Why advice to cease attempts at milk removal when engorgement is severe risks worsened outcomes

The advice to cease attempts at milk removal if the woman is having difficulty expressing milk or bringing baby on risks worsened outcomes for breastfeeding women and their infants.

Unfortunately, the Academy of Breastfeeding Medicine's Clinical Protocol #36 recommends cessation of attempts to remove milk when inflammation is severe and milk is not flowing. Under the headings Spectrum-wide recommendations c. Feed the infant on demand, and do not aim to “empty” the breasts, Clinical Protocol #36 states: “In some instances, in which the retroareolar region is so edematous and inflamed that no milk is expressible by infant breastfeeding or hand expression, the mother should not continue to attempt feeding from the affected breast during the acute phase. She can … return to feeding from the affected breast when edema and inflammation subsides.”

From the perspective of the NDC mechanobiological model, milk removal is critical to swift healing of breast inflammation, and to protection of a woman's milk supply post-inflammation. Ongoing skilful, gentle efforts to remove the milk are required, and will draw on clinical strategies such as

1. Reverse pressure softening. You can watch a video about this here

2. Gentle but skilful hand expression, including by an experienced clinician. You can watch a video about this here.

3. Fit and hold repair, including in side-lying, so that biomechanics are optimised and the infant is able to remove milk. You can find out about this starting here.

4. Use of upper safe doses of non-steroidal anti-inflammatories

5. Very gentle, self-administered movement of breasts using the palm of the hand (but not to cause pain), perhaps in a warm shower. You can find out about gentle movement of the breasts with the palm of a woman's own hand here.

It is very unlikely that milk will not be able to be removed, in time, with skilful assistance, support, and education.