BREASTFEEDING MEDICINE

Volume XX, Number XX, 2018 Clinical Research

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2018.0032

Effect of Herbal Compresses for Maternal

Breast Engorgement at Postpartum:
A Randomized Controlled Trial

Sukwadee Ketsuwan,1 Nongyao Baiya,1 Panwara Paritakul,2

Wipada Laosooksathit,2 and Pawin Puapornpong2
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Abstract

Background: Maternal breast engorgement is one of the most common problems in the postpartum period.
There are several alternative treatments, but there have not been any randomized controlled trial studies about
the effects of herbal compresses for breast engorgement.
Objective: The objective is to investigate the effects of herbal compresses for maternal breast engorgement.
Materials and Methods: A randomized controlled trial was conducted. The postpartum mothers who had breast
engorgement were randomly assigned to herbal or hot compress treatments. The breast engorgement pain scores
were assessed by visual analog scales pre- and post-treatment. The pain reduction scales of the herbal compress
treatments were analyzed and compared with the hot compress treatments. The adverse effects of each treat-
ment were recorded and collected after 24 hours from treatments.
Results: The data from 500 postpartum mothers with breast engorgement were available for analyses, 250 from
the herbal compress group and 250 from the hot compress group. The baseline characteristics of both groups
were similar except baseline breast engorgement pain score (herbal compress group higher than hot compress
group). There were statistically significant mean differences of breast engorgement pain before and after
treatment between the herbal and hot compress groups. No serious complications were found after treatment
from herbal compresses.
Conclusion: Among the postpartum mothers who had breast engorgement, the herbal compresses could de-
crease breast engorgement pain. The pain reduction after herbal compresses was found to be greater than with
the hot compresses.

Keywords: breast engorgement, herbal compress, hot compress

Introduction have similar mechanisms, but also anti-inflammatory effects

M aternal breast engorgement is one of the most
common problems, resulting in discomfort for mothers
and interferes with infants’ breastfeeding during the post-
partum period.1 It may lead to early breastfeeding cessation.
There are many choices of treatments, including hot com-
press, cold pack, herbal remedies, breast massage, acupunc-
ture, cabbage leaves, hand expression, and pump.2 There is
insufficient evidence among most breast engorgement treat-
ments to determine whether one is more effective than an-
other. Hot packs and massages are treatments often used.
Herbal compresses are an alternative treatment that not only
from the herbal ingredients and relaxing effects of the aro-
matic volatile oils.3–6 In Thailand, the herbal compress has
been used for hundreds of years. It was approved by the Thai
traditional medicine service of public health facilities and is
listed in the National List of Essential Medicines.6
The main ingredients of Thai herbal compresses include
Plai or Cassumunar ginger (Zingiber cassumunar Roxb.),
turmeric (Curcuma longa L.), and camphor. There are several
published articles that have endorsed the anti-inflammatory
and analgesic effects of Plai, turmeric, and camphor.3–5 The
safety of herbal compresses used during the early postpartum
and lactating periods was studied and no adverse effects were

1
Obstetrics and Gynecology Nursing Department, HRH Princess Maha Chakri Sirindhorn Medical Center, Nakhon Nayok, Thailand.
2
Department of Obstetrics and Gynecology, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand.

