Reverse Pressure Softening Technique for Engorgement

Breast fullness, engorgement and swelling around the nipple can make it difficult for a baby to attach comfortably to the breast. Reverse pressure softening (RPS) is a technique that uses gentle, sustained fingertip pressure to soften the tissue around the nipple and areola. It may be helpful when firm tissue results from milk engorgement, oedema, or a combination of the two (Cotterman, 2004; Berens and Brodribb, 2016).

The aim is to make the areola more pliable so that a baby can take the breast into their mouth more easily. Reverse pressure softening does not remove milk from the breast. Instead, it temporarily reduces resistance in the tissue around the nipple, potentially making attachment easier and supporting effective milk transfer.

Understanding breast engorgement and areolar oedema

Breast engorgement and oedema can occur together, but they are not the same process.

Engorgement commonly occurs as milk production increases after birth. This process, known as secretory activation, involves the onset of copious milk secretion following hormonal changes after birth. Breasts may become fuller, heavier and warmer as this process progresses. For some women, swelling is substantial enough to make the areola firm and attachment difficult (Pang and Hartmann, 2007; Berens and Brodribb, 2016).

Oedema is swelling caused by excess fluid accumulating in the spaces between tissues. When fluid accumulates around the nipple and areola, the tissue can become tight and less pliable, even when milk volume alone does not explain the degree of firmness (Cotterman, 2004; Kujawa-Myles et al., 2015).

To picture oedema, think about swollen feet or ankles during late pregnancy. Sometimes, pressing gently on a swollen area leaves a temporary indentation. This is known as pitting oedema and illustrates how fluid can accumulate within body tissues. Breast oedema does not always pit, however, and breast tissue is different from the tissue around the ankles. The comparison simply helps illustrate the concept of fluid within the tissues; it does not mean that breast oedema will look or feel the same.

A breast may therefore feel firm because of milk fullness, tissue oedema, or both. Reverse pressure softening may help soften the area around the nipple, but the wider feeding situation and the cause of the swelling still need to be considered.

Why engorgement develops

Milk production increases after birth

In the first days after birth, secretory activation brings an increase in milk production. Some breast fullness is a normal part of this transition, although excessive or uncomfortable engorgement can make feeding difficult (Pang and Hartmann, 2007; Berens and Brodribb, 2016).

Intravenous fluids during labour and birth

Intravenous fluids given during labour and around birth may contribute to postpartum fluid retention and breast oedema in some women. A small observational pilot study involving 17 women found greater breast oedema among participants who received intravenous fluids than among those who did not. The researchers concluded that larger studies were needed to investigate the relationship further. The findings cannot establish that intravenous fluids caused the swelling or determine a volume at which fluids become excessive (Kujawa-Myles et al., 2015).

This is a possible contributing factor, rather than an explanation for every case of breast engorgement or oedema.

Milk is not being removed effectively or frequently enough

When a baby cannot attach effectively, feeds are missed or milk removal is less frequent than the baby needs, milk may accumulate and discomfort can increase. If attachment is difficult because the areola is swollen, this can create a cycle: swelling makes attachment harder, while ineffective milk transfer may contribute to continuing fullness.

It is important to assess feeding and milk transfer rather than assuming that frequent feeding alone will resolve every problem. If there are concerns about swallowing, the amount of milk being transferred or the baby’s weight, prompt assessment is appropriate.

Further information is available in Signs of poor milk transfer in your baby at feeds.

Oversupply and excessive expression

Producing more milk than a baby needs can contribute to persistent fullness and discomfort. Regularly expressing substantially more milk than is needed may also stimulate further milk production in some circumstances. The approach to oversupply should be individualised, because abruptly reducing milk removal can create other problems and may not be appropriate for everyone (Johnson et al., 2020).

See Increasing breast milk production for further information about milk production and the importance of understanding the reason for a supply concern before making changes to feeding or expressing.

Why reverse pressure softening can help

The tissue beneath and around the areola needs to be sufficiently pliable for a baby to attach deeply. When this tissue becomes swollen and firm, the nipple and areola may be more difficult for a baby to grasp. This can contribute to attachment difficulties, nipple discomfort and ineffective milk transfer (Cotterman, 2004).

Reverse pressure softening uses gentle, sustained pressure around the base of the nipple to temporarily move some of the swelling away from the immediate areolar area and further into the breast tissue. The Academy of Breastfeeding Medicine describes the technique as particularly useful when breast oedema affects the areola (Berens and Brodribb, 2016).

The technique may also be useful when milk engorgement contributes to firm tissue around the nipple. Its purpose is to make the area around the nipple softer so that a baby can attach more easily and transfer milk effectively. It does not, however, remove milk from the breast or resolve every cause of breast fullness.

The evidence for treatments for breast engorgement varies in quality. Cotterman (2004) described the rationale and technique for reverse pressure softening, while the Cochrane review of treatments for breast engorgement concluded that the evidence for many interventions was uncertain (Zakarija-Grkovic and Stewart, 2020). RPS is therefore a practical technique supported by clinical guidance, but it should not be presented as a treatment guaranteed to work in every situation.

How to perform reverse pressure softening

Reverse pressure softening is usually performed immediately before a breastfeed, when the area around the nipple feels firm, tight or swollen. It can also be used before hand expressing or using a breast pump if swelling around the nipple is making milk removal difficult.

The technique should be gentle and comfortable. It is not a breast massage, and the intention is not to squeeze milk out of the breast.

Step 1: Get comfortable

Wash your hands and find a comfortable position. If your baby is ready to feed, keep them close so that you can offer the breast as soon as the tissue has softened.

Step 2: Position your fingertips

Place the pads of two or three fingers from each hand around the base of your nipple, positioning them in the area where your baby’s chin will rest against your breast in the feeding position you are about to use. Your fingers should be close to the nipple, rather than further away towards the outer breast.

