Oversupply

Sometimes a mother can make more milk than her baby needs. While having too much milk may seem like a good problem to have, the rush of milk from an overfull breast can make feedings stressful and uncomfortable for both mother and baby. Babies can also be very fussy in between feedings when there is too much milk.

Most babies whose mothers have too much milk gain weight much faster than normal and have many more wet and soiled diapers than normal each day. (See Supplementing for information on normal weight gain and diaper output.) Higher than normal weight gain is absolutely fine for an exclusively breastfed baby as long as he is generally happy and feeding easily. It is only a problem when either the baby or his mother experiences difficulties as a result of having too much milk.

Some babies whose mothers have too much milk actually do not get enough milk because they have trouble handling the strong flow and can't breastfeed easily. These babies need supplementary feedings (preferably with their mothers' expressed milk) until their mothers' milk supply can be adjusted to better meet their needs.

When a mother has more milk than her baby can handle, the following behaviors may be common:

Baby cries a lot, and is often very irritable and/or restless
Baby may sometimes gulp, choke, sputter, or cough during feedings at breast
Baby may seem to bite or clamp down on the nipple while feeding
Milk sprays when baby comes off, especially at the beginning of a feeding
Mother may have sore nipples
Baby may arch and hold himself very stiffly, sometimes screaming
Feedings often seem like battles, with baby nursing fitfully on and off
Feedings may be short, lasting only 5 or 10 minutes total
Baby may seem to have a "love-hate" relationship with the breast
Baby may burp or pass gas frequently between feedings, tending to spit up a lot
Baby may have green, watery or foamy, explosive stools
Mother's breasts feel very full most of the time
Mother may have frequent plugged ducts, which can sometimes lead to mastitis (breast infection)

If many of these experiences seem familiar to you, it may be because you have an overabundant supply of milk, which can cause a forceful milk ejection (sometimes referred to as overactive let-down), and/or foremilk-hindmilk imbalance.(1) (2) The infant behaviors described above are caused by these issues but may frequently be misdiagnosed as colic, lactose intolerance, milk protein allergy, reflux, or hypertonicity (stiff muscle tone).

If you are experiencing oversupply, a forceful milk ejection, or foremilk-hindmilk imbalance, the strategies described below may greatly improve your breastfeeding experience. Fortunately, many mothers find that oversupply naturally adjusts to a more manageable level by the end of baby's third month.

Why Does Oversupply Happen?

There are several reasons why a mother may produce too much milk. Some mother's bodies are very enthusiastic and they seem to overproduce milk from the very beginning. In other cases, the oversupply may result from following breastfeeding management advice that unintentionally increased milk production. This is especially likely to happen if a mother routinely pumps a significant amount of milk before nursing to slow down the flow in order to make it more manageable for baby. She may accomplish the immediate goal, but end up with a chronic problem as a result. Another cause can be routinely switching baby to the other breast before he has finished the first breast. This can happen when mothers feed only a certain amount of time on each breast or when they are trying to find a side that the baby doesn't fuss on. Some mothers' breasts are highly sensitive to stimulation, and switching back and forth without ever draining a breast well can result in production of too much milk in both breasts.

Oversupply problems are frequently created by cultural beliefs about how breastfeeding should happen, which mothers read in books and online, or hear from well-meaning friends, family, or health care providers. A mother may have been told she must nurse a certain number of minutes on each side or that baby must take both breasts at every feeding. Yet, for the mother with an abundant supply, baby may naturally fill up so fast on one breast that she finds herself cutting him off very early in order to get him to still accept the second breast. He is taken off the breast before he gets to the creamier milk, and then fills up on foremilk from the second breast. Large feedings of lower calorie foremilk create a self-perpetuating cycle: baby’s tummy feels distended and uncomfortable from the feeding, yet he still feels hungry because he did not get enough milk fat to satisfy him. So baby cries to feed again, and mother concludes that he must not be getting enough milk because he never seems content.

A further problem may also result from this unintentional mismanagement. Foremilk is high in lactose, a normal and necessary milk sugar that in large volumes causes gassiness and discomfort, frequently with green, watery or foamy stools. Over a period of time, undigested lactose can irritate the lining of the intestines, causing temporary secondary lactose intolerance and possibly small amounts of bleeding into stools that can be misdiagnosed as a food allergy. Adjusting breastfeeding to increase the amount of fat the baby receives ("finishing" the breast before switching) usually corrects the problem. For a more thorough discussion of foremilk, hindmilk, and lactose, see our article on Foremilk, Hindmilk, and Lactose.

