaves 2008
Engorgement score decreased from 5.14 to 2.97
Warm and cold compress was more effective in relieving breast Improvement Ahmadi16
engorgement compared with acupressure 2012
(P ⬍ .001)

(Continued)

Journal of Midwifery & Women’s Health r www.jmwh.org 3

 Table 1. Current Approaches to Treatment of Breast Engorgement
Intervention Outcome Effectiveness Source
Thermal No differences between thermal compared with standard Improvement McLachlan et al24
ultrasound ultrasound, but there was improvement in both groups 1991
compared with baseline
Milk expression Reverse pressure softening to prepare the areola for latching Equivocal Cotterman27
(feeding, (anecdotal) 2004
pumping, or Improved pain immediately after massage Improvement Witt et al25
manual) Engorgement scores decreased by 1.82 points (P ⬍ .01) 2016
Milk ejection via breast pump Improvement Alekseev14
60% (SD, 15%) reduction of pain (P ⬍ .0001) 2017
Massage and electromechanical pumping reduced breast Improvement Heberle et al23
engorgement assessed via temperature by 0.03 degrees Celsius 2014
compared with no change for manual massage and expression
(P = .03)

Abbreviation: SD, standard deviation.

hot and cold compresses were found to be more efficacious
than acupressure (P ⬍ .001).16 A randomized controlled trial
(N = 500) conducted in Thailand compared the use of hot
compresses with and without an herbal component to re-
duce pain associated with breast engorgement.17 Results of
the study revealed that both treatments reduced pain scores:
hot compresses decreased pain scores from 5.8 to 2.8 (on a
10-point scale; P ⬍ .001), and the hot, herbal compresses de-
creased reported pain scores from 6.9 to 1.0 (P ⬍ .001).17 The
hot compress with herbal components was associated with
a statistically significant greater improvement in pain (P ⬍
.05).17 The World Health Organization recommends hot com-
presses or a warm shower to help facilitate milk removal be-
fore feeding a newborn.9 A systematic review of the literature
found unpublished reports that cold compresses are recom-
mended after or between feedings to decrease symptoms of
pain and swelling.13
Cabbage Leaf Application
The use of chilled cabbage leaves applied to the breast to
treat engorgement is popular because of the belief that the
sinigrin substance in cabbage helps reduce engorgement;
however, studies that have evaluated the effects of cabbage
leaf application have differing results.10 A quasiexperimental
study conducted with 60 women in India found that the
use of cabbage leaves may be equivocal or similar to that
of other warm or cold treatments (P = .07).18 Another
experimental study conducted with 28 women in India
examined the difference between chilled and room temper-
ature cabbage leaves. There was a 37% reduction in pain
scores associated with room temperature leaves and a 38%
decrease in pain scores with chilled cabbage leaves.19 The
difference in pain scores from baseline were equivocal and
there was no statistically significant difference between the
2 interventions (P = .84).19 Another comparison study from
Australia compared chilled cabbage leaves with cold packs in
34 women and found that cabbage leaves reduced pain scores
by 1.8 points (P = .0001) compared with baseline, and cold
packs reduced pain scores by 2.2 points (P = .001) compared
with baseline.20 There was no statistically significant differ-
ence between the posttreatment scores comparing cabbage
leaves with cold packs (P = .46).20 Another randomized
controlled trial (N = 39) conducted in Australia examined
the effects of cabbage leaf extract mixed into cream compared
with cream without cabbage leaf extract. Women who used
both creams reported subjective improvements in symptoms
and pain scores decreased by 1.2 points (on a 10-point scale)
without significant differences between groups (P ⬎ .05).21
Nontraditional Therapies
Nontraditional or alternative therapies are often employed for
additional symptomatic pain relief for a wide variety of con-
ditions or discomforts. Gua Sha is a Chinese muscle scrap-
ing therapy applied to the breast that has been traditionally
used to treat pain based on the Chinese principles of the 12
meridians.22 A randomized controlled trial (N = 54) assessed
the effect of Gua Sha on a subjective scale that measured
pain, engorgement, and discomfort on a visual analogue scale.
Women were randomized to hot packs and massage or Gua
Sha therapy. Gua Sha reduced reported pain and discomfort
more than did hot packs and massage at 5 and 30 minutes fol-
lowing the intervention (P ⬍ .001).22
Ahmadi compared acupressure with warm and cold
compresses and found that acupressure produced statistically
significant improvements in pain, but not to the same degree
as did the warm and cold compresses (P ⬍ .001).16 An exper-
imental study conducted with 88 women in Sweden evaluated
the addition of acupuncture to standard care (oxytocin spray,
massage, and hand expression) and found that it was not
associated with a difference in reported symptom severity
(P = .11).23
In addition to Gua Sha and acupressure, thermal ultra-
sound has been assessed for effectiveness in reducing breast
engorgement. A randomized controlled trial conducted in
Australia (N = 109) comparing standard ultrasound with
thermal ultrasound applied to the breast for 8 to 15 minutes

