Oversupply: When there is too much of a good thing.
An Increasing Problem
Many women worry their milk supply might be low, but few women go into breastfeeding anticipating that they might actually make too much milk. In my private practice, about 10% of consults center around the challenge of excessive milk production, sometimes referred to as hyperlactation. These women are seeking help because their babies gulp and choke at the rapid flow of milk, struggle with gas and stomach upset, may have green and frothy diapers, and the mothers may be uncomfortable with frequent engorgement, leaking, plugged ducts and mastitis. Occasionally women are predisposed to hyperlactation as a result of their breast anatomy (high milk storage capacity) or their hormone levels. However, oversupply is becoming an increasingly common phenomenon as breast pumps have flooded the market and mothers may be artificially stimulating higher milk production with excessive pumping. On social media, mommy-groups often promote the idea that women should have a freezer full of pumped breastmilk and be able to pump large quantities in one sitting. Everyone seems to forget that before 2010, most stay-at-home moms relied on a $20 hand pump for occasional relief and only working moms invested in a double electric breast pump (which was mediocre at best). Don't get me wrong - I am thrilled that insurance now makes quality breast pumps accessible to every breastfeeding mother. Women who are able to pump and store large amounts of breastmilk can be altruistic donors who are able to pass on milk to infants who wouldn't otherwise have access to breastmilk. If you have a freezer stash that will be put to good use and you and your baby aren't experiencing any negative symptoms of excess milk production, then there is no need to change anything. But for everyone else, we need to be careful that we don't lose sight of the natural laws of milk production in this culture of artificially stimulated milk production. Here is why:
Overproduction Disrupts the Distribution of Fat & Lactose
When feeding directly at breast, the average 1-9 month old will take about 2.5-5 oz of breastmilk per feed. In the context of oversupply, a woman may have 6 or more ounces in one breast alone. If it has been several hours since the previous milk removal, the milk in the breast will have had time to separate, with the fat floating to the top of the milk glands. If you have ever bought milk fresh from a dairy farm or pumped and then left the bottle to sit, you've seen the same thing happen as the cream rises to the top of the non-homogenized milk (see bottle image). This separation has sometimes been referred to as hindmilk and foremilk, but these terms led to a lot of confusion as people thought it meant the breast produced two different types of milk. It doesn't. The breast makes one consistent type of milk but after a few hours of sitting the fat naturally floats to the top of the breast and sticks to the walls of the milk glands. So, what does this have to do with oversupply? A baby breastfeeding from an overfull breast will not be able to drink all of the milk present and will first be able to drain the lower portions of milk with a higher lactose content. Baby may not have room in his tummy to drink enough of the milk for the cream top to makes its way down and out the milk ducts. In some babies, this disrupted distribution of fat and lactose may cause tummy upset.1 The fat and lactose digested together work as partners, but with lactose in high quantities separate from the fat it can irritate a sensitive tummy, rush through the digestive track and come out with bile present as a green frothy diaper.1 If your baby is showing signs of lactose overload, keep reading to learn about simple solutions to resolve this issue.
Overproduction Causes Rapid Milk Flow
Another way overproduction can cause a baby discomfort is by creating an excessively rapid flow of milk. A very full breast leads to faster milk flow as the weight of milk pushes forward to find release, much like a pent up damn opening the floodgates. If you often hear your baby gulp rapidly only to choke, sputter and cough while your milk continues to flow then you've witnessed this torrent. It can be stressful for babies to try to manage rapid milk flow and may lead to increased air swallowing and gas.
In mild cases, adjusting into a reclined position with baby face down on the breast (see picture) will help gravity to moderate the flow of milk and give baby more control over his suck-swallow-breathe rhythms. Also, please be aware that occasionally babies with tongue-tie will struggle with milk flow even when milk production is normal. This is not caused by rapid milk flow but rather by baby's difficulty controlling the movement of milk in his mouth, leading to accidentally allowing milk into the windpipe when baby tries to take a breath between swallows.
Usually babies are great at self-regulating their intake at breast and will switch to a comfort suck once they feel full. However, very fast milk flow can cause baby to transfer a full feed in 5 minutes, which is not long enough for the hormones that signal satiety to circulate and not long enough to meet a young baby's suckling needs. Baby may even switch to a comfort suck that typically would not draw milk (one of the beauties of breastfeeding!), but due to the excess milk production and torrential flow, even a light suck may draw milk. Occasionally this leads to excessive weight gain (over 2 ounces per day) or a frustrated baby who just wants to comfort nurse and is being unintentionally "force fed." If your baby seems uncomfortable during feeds, frustrated when he tries to comfort nurse, and is gaining over 2 ounces per day this may signal oversupply.
Overproduction Increases Mother's Discomfort
Overproduction is not only unpleasant for baby, it can also be uncomfortable for mothers. Many mothers with overproduction experience frequent engorgement and feel like they have to pump often for relief. Plugged ducts and mastitis are more common because the excessive fullness and can trigger inflammation; inflammation can lead to tissue swelling; tissue swelling can cause ducts to be pinched closed, leading to a build up of trapped milk in the lobules. This is often referred to as plugged ducts and untreated can turn into mastitis. As mothers pump frequently to try to relieve the pressure, the breasts are signaled that the extra milk is being used and needed, and it reinforces the oversupply and perpetuates the problem. This vicious cycle is hard to break, but there are some solutions.
