What is engorgement and how does it dial down your milk production?

What does engorgement look and feel like from the outside?

Engorgement is generalised inflammation of your milk-making breasts. Often both breasts are involved, but occasionally just one. Engorgement occurs along a spectrum of severity. Somewhere between one-third and two-thirds of new mothers experience engorgement.

A woman's milk 'comes in' between three and five days after the birth. The physical signs of your milk coming in occur about a day after transitional milk replaces colostrum in your breasts. Transitional milk has much higher lactose and low sodium levels compared to colostrum.

You can find out about your milk coming in here.

When your milk comes in, you might experience hot, tight and swollen breasts, which are tender. Some health professionals distinguish between what they call physiological engorgement and the engorgement of breast inflammation. However, the difference can't really be properly defined. Engorgement is best just described as generalised inflammation of the whole breast, on a spectrum of inflammation from mild to severe.

What is the evolutionary task of engorgement?

Engorgement in the days after birth can be thought of as an overshoot or temporary excess in initial milk synthesis, since most women are biologically primed to produce milk for twins or multiple babies. Our production then downregulates, due to mechanical backpressures and microscopic inflammatory processes, which may be extensive enough to cause visible and generalised inflammation.

Aching muscles, fever and even rigour may accompany a severe engorgement – but this doesn’t mean that you have an infection. This is just at the severe end of the spectrum of breast inflammation.

It does mean that you need to pay attention to the seven steps, here.

If your milk supply is much more than your baby needs in these early days, you'll need to find a balance between removing milk from your breasts to keep your breasts safe from a localised mastitis, and allowing some persistent backpressure or fullness which will dial down your supply. Only you can experiment with this to know how to keep your breasts safe.

What is happening on the inside of your breasts if they are engorged?

Engorgement is caused by an inflammatory response to high milk pressure in your milk glands and ducts. High backpressures of milk trigger inflammatory cascades. You can find out about this here. As a result

1. The smallest blood vessels which bring nutrients into your breast, known as capillaries, dilate to quickly bring in white cells, the immune cells which clear away the bi-products of inflammation. When capillaries are dilated up in an area of the body, the overlying skin appears red or pink, and the area is warm and tight or swollen.

2. Proteins leak from between the cells lining the tiny veins known as venules, which then results in more fluid being drawn into the stroma or connective tissue by defusion, which results in increased pressures in the stroma. This interstial fluid results in increased pressures upon the milk ducts.

3. Lymphatic capillary dilation is triggered by the increased interstitial fluid and increased stromal pressures. The lining cells of the lymphatic capillaries are anchored by little filaments to the surrounding connective tissue inside your breast. These filaments tug the lining cells apart when the pressure rises in the stroma or connective tissue. This means that fluid and other immune cells and molecules seep into the lymphatic vessels very easily once the surrounding tissue is inflamed. Any pressure on the breast is likely to compress these lymphatic vessels shut, but inflammation naturally opens them up and draws the fluid into them.

Most lactiferous ducts are immediately behind the nipple, in a three centimetre radius, so engorgement in the area of the areola is mostly caused by tightly filled superficial milk ducts and dilated capillaries and venules, not by fluid in the connective tissues.

Engorgement can make it hard for you and your baby to get in sync

Engorgement, particularly if it is severe when your milk comes in, can result in

• Localised areas of inflammation (commonly referred to as mastitis). You can find out about mastitis here.

• Low milk production which doesn’t meet your baby’s needs. You can find out more here.

• You feeling as if breastfeeding is impossible, or even that you need to wean. This is an understandable response to what can feel like an out-of-control situation. I hope that you might hang in there, find good help, and experiment. You could find it helpful to read Amarissa's story, here.

Profound self-compassion is called for, as you do what seems best in your own unique situation.

Is it possible to prevent engorgement?

Intravenous fluids during the birth only make you more likely to have engorgement if you’ve received enough fluids to result in swelling of your lower limbs too.

The best way of preventing engorgement when your milk comes in is to

• Offer frequent flexible breastfeeds (here)

• Offer generous skin-to-skin opportunities (here)

• Resolve underlying clinical problems like breast tissue drag (here) or the spacing out of feeds.

Try to avoid engorgement if you are weaning

Once your supply is established, engorgement typically comes about because you’ve had trouble removing enough milk or have been spacing out feeds, which of course women may find they need to do for a range of reasons – including as a result of coping with nipple pain.

Or you might have an older baby or child and are now trying to wean when you suddenly find your breasts are engorged.

If engorgement has resulted from weaning, it is a sign that you need to decrease milk removal more slowly from your breasts. Weaning does involve letting your breasts run rather full, since this is what turns down the supply. If you don't wish to put your child to the breast, it's important to remove enough milk to protect you from a localised mastitis, through either hand expression or some light pumping.

Does medication help with engorgement?

Anti-inflammatory medications such as ibuprofen may have a role if you have seriously painful engorgement when your milk comes in.

If you've been exclusively pumping, and have accidentally driven your supply up far above your baby's needs, your first step is to gradually dial the supply down by letting your breasts run full - slowly and safely, so that you don't tip your breasts into a mastitis.

Othertimes, you might be trying to wean but again, have such a generous supply that you find yourself in cycles of engorgement and then mechanical milk removal. The remedy is to make very slow changes as you let your breasts run full, but keep them safe.

Occasionally a woman has such a generous milk supply - so far above her baby's caloric needs - that she is almost constantly dealing with engorgement. This is a rare but distressing situation, which may benefit from medication. Use of an oral contraceptive pill containing oestrogen, or a low dose of cabergoline can break the cycle and help dial down milk production, but allow ongoing breastfeeding. If you are in this situation, you would need to seek the support of your GP.