Which response would the nurse provide for a client who reports painful engorgement of the breasts at a postpartum office visit?

Breast engorgement is a painful condition affecting large numbers of women in the early postpartum period. It may lead to premature weaning, cracked nipples, mastitis and breast abscess. Various forms of treatment for engorgement have been studied but so far little evidence has been found on an effective intervention.

This is an update of a systematic review first published by Snowden et al. in 2001 and subsequently published in 2010. The objective of this update is to seek new information on the best forms of treatment for breast engorgement in lactating women.

We identified studies for inclusion through the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2015) and searched reference lists of retrieved studies.

Randomised and quasi‐randomised controlled trials.

Two review authors independently assessed trials for eligibility, extracted data and conducted 'Risk of bias' assessments. Where insufficient data were presented in trial reports, we attempted to contact study authors and obtain necessary information. We assessed the quality of the evidence using the GRADE approach.

In total, we included 13 studies with 919 women. In 10 studies individual women were the unit of analysis and in three studies, individual breasts were the unit of analysis. Four out of 13 studies were funded by an agency with a commercial interest, two received charitable funding, and two were funded by government agencies.

Trials examined interventions including non‐medical treatments: cabbage leaves (three studies), acupuncture (two studies), ultrasound (one study), acupressure (one study), scraping therapy (Gua Sha) (one study), cold breast‐packs and electromechanical massage (one study), and medical treatments: serrapeptase (one study), protease (one study) and subcutaneous oxytocin (one study). The studies were small and used different comparisons with only single studies contributing data to outcomes of this review. We were unable to pool results in meta‐analysis and only seven studies provided outcome data that could be included in data and analysis.

Non‐medical

No differences were observed in the one study comparing acupuncture with usual care (advice and oxytocin spray) (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.13 to 1.92; one study; 140 women) in terms of cessation of breastfeeding. However, women in the acupuncture group were less likely to develop an abscess (RR 0.20, 95% CI 0.04 to 1.01; one study; 210 women), had less severe symptoms on day five (RR 0.84, 95% CI 0.70 to 0.99), and had a lower rate of pyrexia (RR 0.82, 95% CI 0.72 to 0.94) than women in the usual care group.

In another study with 39 women comparing cabbage leaf extract with placebo, no differences were observed in breast pain (mean difference (MD) 0.40, 95% CI ‐0.67 to 1.47; low‐quality evidence) or breast engorgement (MD 0.20, 95% CI ‐0.18 to 0.58; low‐quality evidence). There was no difference between ultrasound and sham treatment in analgesic requirement (RR 0.98, 95% CI 0.63 to 1.51; one study; 45 women; low‐quality evidence). A study comparing Gua‐Sha therapy with hot packs and massage found a marked difference in breast engorgement (MD ‐2.42, 95% CI ‐2.98 to ‐1.86; one study; 54 women), breast pain (MD ‐2.01, 95% CI ‐2.60 to ‐1.42; one study; 54 women) and breast discomfort (MD ‐2.33, 95% CI ‐2.81 to ‐1.85; one study; 54 women) in favour of Gua‐Sha therapy five minutes post‐intervention, though both interventions significantly decreased breast temperature, engorgement, pain and discomfort at five and 30 minutes post‐treatment.

Results from individual trials that could not be included in data analysis suggested that there were no differences between room temperature and chilled cabbage leaves and between chilled cabbage leaves and gel packs, with all interventions producing some relief. Intermittent hot/cold packs applied for 20 minutes twice a day were found to be more effective than acupressure (P < 0.001). Acupuncture did not improve maternal satisfaction with breastfeeding. In another study, women who received breast‐shaped cold packs were more likely to experience a reduction in pain intensity than women who received usual care; however, the differences between groups at baseline, and the failure to observe randomisation, make this study at high risk of bias. One study found a decrease in breast temperature (P = 0.03) following electromechanical massage and pumping in comparison to manual methods; however, the high level of attrition and alternating method of sequence generation place this study at high risk of bias.

Medical

Women treated with protease complex were less likely to have no improvement in pain (RR 0.17, 95% CI 0.04 to 0.74; one study; 59 women) and swelling (RR 0.34, 95% CI 0.15 to 0.79; one study; 59 women) on the fourth day of treatment and less likely to experience no overall change in their symptoms or worsening of symptoms (RR 0.26, 95% CI 0.12 to 0.56). It should be noted that it is more than 40 years since the study was carried out, and we are not aware that this preparation is used in current practice. Subcutaneous oxytocin provided no relief at all in symptoms at three days (RR 3.13, 95% CI 0.68 to 14.44; one study; 45 women).

Serrapeptase was found to produce some relief in breast pain, induration and swelling, when compared to placebo, with a fewer number of women experiencing slight to no improvement in overall breast engorgement, swelling and breast pain.

Overall, the risk of bias of studies in the review is high. The overall quality as assessed using the GRADE approach was found to be low due to limitations in study design and the small number of women in the included studies, with only single studies providing data for analysis.

Although some interventions such as hot/cold packs, Gua‐Sha (scraping therapy), acupuncture, cabbage leaves and proteolytic enzymes may be promising for the treatment of breast engorgement during lactation, there is insufficient evidence from published trials on any intervention to justify widespread implementation. More robust research is urgently needed on the treatment of breast engorgement.

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Cabbage cream for breast engorgement during lactation