A 28-year-old primigravida delivers a healthy 3.2 kg male infant vaginally at term. On postpartum day 3, she reports severe bilateral breast pain, engorgement, and a low-grade fever (38.2°C). On examination, both breasts are tense, swollen, and warm to touch, with no localized fluctuance or erythema. The infant is feeding well and has good latch. What is the most appropriate immediate management?

Explanation

## Diagnosis: Breast Engorgement with Physiologic Inflammation **Key Point:** Postpartum breast engorgement typically occurs on days 2–5 and is characterized by bilateral breast swelling, tenderness, and low-grade fever (often <38.5°C) in the absence of localized infection or fluctuance. ### Pathophysiology Engorgement results from: 1. Rapid increase in milk production 2. Venous and lymphatic congestion 3. Interstitial edema 4. Mild inflammatory response (accounts for low-grade fever) ### Management Strategy | Intervention | Rationale | |---|---| | Frequent milk removal (8–12 times/day) | Reduces intramammary pressure and prevents milk stasis | | Warm compresses before feeding | Promotes vasodilation and milk letdown reflex | | Cold compresses between feeds | Reduces edema and inflammation | | NSAIDs (ibuprofen 400 mg TID) | Analgesic + anti-inflammatory; safe during breastfeeding | | Continue breastfeeding | Prevents complications (abscess, mastitis); infant is feeding well | **Clinical Pearl:** Engorgement is self-limited and resolves within 24–48 hours with proper emptying. Fever in engorgement is due to inflammatory mediators (cytokines), not infection, and does NOT warrant antibiotics. **High-Yield:** The absence of localized erythema, fluctuance, or systemic toxicity rules out infectious mastitis or abscess. Bilateral symmetric involvement is typical of engorgement, not infection. **Warning:** Do NOT discontinue breastfeeding—this worsens engorgement and increases risk of mastitis. Antibiotics are unnecessary and may harm the infant.