The Trials and Tribulations of Forceful Letdown and Oversupply

Forceful let-down and oversupply are nearly synonymous. Can there really be too much liquid gold? As someone who has personally experienced oversupply and its sequelae with both my children, I am here to tell you the costs out weigh any benefit of a freezer packed with frozen breastmilk. Oversupply is accompanied by a range of issues for both mother and infant that can take all the joy out of breastfeeding sometimes leading to early weaning.

What does forceful let-down look like?


Forceful let-down is when a mother’s milk ejection reflex overwhelms the baby. Baby will frequently:

  • Cough, gag, splutter, choke during feeds
  • Bite down during feeds
  • Pull on and off at the breast, especially during letdown
  • Have a shallow latch sometimes making clicking sounds during feeds
  • Refuse to nurse
  • Become agitated during feeds. Feeds are not restful events but instead consist of lots of squirming, kicking or general unrest. Baby is sometimes labeled as a “greedy feeder.”
  • Have frequent green watery stools
  • Become diagnosed with infant reflux or colic

Forceful let-down causes generalized breastfeeding disfunction adding to the anxiety and confusion already felt by breastfeeding mothers. These babies often seem to dislike nursing. The mother will often attribute this to something she is doing wrong or conclude her infant simply “prefers a bottle.” It can also cause discomfort while nursing as baby tries to cope with the fast flow of milk by biting down to stanch the flow or come on and off the breast. For the mother who does not reach out and find support, many give up and quit breastfeeding prematurely. Forceful let-down and oversupply can be managed. It is lack of understanding and experience that leave many mothers feeling like there are no options.

Too much for baby


Beyond impairing the breastfeeding process at it’s most basic level, these babies are often gassy colicky babies. I do not like the term colicky because I think it is too often used as a passive label instead of trying to find the root of why a baby has long inconsolable crying spells. Yet, it is a term most people can relate to when trying to describe a generally unhappy baby.

One of the reasons these babies tend to be uncomfortable is because they swallow a lot of air during feeds while they are trying to cope with the fast flow of breastmilk. This is known as aerophagia and is generally the result of a shallow latch. As a coping mechanism, these infants cope with overflow by coming on and off frequently to allow time to swallow and come up for air. Too much swallowed air can give the infant gas and exacerbate infant reflux symptoms.

It was also thought that foremilk/hindmilk imbalance was a contributing factor to infant GI upset. Foremilk/hindmilk imbalance will actually be a separate post you can review in the near future. Briefly, breastmilk composition changes during a breastfeed. It was understood that early in the feed, breast milk tends to be thinner and more sugary. This is known as the foremilk. As the feed progresses, the milk’s fat concentration increases. This milk is known as the hindmilk. This over simplification of how our body regulates milk composition throughout a feed and really throughout each day does not adequately portray how to ensure baby gets enough milk fat in a day. Coaxing the baby to feed longer does not ensure an increased intake of hindmilk. There is much debate on this topic but the general consensus is that this is looking like an antiquated view and may not be the culprit behind the infants GI upset.

More likely than not, the origin of much of baby’s discomfort is that forceful let-down exacerbates symptoms of infant reflux.   When a baby eats and swallows large amounts of air, the contents are prone to come back up. Most will eventually outgrow this proclivity as mom’s milk supply streamlines and baby’s esophageal sphincter matures and becomes more proficient at keeping stomach contents where they belong. For others, managing mother’s oversupply is only one piece of the puzzle.

Oversupply does not cause reflux; it exacerbates it. Reflux is usually a continuum of issues in which oversupply is only a link in the chain.  Many providers have noticed a correlation between mothers who have oversupply and infants with a sensitivity to milk proteins (another factor for many refluxers). In addition, many mother’s of refluxers have oversupply. There is no formal research to link the two.  Is there a causation effect?  More research is needed to say conclusively but it is reported that many mother’s with oversupply that remove dairy from their diet see an improvement in infant symptoms.  More to come on this topic…

Too Much for Momma


Oversupply can lead to a variety of problems for the mother as well. Because there is an abundance of milk and the infant is at times resistant to nurse and fully drain the breast, some mothers find themselves painfully engorged. Persistent engorgement leads to an increased risk of clogged ducts, abscess, thrush, and mastitis (more to come on these issues).   There can also be nipple trauma associated with the baby’s shallow latch.  All of these are painful conditions that can ultimately cause many women to wave the white flag and give up breastfeeding their infant.

Many find the cycle of feeding followed by crying to be the proverbial final straw.  Some infants end up refusing to breastfeed or become seemingly angry feeders. Mothers often start feeling a lot of anxiety associated with breastfeeding knowing that each feed will be followed by a crying deluge. In addition, these couplets struggle with continuation of breastfeeding because sessions are not harmonious. Baby is on and off the breast kicking and struggling during the feed. All the on/off leaves mom and infant covered in milk by the end of a feed. It is an exhausting pattern leaving these mothers feeling isolated if they are exclusively breastfeeding. It becomes nearly impossible to breastfeed “on the go.” These mothers find themselves limited to outings that can be accomplished between feeds to minimized breastfeeding and it’s aftermath in public.  The combined factors of maternal pain and discomfort combined with fraught feelings of failure are responsible for the high cessation rate for couplets facing forceful let-down.