Strategies to Slow Down the Rate of Milk Production

Changing the way you feed your baby can reduce both the overall milk volume and the amount of lactose baby receives, while increasing the amount of fat. Since mothers with oversupply often produce enough milk in each breast for a full feeding, one strategy that can be very successful is to feed the baby on only one side per feeding. If your baby wants to nurse again within two hours, see how he responds if you continue to offer that same side. In the next two hours, offer only the other breast. The breasts should gradually slow down their rate of milk production because milk is being removed less often. This helps down-regulate the milk production rate to match baby's true needs while also reducing the amount of foremilk and lactose baby receives.(3) When you keep baby at the same breast for a longer period of time, it also ensures that your baby is fully draining the breast and getting more of the higher calorie hindmilk.

If you are uncomfortable on the breast that is not being used before you are ready to nurse on it again, you can hand express or pump for only a few moments (20-30 seconds or less), just enough to relieve some discomfort. Do not pump too much or you will signal your breasts to produce even more milk. There is a certain whey protein in the milk, called "Feedback Inhibitor of Lactation" (FIL), that begins to build up and concentrate when milk is not removed for a while. This protein needs to be allowed to build up high enough to trigger the breast to cut back milk production. By removing just barely enough milk to be comfortable, but still allowing the breast to be full enough to trigger the "cut back milk production" message, most mothers can decrease milk production without risking plugged ducts or a breast infection. Many mothers find that cold compresses -- chilled raw green cabbage leaves or a bag of frozen peas -- help ease the discomfort and reduce swelling from being overly full.

You will know the strategy of feeding only on one side for extended periods is working when your baby becomes less fussy and seems more satisfied between feedings, and his stool becomes less watery and more yellow. He will also gulp, choke, and sputter less during feedings, because the milk is not flowing as fast.

If you find that your baby is still having difficulty after four to seven days of feeding only on one breast per feeding, you may need to breastfeed on just one breast for a longer period of time (two or three feedings or even longer) in order to decrease your milk production further. Some mothers with extreme oversupply may need to feed only on one breast for as long as 12 hours. It is best to extend the time on one breast very slowly and carefully, going longer only if milk production is not slowing down. Feeding on one side for too long could lead to decreasing milk production too much. (Most mothers with oversupply find that it is easy to regain adequate milk production with a few additional pumping sessions.)

If you have very enthusiastic breasts and the strategy of feeding on only one side for extended periods is not taming them yet, you may need to try a more extreme structured approach that initially does include some pumping. Start by pumping both sides thoroughly so that your breasts are fairly soft about an hour before a feeding. Then feed on one breast for several feedings until that breast is completely soft and comfortable and the other breast starts to feel unbearably full. When you feel unbearably full, switch sides and feed on the second breast until the first breast starts to feel unbearably full. It may be necessary to pump both sides a second time during the day, both for comfort and to ward off plugged ducts. For the next several days, continue to feed on one breast until the other one feels overfull. This will result in keeping baby to one side for several hours before switching to the other side. As your body is allowed to get the "overfull" message, it will respond by slowing the rate of milk production, and pumping should gradually become unnecessary.

If after trying these techniques, feedings do not improve significantly, it may be necessary to take stronger measures to regulate your milk production downward. A board-certified lactation consultant can share information with you and your doctor to help manage oversupply using medications and herbs. In certain situations, a four- to seven-day course of low-dose oral contraceptive pills, containing both estrogen and progesterone, may be used to reduce milk production to a more appropriate level. Sage tea has helped some mothers in reducing milk production, as has the conservative use of pseudoephedrine (Sudafed, Halofed, Novafed). Some mothers have also found that mints and cough drops containing peppermint, peppermint tea, sage, and thyme help to reduce milk production, though it would take a lot of cough drops to make a difference in a mother who has a severe problem.

Strategies to Reduce Milk Ejection Force

When a mother produces a large volume of milk, her milk ejection reflex will be stronger. All that milk rushing down the ducts may be more than baby can handle. It's like trying to drink from a garden hose that is turned on full-blast, while lying down on your back. In addition to choking, sputtering, and coughing when the milk comes out, baby may try to control the milk flow by pulling away and adapting a shallow latch. Shallow latching can be very painful for a mother. Or he may simply clamp down in an attempt to slow the flow, resulting in a "biting" sensation. Baby may also scream and arch his back to let you know that something needs to be changed.