This helps you soften the area of the breast where your baby’s chin will make contact during feeding.

Step 3: Apply gentle inward pressure

Press the pads of your fingertips gently and steadily back towards your chest wall. The pressure should be directed inwards, rather than squeezing the nipple or pushing milk towards it.

Keep the pressure comfortable. You should not need to use force, and the technique should not cause pain.

Step 4: Hold the pressure

Maintain the gentle inward pressure for around one to three minutes. Cotterman (2004) describes applying steady pressure to the subareolar tissue to reduce resistance and make the area more pliable.

The aim is to temporarily soften the tissue around the nipple and areola. The amount of time required will vary according to the degree of swelling and how your breast responds.

Step 5: Release and check the area

Slowly release your fingers and gently check whether the area around your nipple feels softer. The areola may feel less taut and easier to compress between your fingers.

If it remains very firm, repeat the technique gently. You do not need to continue until the whole breast feels soft; the immediate aim is to soften the tissue around the nipple sufficiently to help your baby attach.

Step 6: Offer your baby the breast

Offer the breast promptly while the area is softer. Support your baby in the feeding position you have chosen and allow them to open their mouth widely before bringing them towards the breast.

Look and listen for signs of swallowing, and observe whether your baby is feeding actively and transferring milk. If your baby repeatedly slips off, cannot maintain attachment, or is not swallowing effectively, further support may be needed.

You can read more about breastfeeding latch and positioning and recognising infant swallowing during feeds.

Step 7: If your baby still cannot attach

If the breast remains too firm for your baby to attach, gentle hand expression may remove a small amount of milk and soften the breast further. The intention is to make attachment easier and relieve uncomfortable fullness, rather than to repeatedly express large volumes in an attempt to empty the breast.

If your baby cannot feed effectively, seek timely support to assess milk transfer and ensure that your baby is receiving enough milk. You may need an individual plan for feeding and expressing while the underlying difficulty is addressed. Guidance on how to express breast milk may also be helpful.

Preventing engorgement

Not all breast fullness can be prevented, particularly the normal changes that occur as milk production increases after birth. However, recognising difficulties early and getting appropriate support may help prevent engorgement from becoming more severe.

• Follow your baby’s feeding cues and seek support if feeding is difficult or feeds are repeatedly missed.

• Check that your baby can attach comfortably and transfer milk effectively.

• If your baby cannot attach because the areola is firm or swollen, try reverse pressure softening before the feed.

• If needed, hand express gently to soften the breast or provide milk for your baby, following an individual feeding plan.

• Avoid routinely expressing extra milk beyond what is needed, unless this is part of a plan to establish or maintain milk production.

• If you suspect oversupply, seek individual advice before making substantial changes to feeding or expressing.

• Seek support early if your breasts remain very full, feeding is painful, or your baby is not feeding effectively.

An appropriately qualified infant-feeding professional, such as an International Board Certified Lactation Consultant (IBCLC), can help assess attachment, milk transfer, feeding frequency and any need for expressing. Further information about what an IBCLC is and how they support infant feeding is available in the Information Library.

When to seek further support

Reverse pressure softening is a practical technique to help with swelling around the nipple, but it should not be used as a substitute for assessment when symptoms are persistent or worsening.

Seek prompt clinical advice if you develop a hot, red or increasingly painful area of the breast, fever, chills or flu-like symptoms. These can be signs of mastitis or another condition requiring assessment. Also seek feeding support promptly if your baby is unable to attach, is not swallowing effectively, is unusually sleepy at feeds, has fewer wet nappies than expected, or there are concerns about weight gain.

Do not attempt to manage a worsening breast problem solely by repeatedly applying pressure, massaging firmly or expressing more and more milk. Management should be guided by the symptoms, the feeding situation and clinical advice where needed (Mitchell et al., 2022).

References

Berens, P. and Brodribb, W. (2016) ‘ABM Clinical Protocol #20: Engorgement, Revised 2016’, Breastfeeding Medicine, 11(4), pp. 159–163. Available at: https://doi.org/10.1089/bfm.2016.29008.pjb.

Cotterman, K.J. (2004) ‘Reverse pressure softening: A simple tool to prepare areola for easier latching during engorgement’, Journal of Human Lactation, 20(2), pp. 227–237. Available at: https://doi.org/10.1177/0890334404264224.

Johnson, H.M. et al. (2020) ‘ABM Clinical Protocol #32: Management of Hyperlactation’, Breastfeeding Medicine, 15(3), pp. 129–134. Available at: https://doi.org/10.1089/bfm.2019.29141.hmj.

Kujawa-Myles, S., Noel-Weiss, J., Dunn, S., Peterson, W.E. and Cotterman, K.J. (2015) ‘Maternal intravenous fluids and postpartum breast changes: A pilot observational study’, International Breastfeeding Journal, 10, article 18. Available at: https://doi.org/10.1186/s13006-015-0043-8.

Mitchell, K.B. et al. (2022) ‘Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022’, Breastfeeding Medicine, 17(5), pp. 360–376. Available at: https://doi.org/10.1089/bfm.2022.29207.kbm.

Pang, W.W. and Hartmann, P.E. (2007) ‘Initiation of human lactation: Secretory differentiation and secretory activation’, Journal of Mammary Gland Biology and Neoplasia, 12(4), pp. 211–221. Available at: https://doi.org/10.1007/s10911-007-9054-4.

Zakarija-Grkovic, I. and Stewart, F. (2020) ‘Treatments for breast engorgement during lactation’, Cochrane Database of Systematic Reviews, (9), CD006946. Available at: https://doi.org/10.1002/14651858.CD006946.pub4.