1
 2 KETSUWAN ET AL.
reported.6 However, there have been few studies about the
effects of herbal compresses on the outcomes resulting from
breast engorgement discomfort. Thus, we are interested in the
comparisons of breast engorgement treatment outcomes be-
tween herbal and hot compresses as seen in this study.
Materials and Methods
Setting
This study was performed in the Nakhon Nayok province,
a rural area in the central part of Thailand. The data were
collected during the period from July 2016 to October 2017 at
the HRH Princess Maha Chakri Sirindhorn Medical Center.
This is known as a Baby-Friendly Hospital. A routine prac-
tice in the postpartum ward is breastfeeding education. The
1-hour course in breastfeeding includes latching and is taught
on the first day postpartum. One nurse teaches a group of
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three to five mothers. Mothers are encouraged to stimulate
their infants to feed 8–12 times per day. Breast engorge-
ment is a complication that has been routinely assessed by
patients’ nursing staff. If mothers have breast engorgement, a
hot compress treatment is given according to our hospital
guidelines. Mothers and infants are discharged if breast en-
gorgement improves and they have shown no complications.
Procedure and collection of material
This study is a randomized controlled trial. Randomization
was done using a computer-generated list with a block of five
methods. After the allocating sequence was generated, the
researcher enclosed herbal compress or hot compress in se-
quentially numbered sealed envelopes. These envelopes were
kept with the nurses who opened each envelope when a new
participant was recruited from mothers with breast en-
gorgement at the postpartum ward. Mothers with breast
engorgement must have no analgesics or nonsteroidal anti-
inflammatory drug (NSAID) use before the breast engorge-
ment treatment (6 hours at the least). Mothers were divided
by treatment into two groups: herbal and hot compress
groups. Each treatment was given only once and was started
within 30 minutes after diagnosis. Pain scores were assessed
immediately before and after breast engorgement treatments.
The demographic data collected include age, marital status,
educational level, income, occupation, route of delivery,
body mass index, breastfeeding experience, and the time of
the breast engorgement diagnosis. After 24 hours from
treatment, the adverse effects of herbal and hot compresses
were recorded in an adverse effects notation that was sealed
in envelope by the mothers and were collected by the treating
nurses. Differences in pain scores between the before and
after treatments were analyzed and compared between the
herbal and hot compress groups. The adverse effects enve-
lope was then opened and reported by the researcher.
Breast engorgement
Assessment of breast engorgement was graded according
to the criteria of Robson.1 The degree of breast engorgement
has a four-level scale. Grade 1: breast has minimal tender-
ness, minimal distension, and slight edema. Grade 2: breast is
somewhat painful, has moderate distension, and mild edema.
Grade 3: breast is very painful, has large distension, and
moderate edema. Grade 4: breast is extremely painful, has
marked distention, and severe edema. We recruited mothers
with grades 3 and 4 for this study.
Herbal compress
The herbal compress balls were prepared by the Pharma-
ceutical Department, HRH Princess Maha Chakri Sirindhorn
Medical Center, with proper manufacturing practices. The
herbal compress ball weighed 250 g and contained dried
herbs that included the following: Z. cassumunar Roxb. rhi-
zomes (90.5 g), C. longa L. rhizomes (18.2 g), Cymbopogon
citratus (DC) Stapf leaves and leaf sheaths (18.2 g), Acacia
concinna (Willd.) DC leaves (18.2 g), Tamarindus indica L.
leaves (54.3 g), Citrus hystrix DC peels (36.2 g), Blumea
balsamifera (L.) DC leaves (5.4 g), salt (3.6 g), and camphor
(5.4 g).
Before treatment, two herbal balls were steamed in a
stacked steamer for 20 minutes. Then, the first herbal ball was
wrapped with towels to protect the mother’s skin from burns
due to excessive heat. Next, the nurse gently touched and
rolled the herbal ball on the breast area with exception to
the nipple and areola areas. The contact time for each point
was *10 seconds. Then, the towel was unwrapped when the
herbal ball was sufficiently cool to apply directly to the skin.
The first herbal ball was replaced when the second was
lukewarm. The two herbal balls were alternately compressed
and alternately steamed until each treatment session was
completed. The total session duration was 20 minutes.
Hot compress
Before treatment, small towels were prepared and packed
as herbal balls. Two ball-like towels were steamed in a
stacked steamer pot for 20 minutes. Then, the first towel ball
was wrapped with a towel to protect the mother’s skin from
burns due to excessive heat. The nurse gently touched and
rolled the towel ball on the breast areas with the exception of
the nipple and areola. The contact time for each point
was *10 seconds. The towel was unwrapped when the towel
ball was sufficiently cool to put directly on mother’s skin. The
second towel ball was replaced when the first one was de-
tected to be lukewarm. The two towel balls were alternately
compressed and alternately steamed until each treatment
session was achieved. The total session duration was 20
minutes.
Inclusion criteria
The postpartum women who had deliveries without com-
plications (i.e., multiple pregnancies, preeclampsia, an-
tepartum hemorrhaging, and preterm labor) and who had
grade 3 or 4 breast engorgement were recruited. Mothers
had not been given any analgesics or NSAID drugs before
breast engorgement treatments for at least 6 hours. Their
infants had birth weights of more than 2,500 g and were born
without complications. The mothers had suffered no acute
postpartum hemorrhages and had no contraindications to
breastfeeding.
Exclusion criteria
Mothers whose infants were diagnosed with galactosemia
were excluded from this study.
 EFFECT OF HERBAL COMPRESS FOR BREAST ENGORGEMENT
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FIG 1. The flow diagram of partic-
ipants through the study.
Breast engorgement pain score
Pain levels from the breast engorgement were assessed by
use of a visual analog scale (VAS). The pain scale ranged
from a score of 0 (no breast pain) to 10 (severe breast pain) in
10-cm line. Postpartum mothers were asked by nurses to
place a line perpendicular to the VAS line at the points that
represent their pain intensity. After the mothers had marked,
using a ruler, the score is determined by measuring the dis-
tance on the 10-cm line between the ‘‘no breast pain’’ and the
mothers’ mark.
Sample size
We set a mean difference of 17% between the herbal and hot
compress groups from a pilot study of 20 cases. We used 0.05
of a error, a power of 0.95, and an effect size = 0.34. The
calculated sample size numbered 226 cases in each group. The
subjects were totaled with an additional 10% for data loss.
The total samples collected were 249 per group.
Ethical considerations
This study was approved by the Ethics Committee of the
Srinakharinwirot University, Faculty of Medicine, and reg-
3
istered with Thai Clinical Trials Registry (registration num-
ber TCTR20180208002).
Statistical analysis
Demographic data are reported in means and percentages.
We use the t-test to compare the mean of maternal ages,
income, body mass index, and pain scores between the
herbal and hot compress groups. The data regarding marital
status, education, occupation, route of delivery, and
breastfeeding experience were analyzed by chi-square. A
p-value less than 0.05 considered statistically significant.
Statistical analysis was performed using SPSS software
(version 23.0, SPSS, Inc.).
Results
The postpartum women who had enrolled in our research
project totaled 500 cases, 250 cases from each group. A flow
chart of the number of participants is shown in Figure 1.
Mothers were predominately married and high school grad-
uates or lower. The mean income was 23,988 bahts/month
(*769 U.S. dollars/month). The percentage of cesarean
sections was 57 and 59 in the herbal and hot compress groups,
respectively. The mean body mass index was within the
 4 KETSUWAN ET AL.