It is sometimes recommended that mothers who have oversupply or an overactive milk ejection (let-down) hand-express or pump an ounce or so of milk prior to feeding to help slow the milk flow. However, this practice tends to be counterproductive, because removing that much milk from the breasts increases milk production, which in turn will increase the force of flow even more.

There are many strategies that can help manage a forceful milk ejection without increasing milk production. Placing the baby in a more upright position, so that his head is higher than the breast, will allow him more control during the feeding. Or position yourself so that you are leaning backwards, with the baby almost on top of you after he latches. In this position the milk has to flow "uphill," which will reduce the force of your milk ejection reflex.

Some mothers find that a "scissors" hold on the areola, with the nipple between the forefinger and middle finger, helps restrict the flow of milk. Another option is to apply pressure on the side of your breast with the heel of your hand. (Try to vary the position of your hand to avoid constricting the ducts and inadvertently causing a plug.) You may also find it helpful to breastfeed just as your baby is waking from naps. He will suck more gently when he is still sleepy.

If baby starts to choke/sputter, unlatch him and let the excess milk spray into a towel or cloth. Relatch him when the force of the milk ejection has lessened.

Many mothers with oversupply find that nursing in a side-lying position makes feedings go more smoothly because milk flows from the breast horizontally without the force of gravity and babies can let excess milk dribble downward from their mouths rather than having to swallow it all. (Place a towel under you and baby to absorb the extra milk.) Use a rolled-up receiving blanket against your baby's back to keep him from rolling away from you. If you are still lying down together at the next feeding and are ready to offer the other breast, you can just roll with your baby onto your other side, so that the second breast is against the bed and not flowing downhill with increasing force.

You may find that the side-lying position is somewhat difficult to master and that it is not as easy to get a good latch when lying down. Sometimes it helps to place baby with nipple pointing at his nose so that his neck is extended and he is looking up toward the breast as he latches. Some mothers latch baby onto the breast while sitting up and then slowly slide down into a side-lying position while holding baby gently but firmly so he stays attached. One great benefit of learning to nurse lying down is that you can drift off to sleep while your baby nurses. Don't worry that your baby will have difficulty breathing; babies choose air over food. So long as there are no pillows or blankets around his head, he will be able to move his head freely when he is finished nursing. He may rest his head against your breast as if it were a pillow. (Note that mothers with very large, pillowy breasts need to take special care that baby has room to move his head.)

Some babies cope with their mothers' strong milk ejection by taking only a little milk at a time, stopping and starting frequently. It is almost as if they are enjoying several courses to their meal. This is absolutely fine; allow him to come on and off the breast as he needs to, making sure to keep offering your baby the same breast for each course so that he has the opportunity to get the cream.

Although it can be tempting to stretch out feedings when your nipples are sore, feeding baby before he gets extremely hungry will keep him from sucking too aggressively, which not only hurts when nipples are already sore, but can cause further nipple damage. An overly strong suck can also cause a stronger milk ejection, making the feeding more difficult.

Summary of Strategies to Reduce Rate of Milk Production and Force of Milk Ejection

Nurse on one side for a each feeding, continuing to offer that same side for at least two hours until the next full feeding
- Gradually increase the length of time feeding from one breast if necessary
- If this strategy is not effective, try the method of throughly pumping breasts and then feeding on one breast until unbearably full (described in detail above)
If the other breast feels unbearably full before you are ready to nurse on it, pump or hand express for a few moments to relieve some of the pressure
- Use cold raw green cabbage leaves or a bag of frozen peas to reduce discomfort and swelling
Feed baby before he becomes overly hungry to minimize aggressive sucking
Try alternate nursing positions
- Mother leaning far back
- Side-lying (letting milk dribble out)
Use scissors hold or the side of your hand to compress ducts to reduce the force of the milk ejection
If baby chokes or sputters, unlatch him and let the excess milk spray into a towel or cloth
Allow baby to come on and off the breast at will
Burp frequently if baby is gassy
Certain herbs and drugs, used judiciously, may be helpful in reducing milk production

References

[1] Livingstone, V. Too much of a good thing. Maternal and infant hyperlactation syndromes. Can Fam Physician 1996 Jan; 42:89-99.

[2] Smillie, C., Campbell, S., Iwinski, S. Hyperlactation: How left-brained "rules" for breastfeeding can wreak havoc with a natural process. Newborn Infant Nursing Rev 2005; 5(1):49-58.

[3] Newton, M. and Newton, N. The let-down reflex in human lactation. Pediatrics 1948; 33:69-87.