When we covered the story about four Frontier Airlines pilots who said their employer did not provide adequate accommodations for pumping breast milk, more than a few readers seemed to feel like the women just wanted an extra work break. "Bathroom breaks are necessary to ensure the pilot can still perform," a commenter said. "Breast pumping is not."
Au contraire, say women, lactation consultants and health care providers. The painful swelling of engorgement can lead to medical problems and reduce milk supply. And it can make it extremely hard to focus on the job. But many people don't know about it; even new mothers.
"When I had my first and started breast-feeding, I was completely unprepared for any of it. I knew nothing, not even what was normal," says Alissa Parker, now an international board certified lactation consultant in Ashland, Ky. She had her child after earning a master's in nursing as a pediatric nurse practitioner and working in primary care pediatrics for five years. "Breast-feeding education for health care providers is that weak."
She figures that most healthy breast-feeding women have experienced engorgement at least once outside of the immediate postpartum period. That could be because they were unable to pump at work, felt uncomfortable about breast-feeding in public or miscalculated the time they would be separated from their baby or a pump.
Engorgement immediately becomes stressful because it's like a "ticking time bomb," Parker says. "The main thought in your head is, 'How can I get this to stop; when can I pump or feed my baby?' "
And if a woman can't pump, breasts swell and become firm and painful. For Parker, engorgement felt like having two hot, sweaty bowling balls strapped to her chest. That's not unlike my description: like two boulders had been grafted to my chest tissue and magically hooked up to my nerves so that they radiated pain from the inside out. One light touch elicited a scream of pain — definitely more distracting than needing to pee.
"It felt like a toothache that was so bad I would have been headed for a root canal — with a second-degree sunburn to boot," Stephanie Palmieri of Fremont, Calif., told me on social media. And Meribeth Densmore in Santa Fe, N.M., said it was "like my boobs were about to explode."
The pain is often coupled with heat, leading some women to compare it to an actual burn.
"The pain is hard to describe. [My breasts] were sensitive to touch, like sunburn is, and a fairly permanent kind of burning ache set up on my chest, waxing and waning as they filled and emptied," said Madeleine Ware of Wellington, New Zealand. "I wouldn't want my pilot distracted by a burning feeling in her breasts, or hesitant to lean over to perform certain actions because of the risk of pain."
Melina Kolb of Alexandria, Va., described it as "hard lumps that burn and hurt" when she lifted her arms.
"When you are engorged, that is the only thing on your mind," Kolb said. "I could not think about anything else except my breasts and the fear of developing mastitis."
Mastitis is a bacterial infection that can result from engorgement. If a woman can't pump, engorgement can lead to plugged ducts, mastitis and even abscesses, sometimes requiring hospitalization and intravenous antibiotics. One study found that approximately 1 in 10 breast-feeding mothers experienced mastitis in the first month of breast-feeding — and that was in Nepal where far fewer women had to navigate work schedules or similar barriers.
An earlier study in Australia found 27 percent of breast-feeding mothers developed mastitis. Severe mastitis can develop into sepsis — blood poisoning — and require intensive care. Abscesses can require surgery and extra time for wounds to heal. These medical costs can mount up for the woman and her employer if she has employer-provided health insurance, and reduce work productivity.
Even if women don't develop these problems, trying to pump while already engorged can cause nipple trauma and bruising. Further, as few as four consecutive days of inadequate pumping breaks can reduce a mother's milk supply, Parker says, but it takes much longer to bring supply back up — if it ever comes back up.
Breast-feeding or pumping reduces the pressure, but unlike the relief of emptying a bladder, breasts remain tender, bruised and sore even after engorgement has passed.
The only way to reduce the likelihood of engorgement is to breast-feed or pump regularly — which gets us back to the story about the four Frontier pilots. They weren't just seeking a bathroom break. They were trying to maintain milk supply while not risking a potentially serious medical complication.