Postpartum Congestion (Engorgement, Congestion, or Engorgement)

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Occurs during the Lactogenesis II stage, which is defined as the beginning of copious production of human milk. This typically occurs within the first 48-72 hours after childbirth, although it can be delayed due to retained placenta, cesarean delivery, hormonal conditions, and delayed milk emptying when the baby does not latch and breasts or chest are not emptied manually or with a pump. The birth of the placenta results in a rapid decrease in progesterone, activating the action of prolactin. Engorgement is characterized by bilateral congestion (in both breasts or chest) and is related to fluid retention and increased blood in the mammary glands due to these hormonal changes. The onset of lactation is hormonal. When adequate emptying is done, approximately from day 9 until weaning, production is regulated by demand, when stimulation signals cells to produce the amount of milk that is needed. By emptying, we refer to direct breastfeeding or chestfeeding or manual or pump expression. By use, we refer to both the amount of milk consumed and the amount pumped.

 

Management:

Engorgement can be uncomfortable as it is a rapid process and involves inflammation. The best management is on-demand breastfeeding or chestfeeding, either by latching the baby or expressing with hands. When congestion is uncomfortable or painful, the use of cold compresses to reduce inflammation and therapeutic lymphatic massage is recommended, meaning a gentle massage that pushes fluid towards the armpit. In some cases, over-the-counter anti-inflammatory medications can be used if the breastfeeding or chestfeeding person is not allergic. Analgesics are not usually helpful for engorgement. In case the congestion is so marked that the nipple does not protrude, the softening reverse pressure technique can be used, where gentle pressure is applied with fingers around the nipple on the areola to push lymphatic fluid towards the breast chest and help soften the nipple. A gentle hand expression can also be done to relieve congestion.

 

Usually, the use of a breast or chest pump is not recommended during immediate postpartum since colostrum is produced in small amounts and can be lost in the pump's tubing and cups. Additionally, hands are the most effective tool for emptying the breasts or chest and understanding their changes. Also, a pump can lead to excessive production at this stage of establishing lactation. However, when a person is not comfortable touching their breasts or chest or knows that deferred breastfeeding or chestfeeding (exclusive pumping ) is needed due to the separation of the baby and the breastfeeding or chestfeeding person, a condition that prevents the baby from breastfeeding or chestfeeding properly from the breast or chest, or by decision not to breastfeed or chestfeeding directly from the breast or chest, the use of a pump may be useful in providing the necessary stimulation for adequate production. In these early days, it is recommended to empty by hand or pump only to meet the baby's on-demand needs, not to establish a massive milk bank.

 

It is important to emphasize that the use of heat during engorgement is not recommended. Heat can cause blood vessels to swell, and milk may not flow. Although sometimes a "warm shower or bath" can relax the breastfeeding or chestfeeding person and activate oxytocin, allowing very hot water to fall on the breasts or chest can be counterproductive. You may have read or heard that hot or warm compresses are applied in the immediate postpartum. This information is outdated. With proper engorgement management, it should not progress to mastitis, which is discussed below.

 

Mastitis

The protocol for managing mastitis has changed drastically in recent years. While it was previously considered an isolated infection, it is now considered part of a continuum of inflammation of the ducts, alveoli, and breast or chest tissue that can include mild pain, a lump or inflammation in an isolated part of the breast or chest, more widespread inflammation, or even "cellulitis" or an infected abscess. Unlike engorgement, it can occur at any stage of breastfeeding or chestfeeding and is usually unilateral (in one breast or chest), although it can sometimes occur bilaterally. There can be multiple factors causing breast or chest inflammation, from hyperlactation (overproduction), insufficient emptying (for example, missing a feeding or baby having poor suction), tight clothing or bras causing trauma, dysbiosis (imbalance of good bacteria), or other external factors causing inflammation.

 

The mastitis continuum is as follows:

1. Ductal narrowing or inflamed duct: Characterized by mild or intense pain and red or darker color in an isolated part of the breast or chest. Formerly called "plugged duct" or "clogged duct" because it was thought that milk stagnated in a duct and that this stagnation could lead to infection. Therefore, outdated protocols recommended "unclogging" techniques such as frequent breastfeeding or chestfeeding, the use of heat, and intense massage, among other things. Understanding that milk stagnation is actually due to inflammation and narrowing of the ducts and is not the cause of mastitis, we now know that these recommendations could actually worsen the initial condition.

2. Inflammatory mastitis: When ductal narrowing does not resolve, alveoli and tissue around the ducts can become inflamed, resulting in more generalized discomfort that includes erythema (inflammation and redness or darkening) more widespread throughout the breast or chest, edema (inflammation and fluid retention), mild fever, body aches, chills, tachycardia, and fatigue.

3. Bacterial mastitis: When inflammatory mastitis does not resolve properly, it can result in a non-contagious bacterial infection that may require antibiotic intervention to counteract the bacteria. It is characterized by symptoms of inflammatory mastitis with a prolonged higher fever and intensified discomfort. There are some protocols that recommend specific strains of probiotics instead of the use of antibiotics.

4. Phlegmon: The body may try to isolate the infection in a liquid mass within the inflamed tissue. This can result in a hard and warm mass, especially if manipulated excessively.

5. Abscess: When bacterial mastitis that formed the phlegmon does not resolve, this mass can become infectious (cellulitis) and require drainage and the use of more specific antibiotics.