Solutions for Hyperlactation
Alternate Hot & Cold for Engorgement & Plugged Ducts
One of the most common mistakes I notice women make when treating engorgement or plugged ducts is to only use heat, such as in the form of a hot shower, soak or warm compress. If heat is used repeatedly on the breasts and not alternated with cold, it tends to increase swelling and inflammation. Since swelling and inflammation can put pressure on the ducts and compress them, over use of warm compresses can actually make the problem worse. Heat is useful for helping mothers relax and helping milkfat to soften and flow. It is best used while nursing or pumping in combination with massage. Cold packs are best used during the time in between nursing/pumping sessions. Cold helps to reduce inflammation and swelling, reducing the pressure on the ducts and helping trapped and backed up milk to escape the glands deep in the breast. If you are experiencing engorgement, use cold compress in between pumping/nursing sessions and warm compresses while pumping/breastfeeding. More time should be spent with cold packs applied to the breast than heat. Try these Lansinoh cold/hot packs for relief.
Use Breast Massage to Mix it Up
If your baby is having green diapers every day, you can easily resolve the foremilk/hindmilk separation by briefly massaging and jiggling your breasts before latching. Studies have found combining massage with pumping or breastfeeding actually increases the fat content of the breastmilk.2,3 It works by mixing the milkfat back into milk, much like shaking a bottle redistributes the fat that clinged to the edges and floated to the top. Breast massage and jiggle before latching is called "The Milkshake Technique" and it works wonders at instantly resolving foremilk/hindmilk imbalances. If used consistently, especially anytime a woman feels full and it has been several hours since the last feed, the Milkshake Technique should quickly eliminate the green stools, gas and accompanying discomfort. There is absolutely no need to overthink the process. I do not recommend forcing baby to stay on one breast or other complicated measures that overthink the issue. Simply give those girls a little shake to mix then latch - easy peezy!
Avoid Overstimulating Production
This section applies only to women who are pumping regularly. If you or your baby are experiencing unpleasant symptoms of oversupply, the most important intervention will be to avoid artificially stimulating your production. Ideally, pump only when your baby takes a bottle and only the same amount your baby drinks in a bottle. If you are used to pumping really high quantities (over 5oz combined), gradually shorten your pump sessions until you are only pumping to replace your baby's breastmilk intake, which is usually around 3-4oz. A little extra is fine (3oz per day into your freezer stash), but pumping high quantities will only signal your body that the milk is used and needed and to continue making that much. Make these downward adjustments to your pump sessions gradually, staying tuned in to how your body is handling the adjustment. Its okay to feel a little full during the transition, but your breasts shouldn't feel hard or inflamed. If they start to feel that way, pump or nurse enough to take the edge off and then place cold packs in your bra to reduce swelling and give soothing relief. If you have massive oversupply and are having difficulty with engorgement, then once a day, first thing in the morning, pump to fully empty your breasts so that you are starting the day with light, empty breasts. After that, follow the guidelines above to gradually shorten your pump sessions during the rest of the day.
If you are exclusively breastfeeding while coping with oversupply, your body will naturally regulate your milk supply over time. Its not unusual for women to bring in more milk than their baby needs and it takes time for the body to modify its milk production in keeping with baby's daily intake. This can take anywhere from a few weeks to a few months. Continue nursing on demand, using a reclined breastfeeding position, the Milkshake Technique described earlier, offering both breasts, and letting baby decide how much he/she wants to nurse. If your baby regularly gets full nursing from just one breast and declines the other breast when you offer it, you might consider using a silicone suction pump on the skipped breast while nursing to provide some relief. Avoid using it to collect more than 3-4oz per day as this will signal your body to continue overproducing.
Consider Herbs & Medications
If you feel you need fast relief from the symptoms of oversupply and your baby is gaining at a rate of 2oz or more per day, you can consider herbs or medications that can actually reduce milk production. Sage, in either capsule or tea form, can be consumed a few times per day to reduce production. Cabbage leaves contain a substance that can reduce production. Apply cold cabbage leaves to your breasts and change them out at each feed or when they wilt. Psuedoephedrine (behind the counter Sudafed) has been shown to reduce milk supply by 24%.4 Some women will take one dose a day of Sudafed until their milk supply regulates. With all of these options, be sure to carefully monitor for signs your milk supply is regulating and stop these measures as soon as you and your baby are feeling relief. An additional measure that won't address milk production but may help prevent plugged ducts is to take sunflower lecithin, an emulsifier that helps prevent fat from forming clumps. Ibuprofen can be used during periods of engorgement or to treat plugged ducts by reducing inflammation and thereby improving flow. Discuss any of these remedies with your doctor if you have health conditions or take medications.
Rule out Underlying Causes
In severe and persistent cases of hyperlactation, we recommend making an appointment with a breastfeeding medicine doctor or your OBGYN. They can perform bloodwork to see if a medical condition is causing extreme overproduction. In rare cases, hyperlactation can be due to hyperthyroidism, a pituitary tumor, or a side effect of a medication. Some lactation specialists speculate that systemic inflammation causes oversupply for some women, but this is not well understood yet. Think of it like your nasal passages - when they are inflamed they produce more secretions and feel swollen. Hypothetically, generalized inflammation could cause your breasts to produce more fluid and swelling. Again - not very well understood, but its food for thought! Women could try eating a Mediterranean Diet, exercise, omega 3 fatty acids, and turmeric (curcumin) if they would like to explore a natural approach to systemic inflammation, in conjunction with seeking medical evaluation.
1 Resolution of Lactose Intolerance and Colic in Breastfed Babies, Health-ELearning, accessed August 2019
2 Higher Fat Content in Breastmilk Expressed Manually, Breastfeeding Medicine, 2015
3 Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants, Journal of Perinatology, 2012
4 Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk, Br J Clin Pharmacol. 2003