Table 1. Baseline Demographic Data of the Mothers

Mothers’ data Herbal compression group (n = 250) Hot compression group (n = 250) p
Age (years) 27.9 – 6.3 28.0 – 6.3 0.837
Marital status, n (%)
Married 241 (96.4) 241 (96.4) 1.000
Single 9 (3.6) 9 (3.6)
Education, n (%)
High school and lower 174 (69.6) 158 (63.2) 0.155
Bachelor’s degree and higher 76 (30.4) 92 (36.8)
Income (bahts/month) 23436.6 – 23826.7 24540.6 – 20702.7 0.581
Occupation, n (%)
Housewife or self-employed 112 (44.8) 119 (47.6) 0.590
Employee 138 (55.2) 131 (52.4)
Route of delivery, n (%)
Vaginal delivery 102 (40.8) 107 (42.8) 0.717
Cesarean section 148 (59.2) 143 (57.2)
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BMI (kg/m2) 26.7 – 4.6 26.0 – 4.8 0.086

Breastfeeding experience, n (%)
Yes 121 (48.4) 131 (52.4) 0.421
No 129 (51.6) 119 (47.6)
Time of breast engorgement diagnosis 25.9 – 7.7 26.7 – 6.3 0.726
(hours postpartum)
Breast engorgement grading 0.096
Grade 3 167 (66.8) 184 (73.6)
Grade 4 83 (33.2) 66 (26.4)
Baseline breast engorgement pain 6.9 – 1.6 5.8 – 2.4 <0.001
score before treatment
Age, income, BMI, time of breast engorgement, and baseline breast engorgement pain score data are expressed as mean – SD. Marital
status, education, occupation, route of delivery, breastfeeding experience, and breast engorgement grading are expressed as number
(percentage).
BMI, body mass index; baht, basic monetary unit of Thailand.

