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Breast engorgement, unavoidable?

Breast engorgement; “automatic” and unavoidable?

One of the most irritating and well established breastfeeding myths, repeated even by knowledgeable parents and health professionals; “Milk comes in on Day 2 to Day 4, and is an automatic process dictated by the change in circulating hormones in mother’s body”. “Whatever you do within the first couple of days after birth, milk comes in for all women”. This misconception cannot be more untrue.
Yes, it is true that the removal of the placenta at birth reduces the amount of circulating progesterone, which changes the balance with prolactin and estrogens, so that more milk gets to be produced. But good breastfeeding practices during the first couple of days of life, effective exclusive optimized breastfeeding on cues from the first hour of life, will also determine how much oxytocine and prolactin will be produced in both mother and baby, how many prolactin receptors will proliferate over the crucial first days of lactation, and will also cause frequent emptying of the breast, so removing a protein present in human milk called inhibiting factor of lactation, which inhibits milk production. On the opposite side, a mother subjected to all the wrong breastfeeding practices from birth (ie no breastfeeding for the first 2 hours of life, restricted frequency and duration of breastfeeds, not feeding on demand but on schedule, no rooming in, bad positioning and attachment of the baby to the breast, giving routinely breastmilk substitutes without a medical reason, giving routinely feeding bottles causing nipple confusion) will, as a result, have much less amounts of prolactin and oxytocine in her body, form less prolactin receptors in her breast, and retain much of the inhibiting factor of lactation in her breasts, all resulting in a bad start leading to an abnormal second stage in lactation (galactopoiesis 2). So, you can facilitate the normal process of milk coming in. Or you can affect it with major blows.
That’s why in the vast majority of natural term unmedicated births or home births, mothers experience a timely not painful fullness of their breasts from Day 2 or 3 after birth and do not experience painful or sustained breast engorgement. This is also why mothers that have breastfed successfully and for long a first child usually have their milk for their second baby coming in early, with baby swallowing and drinking as soon as Day 1 or 2 of life. And this is why studies of Michel Odent more than 2 decades ago have shown us that the amount of colostrum produced by a mother during the first two days after birth is not the same, but depends significantly by birth conditions and early practices; Mothers after natural births with minimal interventions tend to have on average double the amount of colostrum produced even on Day 1 (80ml), compared to mothers after a routine heavily medicalised hospital birth (40ml). This is also the reason why painful breast engorgement is a well-documented common condition seen in US hospitals (and in Greek hospitals), but, on the contrary, the condition is rarely seen or even unheard of in hospitals in other parts of the world, hospitals with less birth medicalization and more baby friendly practices. Most women should not experience painful milk coming in, but this is often a result of bad birthing and breastfeeding practices.
We can distinguish between 3 abnormal outcomes of the period of “milk coming in”’;
1. Painful and sustained breast engorgement
Seen on Day 3 to 5 after birth, I see it commonly in cases of heavily medicalised births – common in Greece. Cesarean sections before signs of labour, early cesarean sections at 37 and 38 weeks of gestation, birth induction before 39 weeks gestation, administration of large amounts of IV fluids to the mother, administration of large amounts of synthetic oxytocine to the mother etc. Also seen commonly as a result of not up to date, unscientific breastfeeding practices from birth (ie undue separation of mother and baby, no guidance on positioning and attachment resulting in ineffective sucking, restrictive and arbitrary schedules of feeds, restricting time on the breast etc). Mother has painful milk retention and oedema. Inappropriate or inadequate management at this stage – commonly seen in Baby Unfriendly Hospitals – will result in more and sustained engorgement for more than 24 hours, painful and traumatized nipples, giving more breastmilk substitutes, baby continuing to lose weight, baby jaundiced etc, all putting lactation into vicious cycles resulting in premature weaning. The most severe consequence of serious engorgement is long-term and I see it too often; after 1-2 days of inadequately treated painful oedema inside the maternity ward, mums come home and suddenly experience their breasts to feel “empty” and baby not content, struggling at the breast. This of course is the result of a counter-reaction of breast cells, which, during the time of breastmilk retention, get the message to stop producing any more milk, so that the breast doesn’t “burst”. This will save the breast, but will have a detrimental effect on lactation, will definitely reduce milk supply over the next days and weeks.
2. Delayed milk coming in
Mother feels her breast empty for several days after birth, and starts to feel fullness on Day 5 or 6, commonly several days after coming home. This is most commonly a result of bad breastfeeding practices in the hospital, with restricted inefficient feeds and improper positioning and attachment of baby to the breast. Heavily medicalised birth plays its negative role too, and other times it is due to a heavily medicated baby from birth or an ill baby or one with severe jaundice, ineffective sucking or tongue tie. Problematic consequences in this scenario is significant weight loss of the baby, sleepy baby, jaundice requiring management, and supplementation with bottles and substitutes overall giving breastfeeding a bad start.
3. Milk never coming in
Perhaps the most serious scenario, it is usually the result of a gross combination of improper birthing and breastfeeding practices, particularly if these are faced by women who had a primary risk factor for ineffective breastfeeding, and required full breastfeeding optimization from birth in order to do well. These may be mothers with reduced breast tissue, plastic surgery on the breasts, polycystic ovary syndrome, severe untreated hypothyroidism, or pituitary problems. It can also be a result of incomplete removal of the placenta after birth.

Lactation is at no stage an “automatic” process. It is a learned skill for the mother and, in a routine birthing environment doing all the outdated, unscientific and wrong things, it is immediately surrounded by multiple obstacles impeding its crucial start. Its pitiful that most mothers who fail to come up to their breastfeeding goals are wrongly guided to the impression that their body didn’t have “the capacity” to make milk for their babies or that breastfeeding is a difficult, almost impossible task. The truth is that in most cases, their intention to breastfeed was failed and violated by an unhealthy birthing system pushing every mother systematically away from the breast and into bottles and formulas, putting obstacles and walls of bad practices at every step, during the time of crucial start. Walls of misconceptions, misleading information and false breastfeeding education – just imagine yourself having your first ever driving lessons and the teacher encouraging you to start the car at 100 miles per hour and drive on the highway before you get to understand any road signs. This is what happens every day with women and breastfeeding; bad advice, bad guidance, bad start and working against a stream of bad practices leading to bottle formula feeding.
Breastfeeding people should stop saying to mothers that milk will come in no matter what. It is not an automatic process but is largely dependent on correct practices from the first minutes of life. Effective, exclusive breastfeeding on cues from birth is likely to give mothers a normal outcome after 2 or 3 days, which is breast fullness. On the contrary, heavily medicalised or early or forced births, undue separation of mother and baby and bad practices – with not teaching correct positioning and attachment to be of paramount importance – will likely result in pains and problems a few days later, which in turn will establish all the wrong vicious cycles that usually finish lactation off for an individual mother.

Stelios Papaventsis MBBS MRCPCH DCH IBCLC 2014

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