by Mary Francell, Washington, USA
Based on a talk by Kay Hoover presented at the LLLI 65th anniversary conference
Having a robust milk supply usually ensures that a baby thrives and grows. However, sometimes an oversupply or a rapid milk ejection reflex (MER) can cause problems for both mother and baby. At the LLLI 65th anniversary online conference, long-time La Leche League Leader and IBCLC Kay Hoover presented a session on this important topic.
Infants who are dealing with a rapid MER often gulp loudly at the beginning of a feed, choke or gag, pull off and cry, make clicking sounds (although there are several other causes for clicking) and may even cause nipple pain by pressing their tongue on the nipple to slow the milk flow. Because they get too much milk too fast, these babies may be fussy and gassy or have nasal congestion from milk in their sinuses. However, not all nursing parents who have a rapid MER also have an oversupply. Distinguishing between the two is important. Giving information on reducing the milk supply could be detrimental to breastfeeding if a mother simply has a rapid MER along with a normal volume of milk.
If there IS an oversupply, in addition to the already mentioned challenges, these characteristics may also be present in the baby:
- gains weight very rapidly
- may feed only from one breast at a time
- may nurse for a short time either frequently or infrequently
- will often not breastfeed for comfort
- may have green, frothy or watery stools
- may have a diaper rash from frequent bowel movements
Infants dealing with an oversupply or a rapid MER may spit up often and sometimes find nursing so unpleasant that they begin refusing to feed after several months and stop gaining weight.
In addition to worries about an unhappy baby, a mother with this condition may believe she does not have enough milk or that something she is eating does not agree with her child. She may also experience a painful MER, large amount of leaking, repeated plugged ducts and mastitis, and burning nipple pain. Leaders can counsel parents on these issues. If someone is experiencing significant leaking, temporary direct pressure on the nipple can help, or they may need to use a newborn diaper (nappy) as a breast/chest pad. Breast shells or other milk collectors can make leaking worse, although a mother may want to use them to release milk if her breasts are overly full. Very full breasts may also benefit from expressing just enough milk to stay comfortable and applying cold compresses (maximum 20 minutes) between feeds.
When a Leader is supporting a parent with repeated plugged ducts or mastitis often seen with abundant milk, it is important to discuss helpful measures such as gentle massage, warm compresses and limiting saturated fats. If a mother experiences recurrent plugged ducts, she may also benefit from the addition of lecithin to her diet. In addition, a parent experiencing pain with blanching (whitening) of the nipple after nursing may be experiencing vasospasms from baby compressing the nipple to slow milk flow. Comfort measures for vasospasms include applying dry heat after baby releases the nipple (or simply pressing a hand over it), massaging blood back into the nipple and holding baby skin to skin.
Several nursing techniques have been found to help mothers with a rapid MER. It is important to keep the baby’s head higher than their bottom, which is why holding baby in upright and semiprone positions often work best. The mother can also compress and hold her breast or press down with the flat or side of her hand, in order to block some milk ducts during letdown. It can also be useful to hand express a small amount of milk before feeds, burp baby frequently during a nursing session and hold baby upright after eating. In some cases, it may be necessary to use a nipple shield to slow down the sprays of milk.
For babies who are receiving too much milk, comfort measures include not using elastic waist bands on their clothing, not bringing baby’s legs up to the stomach when burping, rolling baby to the side to change diapers (nappies) rather than lying on their back and using a pacifier occasionally to satisfy sucking needs.
Other strategies can be added if the parent has an oversupply, although these should wait until baby is at least three weeks of age to allow the breasts to self regulate the milk supply. One strategy is to start by using one breast per feed once a day and gradually increase until all feeds are one sided – most of the time, keeping baby on one breast for two to three hours is enough to diminish supply to a manageable level. In rare instances, it may be necessary to breastfeed from one side for up to six hours before switching or to pump both breasts fully one time before beginning one sided nursing. In all cases, it is important to carefully monitor for plugged ducts and it may sometimes be necessary to remove a small amount of milk to soften a full breast.
If the management techniques above have been used for a number of weeks without relief, the nursing parent may need to speak to their primary care practitioner about possible medications to reduce supply. Some providers may suggest considering pseudoephedrine (a decongestant with a side effect of reducing milk supply) or even low-dose birth control pills for a few days. It may also be helpful to rule out medical causes that could contribute to an oversupply, such as a pituitary tumor, prolactinoma, postpartum thyroiditis or Celiac disease.
When experiencing an oversupply, it may also be helpful to cut back on foods or herbs that are purported to increase supply, such as oatmeal or fenugreek tea. Parents may sometimes ask their supporting Leader about things like applying cabbage leaves to their breast/chest or ingesting large amounts of parsley, peppermint or sage. It’s important to let these parents know that there is currently no research supporting the efficacy of these approaches.
Due to an oversupply, some babies experience lactose overload, which used to be known as foremilk/hindmilk imbalance. This is usually caused by an infant ingesting mostly lower fat/higher lactose milk, which moves through the gut too quickly to be fully digested. It often results in excess gas, abdominal pain, frequent liquid or explosive stools and a red rash around the anus. Lactose overload can usually be resolved by letting the baby finish the first breast without moving to the other side after a set period of time and reducing the milk supply. There is also anecdotal evidence that gentle breast massage before feeding can help release more fat into the milk ducts.
Oversupply and rapid MER can be challenging issues for mothers and nursing parents. La Leche League Leaders can help by distinguishing between the two conditions and sharing information about these conditions and strategies to help resolve them.
Kay Hoover has been an LLL Leader for 50 years and an IBCLC since 1985. She is the mother of three sons and grandmother of three grandsons. During her time as a Leader with LLL of Eastern Pennsylvania, she served as a District Advisor, Area Conference Supervisor and Area Professional Liaison. Kay is co-author of The Breastfeeding Atlas, soon to be available in its 7th edition, and she has worked in a variety of settings, including training health professionals and lactation consultants. She is a frequent speaker at national and international conferences.
Mary Francell and her husband Howard are the parents of three adult children. She has been an LLL Leader for over 25 years and is a contributing editor for Leader Today. Mary is an International Board Certified Lactation Consultant (IBCLC) in private practice in Bellingham, Washington, USA and currently serves as Associate Area Professional Liaison for LLL of Washington, USA.
Banner Image: Courtesy Ken Tackett