4 Volume 00, No. 0, xxxx 2019

found that both yielded improvement in pain scores but had
no statistically significant differences between interventions
(P ⬎ .05).24
Breast Massage and Milk Expression
Techniques to facilitate milk removal may reduce breast
congestion and fullness, leading to relief from pain and
discomfort. Although breastfeeding education that recom-
mends frequent feedings has not decreased the incidence
of engorgement, techniques such as emptying one breast
entirely during feeding and alternating breasts with each
feed has been reported to reduce breast engorgement.3 An
experimental study conducted in the United States (N = 42)
found that therapeutic breast massage during lactation
reduced reported pain by 3.6 points on a 10-point scale (P ⬍
.001).25 The study also reported that women had improved
home management of future engorgement episodes, although
this finding was anecdotal.25 Other literature from Russia
anecdotally describes the benefits of breast massage com-
bined with hand expression to facilitate drainage, reduce
swelling, and help improve newborn latch.26
Additional techniques described in the literature include
reverse pressure softening (gentle application of pressure from
the fingertips around the areola prior to feeding) to improve
newborn latching and milk expression leading to pain relief.27
An experimental study with 16 women in Brazil compared the
use of a breast pump and manual expression and found that
improved relief of engorgement (as evaluated by breast tem-
perature) was associated with pumping after massage (P =
.03), whereas there was no difference in those who only un-
derwent hand expression (P = .8153).23
CLINICAL IMPLICATIONS AND
RECOMMENDATIONS
Based on the studies evaluated, effective approaches to pro-
viding relief from breast engorgement include Chinese breast
scraping, warm compress (with or without herbal compo-
nents), cold compress, ultrasound, cabbage leaves, and milk
expression.13 Treatments that did not show improvements in
symptoms included hormone cream, oral supplements, and
acupuncture (Table 1). This review illustrates the lack of ev-
idence for effective management of breast engorgement. Ad-
herence to best practices is difficult when there are no clear
best practices in existence. Further research is needed to stan-
dardize best practices for treatment.
Using cold compresses after each feeding appears to be
the method most frequently employed to reduce discomfort
associated with primary breast engorgement. In this case re-
port, A.M.’s breast engorgement resolved after she initiated
nursing every 3 hours, breast massage, pumping, and apply-
ing cold packs after feeding. Use of cold or warm compresses
are safe, generally accessible, relatively inexpensive, and can be
readily performed in the home. Treatment effectiveness was
largely contingent upon A.M.’s ability to maintain the regimen
at home.
Education is an evidence-based approach that can help
prevent severe breast engorgement. Discussing the impor-
tance of emptying each breast with feeds can promote
Journal of Midwifery & Women’s Health r www.jmwh.org
successful breastfeeding and help prevent engorgement.3 An-
ticipatory guidance regarding breast engorgement should be
given to all women during prenatal visits and prior to postpar-
tum discharge. Techniques that may help prevent and treat en-
gorgement can be discussed and taught prior to discharge af-
ter birth. During this education, health care providers should
assess the feasibility a woman’s ability to perform and main-
tain appropriate techniques should they be required.
One of the problems experienced by A.M. was the
diverse, conflicting recommendations she received from
different health care providers. Recent studies have shown
that interprofessional care is important to increase rates of
breastfeeding and provide adequate support for women.28,29
One qualitative study found a discontinuity in lactation sup-
port across a continuum of health care providers.30 As there is
no one clearly effective treatment for breast engorgement, and
women interface with multiple different health care providers
in the postpartum period, women often receive conflicting
advice on how to deal with breastfeeding problems when they
arise. This case study demonstrated that conflicting advice
from multiple sources was overwhelming and not evidence
based. The conflicting recommendations made it difficult for
A.M. to identify a treatment that was most effective for her.
Increasing linkages between women’s health and pediatric
providers, especially during the postpartum period, could fur-
ther bolster breastfeeding support when needed. As this case
report also demonstrates, providing a clear, easy-to-follow
regimen can best help an individual manage painful symp-
toms and facilitate continuation of breastfeeding. Future re-
search should explore the role and benefits of postpartum
doulas and other community support members in providing
breastfeeding support.
Many organizations support interprofessional education
of patients and families regarding breastfeeding and related
issues. The American College of Nurse-Midwives states that
health care providers should participate in comprehensive
education to educate and support breastfeeding practices.31
With multiple platforms of text messaging, phone calls, and
distance support for breast engorgement, the opportunity to
give appropriate guidance and support to women who are lac-
tating may lead to an even greater increase in successful long-
term breastfeeding outcomes.
CONCLUSION
As seen in this case report, the solution to A.M.’s case of breast
engorgement was a treatment regimen that was clear, easy
to follow, and based on evidence-based practice provided in
the home environment. This case report highlights the im-
portance of health care providers supporting evidence-based
breastfeeding practices and ensuring that appropriate treat-
ment is given for breast engorgement. Although there is no
single best treatment, there are multiple interventions that
demonstrate some success in treating breast engorgement.
The use of cold compresses and breast massage after feedings
was found to be most effective in this literature review and
case report. Through anticipatory guidance and prompt treat-
ment, women who are breastfeeding can be helped to increase
their likelihood of having a successful, long-term breastfeed-
ing experience. Given that many health care providers from
5
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Continuing education units (CEUs) are available for
compress (hot and cold) on breast engorgement in lactating this article. To obtain CEUs online, please visit www.
women. Iranian Registry of Clinical Trials. Registration num- jmwhce.org. A CEU form that can be mailed or faxed is
ber IRCT201204065698N3. Registered June 6, 2012. www.irct.ir/ available in the print edition of this issue.
trial/6220. Accessed May 15, 2019.

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