To provide health care providers with appropriate information to assist the woman to manage an oversupply of breast milk and its possible complications.

To provide effective prevention and treatment of full breasts, oversupply, blocked ducts and engorgement during lactation.

Full breasts: common and considered normal when the milk supply first establishes between day three and seven postpartum when Lactogensis II occurs. Mothers should be reassured that the supply will adjust to the infants intake over the next week or so.

Oversupply: at the onset of lactation, supply commonly exceeds demand but usually adjusts to the baby's demands over the first few weeks. Oversupply refers to continued excessive milk production over and above the infant's needs.

Blocked ducts: presents as a breast lump which may be a tender and sometimes reddened area. If the blockage causes milk to build up behind the blockage, causing inflammation of the surrounding breast tissues, breast inflammation may worsen and there is a risk of developing mastitis.

Engorgement: The breast is overfilled with both milk and tissue fluid. Venous and lymphatic drainage are obstructed, milk flow is hindered, and the pressure in the milk ducts and alveoli rises. The breasts become swollen and oedematous. This may occur when a baby does not sufficiently drain the breast or breastfeeds are restricted. The breasts are hard, distended and painful, the skin is stretched and shiny and superficial blood vessels may be distended. The ‘letdown’ reflex may also be inhibited.

Differentiating between full breasts and engorgement

Causes of blocked ducts, engorgement and oversupply

• Inadequate breast drainage

  • Poor attachment

  • Sleepy baby

  • Inappropriate use of nipple shields

  • Excessive use of a pacifier instead of feeding the baby

• Delayed or missed feeds (e.g. supplementary feeds, maternal medical condition)

• Constricting clothing

• Pressure in one area - holding breast too tightly during feeds, such as when the mother is holding the breast away from the baby's nose.

• Blocked nipple pore (white spot).

Prevention of blocked ducts, engorgement and oversupply

• Early and unrestricted breastfeeding (or expressing if mother and baby are separated) from birth 8-12 times in 24 hours.

• Correct positioning and attachment.

• Avoid constrictive clothing and bras. However, some women will need the support of a bra, ensure that it is not to tight, suggest a singlet or loose crop top as an alternative.

• Removing the bra completely during feeds may assist in adequate breast drainage by relieving any restriction.

• Avoid long intervals between feeds

• Feed from the first breast until it feels well drained before offering the second. Alternate the 'starting' breast every time a new feed is commenced

• Avoid pacifiers, teats and non- medically indicated formula supplementary feeds.

Management of Blocked Ducts

Women should be advised to check breasts often to identify any blocked ducts and to begin treatment as soon as any blockage is noticed. Management should follow the principles of prevention as outlined above. Additionally, women should be advised to:

• Empty the affected breast by feeding frequently or expressing.

• Apply warmth to the affected area before and during feeds.

• Apply gentle circular massage over the affected area during feeds, and whilst showering or bathing.

• Alternate feeding positions. If able, point the baby's chin towards the blockage, this may help relieve the blockage.

• If a lump is still present after the feed, expressing with an electric breast pump may assist with drainage

• Application of cold to the affected area for 5-10 minutes after feeding may reduce inflammation

• Administer analgesia for comfort if required. Consider paracetamol and an anti-inflammatory (eg. ibuprofen).

• Observe a full feed ensure good positioning and attachment, assess milk transfer and breast drainage,

• Seek medical advice if the blockage has not begun to clear in 8-12 hours or if flu-like symptoms appear. NOTE: If the lump remains red after drainage with an electric pump and/or flu like systems are present, suspect mastitis.

Management of Full Breasts / Oversupply

Management of uncomplicated breast fullness or oversupply should follow the principles of prevention as outlined above. Additionally, women should be advised to:

• Soften the areola before feeds by expressing a small amount of milk or apply reverse pressure softening. This will ensure deep attachment and prevent nipple trauma. See reverse Pressure Softening heading below or appendix 3.

• Continue to demand feed, imposing no restrictions on length of time at the breast. Ensure that adequate drainage of breast is occurring each feed.

• Alternate feeding positions to facilitate breast drainage.

• Allow milk to drip from one side while feeding from the other.

• Only offer the second breast if the first breast has been well drained.

• Express the second side for comfort if necessary. Express only enough milk to ease pain or discomfort.

• Apply warmth to breasts prior to feeding to assist with milk flow and cold after feeding to provide relief.

• Check breasts after feeding for lumps and blocked ducts. If there are lumps then advise the woman to follow the blocked duct management.

• Gently massage the breasts under the shower, allow milk to flow out spontaneously.

• Analgesia such as paracetamol or ibuprofen if required

• For oversupply which does not respond to conservative measure above, block feeding may be suggested - refer to Appendix 1 "Too Much Milk"

Management of Engorgement

If breast fullness is not managed properly and the breasts are not effectively drained, engorgement may result. Prevention and management of engorgement should include all of the measures outlined above. Additionally, women should be advised to complete the Full Breasts Regime as follows:

1. Feed the baby on one side only

   • Express the same side by hand or pump after the feed, if necessary until the breast is drained.

   • Express the second side for comfort if necessary. Express only enough milk to ease pain or discomfort.

   • Avoid excessive expressing which will only increase supply further

2. Next feed, repeat step 1 on the opposite side.

3. Continue to feed one side only at each feed, utilising the other measures listed until the supply settles down.

• Breasts should only be expressed to empty once in a 24 hour period.

• Once the fullness/engorgement has settled down advise the mother to start offering both sides again, allowing the baby to determine length of feeds.

• Any milk expressed can be stored for later use if required.

• Educate all breastfeeding women about signs and symptoms of mastitis and advise to seek early medical treatment if suspected.

Reverse pressure softening (RPS) (See appendix 3)

• Reverse pressure softening can be used immediately before attaching the baby to the breast

• It may reduce peri-areolar oedema by moving interstitial fluid deeper into the breast away from the areola.

• The technique can be demonstrated using a cloth breast.

• The mother should wash and dry her hands first

• Using all five fingertips, the mother applies steady, gentle inwards pressure over the areola at the base of the nipple for 1-2 minutes.

• Alternatively the flat of the fingers is used to exert gentle inwards pressure over the entire areola.

• As soon as the pressure is released, the mother should bring baby quickly to the breast while the areola is less oedematous.

Follow up support

• Provide women with the BHS consumer pamphlet "Full Breasts" on discharge. see Appendix 1.

• Ensure women are aware of how to obtain help with breastfeeding problems following discharge (e.g. Australian Breastfeeding Association, Breastfeeding Support Service at BHS and Parent Place)

• Ensure adequate clinical handover to the Domcare and/or MCHN service so timely follow up can occur.