Breast engorgement occurs when the breasts are overfilled with milk and swollen, causing them to feel firm, tender, and painful. This can occur 3 to 5 days after delivering a baby, due to the onset of copious milk production (called primary breast engorgement), or at any time during the postpartum period when milk supply exceeds milk removal (called secondary breast engorgement). Strategies to manage and prevent engorgement are important because this condition increases the risk for breastfeeding problems like mastitis, clogged ducts, latching difficulties, infant feeding refusal, and premature cessation of breastfeeding.^[1]

When the breasts are engorged with milk and swollen, some common signs and symptoms appear in one or (more often) both breasts. The breasts can feel firm, tender, tight, painful, warm, and even lumpy. They will look larger, can be uneven or lopsided, and the skin covering them may appear shiny (due to being stretched) and have more visible veins. The swelling sometimes extends to the armpit or across the sternum and can also affect the nipples, making them firm and flat (or even inverted).^[2] Systemically, a mildly elevated body temperature may be present.^[3] These signs and symptoms can ebb and flow, remain constant, or progressively worsen with time.^[4] It is considered normal to experience some degree of breast engorgement in the first week after giving birth.^[5]

Breast engorgement is a clinical diagnosis that is made based on the presenting signs and symptoms.^[6] There is no test or imaging needed to make the diagnosis. If symptoms worsen or a fever develops, it is important to seek medical attention because breast engorgement can precede mastitis, clogged ducts, and other more serious conditions (like a breast abscess).^[3]

Most of the treatments for breast engorgement can be done at home and are centered around effective removal of milk through frequent (but not excessive) breastfeeding or pumping with proper technique. Medical management usually isn’t required, especially for self-limiting cases of primary engorgement. Over-the-counter pain relievers, such as ibuprofen and acetaminophen, can be taken at the appropriate dose to reduce symptoms and improve comfort. These medications are safe to take while breastfeeding.^[5] Antibiotics are not appropriate for breast engorgement, although they may be used to treat some cases of mastitis.

There is no evidence to support the use of oral supplements in the treatment of breast engorgement, but there are studies on the use of supplements to increase or decrease breast milk production, as found on the lactation page.

Sunflower lecithin is commonly used in the context of breast engorgement to prevent clogged milk ducts by making breast milk “less sticky”. However, there are no controlled trials to support this claim. Similarly, probiotics, specifically Lactobacillus salivarius and Lactobacillus fermentum, are sometimes used during breast engorgement to prevent mastitis, but high-quality evidence for this practice does not yet exist.^[7][8]

Diet, including fluid intake, is unlikely to affect breast engorgement, and there are no studies linking diet to the presence or absence of breast engorgement. The volume of milk that a lactating parent produces is primarily driven by the amount of milk that is removed from the breasts,^[9] not by the dietary choices of the parent.^[10]

Frequent (but not excessive) removal of breast milk is the primary treatment for breast engorgement, which means either the infant or a pump must effectively drain milk from the breasts. If breastfeeding, there are some simple techniques to help an infant achieve better feeds from an engorged breast and thus treat the condition. Manual expression of small amounts of milk prior to beginning a feed can soften the breast and help the infant latch onto the nipple more easily. Just remember to keep the amount of expressed milk small because overstimulation will worsen the problem. Reverse pressure softening, pressing into the chest wall with 2 fingers on each side of the nipple, can also help an infant latch on by pushing fluid away from the nipple. If the engorgement is causing a strong let down (ejection of milk), breastfeeding in a reclined position can slow the flow of milk and improve infant feeding.^[5][3]

Comfort measures are another important aspect of treating breast engorgement. One of the most common methods of reducing pain from engorgement is the use of cold compresses for 15 to 20 minutes between feedings. The compress can be an ice pack, a bag of frozen vegetables, cabbage leaves, or an herbal compress.^[1] Heat, applied via a warm shower or warm pack, is sometimes used to facilitate milk removal; however, heat should be limited to only a few minutes immediately prior to a feeding because heat increases blood flow and can worsen breast swelling. Breast massage, acupuncture, and ultrasound therapies have also been used to treat breast engorgement, but there is limited evidence on their efficacy. Of the three methods, gentle massage is the most promising for symptom relief.^[5] Additionally, wearing a well-fitting bra that is supportive but not overly tight can reduce discomfort.

Primary breast engorgement is caused by hormonal shifts that cue the production of copious amounts of milk, and these shifts are called lactogenesis II or the second stage of milk production. During this stage, there is a rapid drop in progesterone and a rise in prolactin, cortisol, and insulin, which stimulate breast milk to “come in” and replace colostrum (the “first milk”).^[11] This sudden increase in milk production and interstitial fluid volume causes breast swelling and the signs and symptoms of engorgement. When no complications are present and feeding techniques are effective, it is a self-limiting condition that resolves within the first week postpartum as milk production regulates to match infant demand.^[1]

Secondary breast engorgement occurs later in the postpartum period when there is a mismatch between milk production and milk removal.^[3] There are a wide variety of reasons why this might happen, some related to the lactating parent, some to the infant, and some to both. Examples include a hormonal imbalance in the parent that increases milk production (like hyperthyroidism), pumping too frequently and stimulating excessive milk production, breastfeeding difficulties (like poor latch or positioning), and decreased infant feeding (maybe due to weaning, an infant sickness, or the infant sleeping for longer periods of time at night). Identifying the underlying issue is integral to finding the appropriate treatment.^[12]