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What You Need to Know about Pathologic Engorgement

Woman in white shirt holding breast in pain from pathologic engorgement.

In a previous post, I explained how physiologic engorgement normally occurs in all mothers who have given birth. Here, we’ll explore pathologic engorgement.

Definition and description

As the word pathologic implies, pathologic engorgement is not normal. It occurs when milk has not been removed from the breast in a timely manner. As a result, the breast becomes painfully overdistended. The milk is stuck.

Presuming that all the anatomical structures and endocrine functions are normal, physiologic engorgement occurs in all breastfeeding mothers. It starts during the first few days, and fully resolves about 10-14 days; maybe less. That’s not the case with pathologic engorgement.

Pathologic engorgement might never occur in a breastfeeding mother.

Moreover, it can and often does happen later in lactation in situations where there’s a long interval between one feeding (or pumping) and the next. For example, when mothers go back to work, and wait “just a few minutes more” and those “few’ minutes turn into more than a few.

Risk factors for pathologic engorgement

This isn’t an exhaustive list, but I’d say these are the most common situations that herald the development of pathologic engorgement.

  • Start up: Delayed initiation of breastfeeding.
  • Continuation: Large intervals of time (more than 3 hours) between episodes or successful suckling or expressing. Similarly, if the breast is not fully drained during those sessions, pathologic engorgement can follow. (Understand, the breast is never truly “empty,”)
  • Supplementation: Taking in formula means the baby is not taking in the mother’s milk. Which basically means, the breast continues to fill with milk, but the milk is not removed.
  • Abrupt discontinuation: A sick baby or a sick mother can result in longer intervals between feedings, or even a complete discontinuation of breastfeeding. The aim here is to at least express enough milk for comfort.

Signs and symptoms of pathologic engorgement

I’ve seen severe cases of pathologic engorgement.

I’m talking about cases that were so bad that I can see them in my mind’s eye, just writing this post. I’m talking about cases where the breasts were as hard a board (no exaggeration). I can immediately call to mind situations where the baby was crying from frustration and the mother was crying from excruciating pain.

Not all cases of pathologic engorgement are quite that bad. But generally, the signs and symptoms you’ll see include the following:


Sure, the breasts are enlarged when a mother is lactating, and especially so even with physiologic engorgement. But in a pathologic engorgement, the enlargement is much greater.


In physiologic engorgement, the swelling, enlargement, and tenderness is generally confined to the area of the breast itself. Not so in pathologic engorgement. In pathologic engorgement, the swelling and distended tissue is more widespread.   


Breasts are usually firm in physiologic engorgement. But in pathologic engorgement, breasts can become hard, not just firm. The contour of the breast is often situated so that it is at a complete right angle to the chest.

Shiny skin

Whereas in physiologic engorgement, the skin looks stretched and perhaps reddened, it’s downright taut and shiny in pathologic engorgement. It’s tough to explain, but if you ever see it, I’m willing to bet that you’ll recognize this very characteristic difference. 

Nipple contour

The shape and protrusion of the nipple is altered substantially. This makes it difficult for the baby to latch. Often, expressing a little milk – just enough to soften the areola, can improve latch.

Complications of unrelieved engorgement

Any or all of these situations are possible. Meaning, these are possible, but not all.

Whereas physiologic engorgement involves distension and some degree of discomfort, unrelieved engorgement results in severe breast distention and pain.

I’ve already mentioned the mother’s pain and the baby’s difficulty latching. But this can lead to something else: Cracked nipples, and a lower milk supply. The lower milk supply occurs because the baby is not draining the breast, and the FIL mechanism kicks in.

Mothers who have had augmentation mammoplasty with implants should be aware that severe engorgement should be especially careful to avoid severe engorgement. Severe engorgement can decrease pressure involution and subsequent reduction in milk supply.

Engorgement must be relieved. Stay tuned for part 3 where I describe prevention and treatment of engorgement.

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