 

Other anomalies in the mastitis continuum or inflammatory breast or chest conditions that are not postpartum congestion or mastitis:

1. Galactocele: A benign cyst filled with milk. If it fills excessively, it may need drainage. Normally, it should not cause any inflammatory condition unless it becomes infected.

2. Infected galactocele: A worsening galactocele that is not treated or is manipulated with intense massages can result in infectious mastitis. In these cases, antibiotics and drainage may be needed, but breastfeeding or chestfeeding is not discontinued.

3. Milk bleb: Occurs when there is a white spot on a part of the breast or chest where there is inflammation, often on the nipple. It looks like a pimple. It is more painful at that specific point. It is related to milk stagnation due to an inflamed duct but is a symptom and not the cause of the infection. It should not be squeezed or emptied with a syringe.

4. Thrush (candidiasis): There is no evidence that candidiasis is anything more than cutaneous (superficial on the skin), even itching on the skin of the areola or nipple could be eczema. When experiencing intense pain within the ducts, it has been proven that this can be bacterial inflammation, and it is not a fungus.

5. Intraductal papilloma: A small, non-cancerous growth that occurs in the mammary ducts, which can cause bleeding during breastfeeding or chestfeeding or blood in expressed milk. Depending on where the growth is, a lump may be felt. Generally, the lump does not continue to grow, and bleeding only lasts a few days.

6. Ectasia of the mammary ducts: More common in menopause, where the ducts become inflamed and/or infected. They should be evaluated and treated by a doctor.

7. "Rusty pipe" syndrome: Some people express milk with an orange or reddish color, as if they were rusty or dirty pipes, sometimes compared to brick dust. This usually happens in the first weeks of breastfeeding or chestfeeding and without other inflammation, it is not considered dangerous for the breastfeeding or chestfeeding person or their infant.

8. Inflammatory intraductal cancer: Not the most common type of breast or chest cancer, although it is a type of cancer. When there is mastitis that does not improve, particularly if it is in the same place, when there is abundant blood in the milk, or when there is skin that seems to be orange, all could be signs of cancer and require specialized medical intervention.

 

Symptoms of the mastitis continuum:

Isolated pain or tenderness in one part of the breast or chest, swelling, pain and a feeling of warmth, fever and general discomfort, a hard and warm mass, a red or dark mass with a white spot or very inflamed.

 

Prevention:

Ensure proper latch, correct structural pathology in the baby's mouth such as restrictive ties, on-demand breastfeeding or chestfeeding (neither excessive nor skipping feedings or emptying), avoid tight clothing that inflames the breasts or chest. Daily consumption of probiotics containing strains of L. fermentum or, ideally, L. salivarius when recurrent. There is mixed evidence on the use of soy or sunflower lecithin for milk viscosity for prevention.

 

Treatment:

Continue feeding at the breast or chest or emptying on demand, use cold on the isolated painful area or on the congested area, consume anti-inflammatory medications to reduce inflammation and analgesics for pain, and therapeutic massage to move lymphatic fluid toward the armpit. Rest and hydration. Avoid the use of heat, frequent breastfeeding or chestfeeding or pumping, and intense massage or manipulation of the bulging area. Do not attempt to "unclog" or use positions directing the baby's chin toward the inflammation or breastfeeding or chestfeeding on all fours or with gravity. There is mixed evidence on the use of soy or sunflower lecithin for milk viscosity as a treatment therapy. The use of cabbage leaves or potato poultices probably has an anti-inflammatory effect due to the cold and not because of a property that can penetrate the skin and reach internal tissue. Castor oil compresses cannot penetrate the tissue either. There is no evidence that a particular diet specifically contributes to mastitis, although there are some foods that can cause inflammation or imbalance normal flora. When there is a milk bleb, it should not be attempted to be "popped" either with hands or a sterile needle or drained with a syringe, as although it may provide initial relief, this can cause greater inflammation and worsening of mastitis. A milk bleb can be treated with prescribed topical steroids.

 

If the fever lasts more than 24 hours, consult a doctor about the use of antibiotics. There is also empirical evidence on the use of specific probiotic strains. For this reason, it is important to consult with a doctor knowledgeable about breastfeeding or chestfeeding, typically avoiding the emergency room since unfortunately, some emergency room physicians may not be prepared in human lactation and may recommend discontinuing breastfeeding or chestfeeding based on incorrect concepts such as bacteria in the milk or antibiotic incompatibility, which are not true. The abrupt cessation of breastfeeding or chestfeeding can worsen inflammation and cause weaning. In almost no circumstance should breastfeeding or chestfeeding be discontinued, although in the case of very intense pain, it may be necessary to empty the breast or chest with hands instead of breastfeeding or chestfeeding the baby, but the emptying should not be increased. In the case of an abscess, it may be necessary to empty it and use intravenous antibiotics. Milk from the breast or chest should continue to be emptied, and this milk can be consumed. In cases where mastitis is related to hyperlactation (overproduction), some reduction in feeding frequency under supervision may relieve symptoms in the long term.

In the case of recurrent mastitis, structural problems with the baby's latch or mouth should be evaluated, manage hyperlactation if it exists, provide guidance on outdated techniques such as heat, massages, and frequent emptying, and carry out a bacterial culture of the milk to rule out antibiotic-resistant pathogens to ensure that the antibiotic is appropriate. An ultrasound can also be performed to rule out granulomatous mastitis (inflammation of the breast or chest not related to breastfeeding or chestfeeding ) or inflammatory breast or chest cancer when the infection always occurs in the same place on the breast or chest.

 

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