What Can We Do?


There are many methods that can help mothers manage oversupply and forceful let-down. Always start with the least invasive interventions before attempting to reduce supply. Many mothers will experience some of these symptoms early in their lactation cycle as their body regulates milk supply.  It is normal for baby to occasionally cough and sputter during a feed.  Invention is needed if the infant is falling into the discomfort cycle mentioned earlier OR if mother is suffering from conditions associated with severe engorgement.

If you notice your infant consistently choking, gagging, or seeming to struggle to keep up with let-down, the first intervention I recommend is trying some different breastfeeding positions that allow gravity to work on your side. Avoid positions where the infant is on it’s back and milk is flowing downward. This exacerbates the problem when they are unable to keep up with milk flow. Try “uphill nursing” positions where baby is on top or vertical during feeds such as the laid back position. Side lying is also an excellent position that allows baby to come on and off the breast as needed to help regulate their intake.

Another helpful method is to initiate letdown before applying the baby to the breast. Pumping or hand expressing until let-down is achieved helps avoid the initial surge.  This allows many infants to cope better with milk flow. For some, position changes and applying baby to the breast after letdown help enough to get through the early days until mom’s supply streamlines.

Mothers with more extreme oversupply issues may find these methods are not enough. Block feeding is usually the next recommended course of action. Instead of offering both breast with each feed, only one breast is offered per feed or for a set period of time. By limiting feeds to one side we are decreasing demand to the breast by spacing feeds out on each side. Ultimately, this will decrease milk production. Block feeding is best executed with the support of an IBCLC to ensure we don’t over correct supply and end up limiting milk production.

The downside to block feeding is it can take some time for the mother’s body to reabsorb unused milk in the breast. This is further exacerbated by the fact that mothers are often already engorged. An engorged breast will have a stronger faster let-down continuing to be a problem for baby. This can be discouraging for a mother whose infant is already unhappy.

This is why I LOVE a technique called Full Drainage Block Feeding. I used this technique with my second child and was surprised how well it worked to regulate my supply. Full drainage block feeding starts by pumping both breasts until they are completely drained followed by initiating block feeding. For some moms, one pump session is enough and her body will regulate milk production before she becomes engorged again. If the breasts becomes engorged a second time, a second pump to empty session is performed and block feeding is recommenced. The idea is that by fully empting the breast, we are alleviating engorgement and discomfort for mom and it’s let-down side effects for the infant. One or two times of pumping to empty is not enough stimulation to cause an increase in supply. The results are much more immediate for mom and baby.

Any mom who has struggled with oversupply knows that there is such thing as too much milk. Unfortunately, many moms prematurely stop breastfeeding because they do not know what the problem is or how to remedy it. Personally, I was on the verge of quitting multiple times with both my children. My kids started out as awesome breast feeders in the hospital. It was not until my milk came in and I was on my own that I found myself alone and down a rabbit hole with seemingly no way out. If this article is hitting home, reach out to a lactation consultant. You are not alone. If your goal is to exclusively breastfeed; YOU CAN DO IT!

References


Forceful Let-down (Milk Ejection Reflex) & Oversupply • KellyMom.com. (2017, March 21). Retrieved October 25, 2017, from https://kellymom.com/bf/got-milk/supply-worries/fast-letdown/

Understanding oversupply. (2014, June 11). Retrieved October 25, 2017, from https://dianaibclc.com/2012/06/15/understanding-oversupply/

Veldhuizen-Staas, C. G. (2007). Overabundant milk supply: an alternative way to intervene by full drainage and block feeding. International Breastfeeding Journal, 2(1), 11. doi:10.1186/1746-4358-2-11

Worries About Foremilk and Hindmilk. (n.d.). Retrieved October 25, 2017, from http://www.nancymohrbacher.com/articles/2010/6/27/worries-about-foremilk-and-hindmilk.html

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2 Comments on “The Trials and Tribulations of Forceful Letdown and Oversupply”

  1. Excited to read this….my little one pulls off multiple times in the beginning due to a forceful let down. I was pumping for 1-2 min before nursing on that side but don’t want to do that forever

    1. I hope this article sheds some light for you! Agreed, pumping before every feed is a real grind. I did that with my first for a long time until my supply regulated itself. With my daughter, I was desperate to make a change early on to “prevent” the issue from reoccurring. While it didn’t prevent my oversupply, I a felt like I was able to manage it early on with the full drainage block feeding. I still had to be really vigilant about my letdown. If my daughter looked like she was floundering I would immediately remove her and hand express into a towel. With full drainage block feeding, I was really able to get things under control quickly. My daughter had pretty severe reflux and was still a “colicky baby” but I was really confident at that point that oversupply was no longer to blame. Hope the article was helpful.

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