Engorgement and mastitis, easing painful and swollen breasts

Engorgement and mastitis are among the most common problems I am called about, and the advice has changed a great deal. Parents often tell me they have been told to massage hard and apply heat, which we now know can make things worse. Painful, swollen or hard breasts are common in the early weeks, and most of the time they settle with the right, gentler care. This guide explains engorgement and mastitis, how to ease them, and when to get medical help.

What engorgement is

When your milk comes in, usually around day two to four, your breasts can feel very full, firm, warm and tender. This is engorgement, and some of it is normal as your supply settles. It usually eases within a day or two.

Easing engorgement

• Feed your baby responsively and often, whenever they show feeding cues.
• Make sure your baby is well positioned and deeply attached, as this is how milk is removed most effectively. You can read more in Latch and nipple pain.
• If your breast is too firm for your baby to latch, soften the area around the nipple first, using gentle reverse pressure softening or by hand expressing a little milk.
• Use cold compresses, such as a cool flannel or a cold gel pack, between feeds to ease swelling and discomfort.
• Try gentle breast gymnastics, which are slow, light movements where you cup and gently lift and move your breasts, along with soft shoulder and arm circles. This encourages the lymph fluid to drain and helps settle the swelling, without the firm pressure of deep massage.
• Express only enough to feel comfortable. Fully emptying the breast tells your body to make more milk and can prolong the problem.
• Wear a supportive bra that is comfortable and not too tight.
• Ask your GP or pharmacist about pain relief such as paracetamol or ibuprofen, which are usually compatible with breastfeeding.

Blocked ducts and mastitis

Sometimes one area of the breast becomes firm, tender and discoloured. This sits on a spectrum, from a narrowed or blocked duct, through inflammation of the breast tissue, to a bacterial infection. Mastitis means inflammation of the breast. It often comes on quickly, with a hot, painful area, and it can make you feel unwell with flu-like symptoms, aches and a fever.

On pale skin that area usually looks red. On brown and Black skin it may look darker, purplish or browner than the skin around it, or show no colour change you can see at all. Heat, firmness, swelling and pain are the signs that hold true whatever your skin tone, so trust those rather than waiting to see redness.

Mastitis is not always caused by milk that is not draining well. It can also be an infection of the breast tissue, which sometimes enters through a cracked or damaged nipple. Most cases happen in the first six weeks, but mastitis can occur at any stage of breastfeeding.

Guidance on this has changed. Deep, firm massage and heat were once commonly advised, but they can worsen swelling and inflammation, so a gentler approach is now recommended.

What it was like when I had it

I had mastitis twice, and both times it took me by surprise, which is why I am careful never to tell anyone to wait and see how they get on.

The first time, I was travelling from London to Scotland with my baby. I had a big oversupply and I had been sitting in soggy breast pads all the way, with my baby strapped to my chest. I felt completely fine all day. Then we got on the plane and I felt shocking. I started shaking from my head to my toes, the kind of shivering you cannot stop, and I had to ask the flight staff for paracetamol. It was only a ninety minute flight and I have never been more grateful for that.

The next day I started on flucloxacillin, and I felt better within twenty four hours. The redness faded soon after. What I want people to notice is that I had no lump and no blocked duct at any point. I am fairly certain it came from bacteria on my nipple, sitting in wet pads I had not changed often enough.

What I did not realise at the time is that it had not really gone. The infection lay dormant after that course of antibiotics, and a month later it came back.

I was sitting feeding, perfectly comfortably, no problem at all, and it happened again out of nowhere. Twenty minutes earlier my breasts had been white. Now one was bright red. This time I had temperatures of thirty nine to forty degrees, the same uncontrollable shaking, and my blood results were abnormal. It behaved more like a cellulitis of the breast than a straightforward mastitis, so metronidazole was added alongside the flucloxacillin to treat it properly.

That is what I take from having had it. It comes on fast, it does not always announce itself with a lump, and feeling fine an hour ago means nothing. If you are shaking and you feel dreadful, that is not something to sleep on.

The other thing I learnt the hard way is that finishing a course of antibiotics is not the same as it being gone. If your symptoms come back, or they never completely settled, that needs looking at again rather than being treated as bad luck. Sometimes the antibiotic needs changing or something needs adding, and that is a conversation to have rather than another week of hoping.

It is also why I go on about breast pads more than anyone expects. Changing them often, so your nipple is not sitting in warm, wet milk, is a small thing that genuinely matters, particularly with an oversupply. There is more in Oversupply and a fast let-down.

Easing mastitis

• Take pain relief. Paracetamol and ibuprofen are the first-line treatment for mastitis and can be taken straight away. They ease the pain, and ibuprofen also helps to reduce inflammation. Both are usually compatible with breastfeeding.
• Keep feeding your baby as normal from both breasts. There is no need to stop, and your milk is safe for your baby.
• Feed or express only to comfort. Try not to empty the breast or add extra pumping, as this can increase both inflammation and your supply.
• Use cold compresses on the sore area between feeds to reduce swelling and pain.
• Rest as much as you can, and keep well hydrated.
• Use gentle, light touch only, and avoid deep or vigorous massage. A light stroke towards your armpit can help to move fluid.

When to see your GP

Contact your GP, or NHS 111 out of hours, if:

• You feel unwell with a fever or flu-like symptoms that do not improve within 24 hours.
• The affected area or the pain is spreading or getting worse despite the steps above.
• You have a cracked or damaged nipple that looks infected.
• You feel too unwell to cope.
• Your symptoms come back after a course of antibiotics, or never fully settled.

Treatment may include a course of oral antibiotics if there is a bacterial infection. Keep feeding while you take them, and finish the full course. If you are no better after two or three days, or it returns once the course has finished, go back rather than waiting. The antibiotic may need changing, or another one adding, particularly where the infection is behaving more like a cellulitis of the breast. Rarely, if you are very unwell or the infection is severe, you may need to be admitted to hospital for intravenous antibiotics, which are given straight into a vein.

How a consultation helps

If you keep getting engorged, or mastitis keeps coming back, that pattern usually has a reason, and finding it is what stops it happening again. When I see you I look at how your baby is positioned and attached and how well they are draining the breast, and I check whether an oversupply of milk is part of the picture. We then sort the cause, not just the flare-up, alongside the gentle self-care that keeps you comfortable. Caring for your breasts well matters too, and you can read more in Looking after yourself while breastfeeding.