overweight ranges. There were no significant differences in Discussion

the demographic data between both groups except baseline
breast engorgement pain score. The details of the demo-
graphic data are shown in Table 1.
There were statistically significant differences in the pain
scores between both groups before and after treatment. The
details of pain scores before and after treatment are shown in
Table 2. There was a statistically significant difference be-
tween the two groups in the mean difference of pain scores
before and after treatment (Table 3).
All adverse effects recorded in the notes of both treatment
groups were collected (500 cases). There were two cases
(0.8%) with skin irritation in the herbal compress group and
no cases had shown this adverse effect in the hot compress
group. The skin irritation resolved without any additional
treatment at the 24-hour follow-ups.
Table 2. Pain Scores Before and After Treatment
Mean of VAS Before treatment After treatment p Herbal
Herbal compress 6.9 – 1.6 1.0 – 1.0 <0.001
Hot compress 5.8 – 2.4 2.8 – 1.9 <0.001
Pain scores in herbal and hot compresses are expressed as
mean – SD.
VAS, visual analog scale.
The demographic data of both groups were similar from
that expressed in randomization except baseline breast en-
gorgement pain score. These factors include mothers’ ages,
marital status, education, income, occupation, route of deliv-
ery, body mass index, and breastfeeding experience that can
affect breastfeeding practices and outcomes.7–11 Baseline
breast engorgement pain score in the herbal compress group,
higher than the hot compress group, might cause a higher
number of grade-4 breast engorgements. However, this dif-
ference was not statistically significant. We found that the ce-
sarean section rate was high in this study. The cesarean section
factor might be associated with breast engorgement as it delays
breastfeeding initiation and makes latching difficult.12 When
Table 3. Mean Difference Before and After
Treatment Between Herbal Compress
and Hot Compress Groups
Hot
compression compression
Variable group (n = 250) group (n = 250) p
Mean difference 5.9 – 1.8 3.1 – 3.0 <0.001
Mean differences of pain scores between two groups before and
after treatment are expressed as mean – SD.
 EFFECT OF HERBAL COMPRESS FOR BREAST ENGORGEMENT
the infant did not extract milk, stasis was more likely. However,
the association between cesarean section and breast engorge-
ment was not reported in previous studies.13 The body mass
index mean was within an overweight range. The weight might
also be associated with breast engorgement as it is associated
with delayed initiation of breastfeeding.10 The factors associ-
ated with breast engorgement should be investigated in further
studies.
There was a statistically significant difference between the
two groups in the mean difference of pain scores before and
after treatment. It showed that the herbal and hot compresses
could reduce pain from breast engorgement. This result is
consistent with the Cochrane Database of Systematic Review
of Mangesi and Zakarija-Grkovic; the hot packs could sig-
nificantly decrease breast temperature, engorgement, pain,
and discomfort at 5 and 30 minutes post-treatment.14 Herbal
compress treatments have been showed to significantly de-
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crease breast pain and decrease the pain scores more effec-
tively than hot compresses in this study. We believed that the
pain reduction of herbal compress was caused by the elevated
temperature and the herbs that were the components of the
herbal compress balls. Plai or Z. cassumunar Roxb. rhizomes,
C. longa L. rhizomes, and camphor had anti-inflammatory
and analgesic effects.3–5 The other components had relaxa-
tion effects as seen in aromatic volatile oils.6
The adverse effect of the herbal compress treatment was
skin irritation. The skin irritation might be caused by an al-
lergic reaction to some of the herbs used as components of the
herbal compress balls. However, it was rare and resolved
spontaneously and was not considered to be a serious com-
plication. The safety of herbal compress use during lactation
might be concerning as no active substances were investi-
gated or measured in the breast milk. However, herbal
compresses have been used for hundreds of years and is ac-
cepted for the analgesic and anti-inflammatory indications.
These indications include labor pain reduction and milk in-
duction.6 It is approved and listed in the Thai National List of
Essential Medicines.
The strength of this study is that it is a randomized con-
trolled trial. The definition of breast engorgement and the
methods of treatment have been clarified. Mothers reported the
adverse effects in sealed envelopes to decrease any bias. We
found that the high cesarean section rates and the mothers’
body mass index within an overweight range might have
contributed to breast engorgement. The association of these
factors with breast engorgement is a limitation of this study.
Further research is needed to evaluate any associative factors.
Besides, there is no long-term follow-up with regard to en-
gorgement; this is another limitation of the study and may be
the next step in assessing the effect of herbal compresses.
Conclusion
The herbal compresses can decrease breast engorgement
pain. The pain reduction after herbal compresses was greater
than was seen in hot compresses. There were no serious
complications after the herbal compress treatments.
Acknowledgments
Thanks to the HRH Princess Maha Chakri Sirindhorn Med-
ical Center and the Faculty of Medicine, Srinakharinwirot
University, for supporting our research.
5
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Pawin Puapornpong, MD
Department of Obstetrics and Gynecology
Faculty of Medicine
Srinakharinwirot University
62 Moo 7 Ongkharak
Nakhon Nayok 26120
Thailand
E-mail: pawinppp@yahoo.com