Intro

All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

Breastfeeding - When Is Fast Letdown Not Over Supply?

If baby coughs, splutters, gulps, pulls back or clamps down, clicks and/or is windy/fussy - often mum is told she has a fast letdown, caused by an over supply.  If baby has green stools, this for some is the green light that it has to be the case, as it means baby is getting too much lactose rich milk right?  And sometimes this will be true - a very full, engorged breast will eject milk faster; therefore mum may be told to block feed to reduce her supply.

Unfortunately it's really not that simple.

Firstly, other problems apart from an over supply and fast let down can cause all of the above.

Secondly, as with most things even if there is a huge supply, we shouldn't start with resolution but with the question of why.  Is there a reason mum's breasts are not regulating?

1.  What else can present as fast letdown/milk ejection?

I began pondering "fast letdown" with my first baby.  She had all the above symptoms when feeding.  If she pulled off, milk would shoot everywhere and I could always feel a strong sensation during letdown.  She would suffer intermittent green explosive nappies too.

A breastfeeding counsellor at the time suggested I had over supply and to block feed.   I did some reading and much seemed to confirm what I was being told. 

Yet I didn't feel I had an over supply - I felt I had a good milk supply, but no engorgement or over fullness like in the early days.  What's more block feeding wasn't really an option, because after a few minutes on the first side she would pull, writhe, fuss and refuse to go back on it - so the only option was to switch her to the other.

I now know that my daughter had a disorganised suck.

My milk ejection/letdown was totally normal, but my daughter couldn't co-ordinate sucking, swallowing and breathing rapidly enough - and hence ended up doing the above.

This was further confirmed during out attempts to introduce a bottle (I bought in to the notion/myth that all babies would need to take one at some point and should be introduced at 6 weeks).  When we finally managed to coax her to take even a small amount (which was no mean feat!) she would also cough, splutter and appear to drown on a slow flow teat.  The Health visitor at the time said it was because a breastfed baby had a stronger suck - in reality a baby struggling to use the appropriate action, may compensate with an almost "super suck".

Catherine Watson Genna in her book Supporting Sucking Skills writes:
"Multiple studies confirm that during infant feeding, breathing stops during each swallow.  This presents a unique challenge for a baby, who swallows after each suck, and must rapidly switch between swallowing and breathing "
and
"Flow plays an important role in these relationships. High flow, whether it is actually high or just perceived by the baby as high, can upset the delicate balance of sucking, swallowing and breathing co-ordination."
What I now observe in practice is if we take a baby with a very co-ordinated organised suck, and give him a good flow of milk - he will feed with long pauses, swallowing big mouthfuls of milk:

Click here to see this in practice

But a baby with a disorganised suck receiving a good letdown, will often start to get faster and faster, as they struggle to switch rapidly between swallowing and breathing - the result?  Coughing/spluttering/pulling off...

I liken it to running down a steep hill, you manage it for so long - getting faster and faster until you reach a point it all goes wrong and you fall over.

In fact if we read this great list on Kellymom regarding over supply, every single symptom of forceful letdown can also be attributable to a disorganised suck - because as Catherine highlighted if the baby perceives the flow as fast, that is problematic.  It was this piece at the time I was struggling with my daughter, and the words "often linked with over supply" not "always linked with", that gave me the confidence mine wasn't supply linked - but for years it puzzled me what caused these "fast supply" symptoms.

What's more these babies may also struggle to continue pulling milk from the breast once the initial milk ejection reflex has subsided. So they may fuss, pull, arch and cry - if the other breast is offered they may again drink rapidly for a few minutes before again stopping.

Sometimes these mums are told their baby is just a "rapid, effective feeder", that they "power feed" in a few minutes, or perhaps that they are snackers or grazers - and again sometimes this is true; as the video link above highlights a baby feeding effectively needs to feed for a much shorter period than one who isn't.  Other times feeds are short because the baby can't sustain effective feeding for a longer period of time - you need to be pretty sure which situation you have in front of you before thinking about the best course of action to resolve?

Considering  green stools -  if we think of why a baby dealing with over supply has green nappies - it is because the lactose/fat ratio is out of whack.  See why a baby not feeding great may also end up in this situation, even if mum had a normal supply?

2.  The problem with starting with a solution.

If you consider the above, it's pretty clear that "misdiagnosing" an over supply and recommending techniques to reduce (such as block feeding) can quickly cause more problems if supply wasn't the problem at all.

Furthermore, if a baby is continually not feeding effectively, the breasts can struggle to regulate.
Piazza Maggiore, Italy, taken by Gio
Some mums find they experience a drop in supply, others find it goes the other way and the little and often "taking the top off" provokes an overly abundant stash. But again suggesting techniques to reduce this without being absolutely confident you do have an effectively feeding baby, can come back to bite you in the butt later if a baby is reliant on this abundant milk ejection. Yet once baby is feeding well, the breasts are much more likely to regulate.

Also interesting are the cases where one breast appears to be over producing whilst the second seems to have much less supply. Watch these babies carefully and you may note they feed much more effectively from one side than the other, so it may not be the case that one breast is "over producing", as much as one breast is providing most of the nutrition because baby isn't feeding well on the other.

Again reducing supply in this instance can quickly leave baby in a tricky position!

Lastly please never consider taking steps to block feed or reduce supply if you have a baby that isn't gaining weight appropriately, without seeking help from someone appropriately qualified such as a Lactation Consultant.

A mum I saw recently had been advised to do so as her breasts were full and painful. This however wasn't because of a production issue, but because her baby was not feeding effectively enough to drain the breasts well causing blockages and congestion (which was reflected in his weight). Mum followed advice to block feed and ended up having to source donor milk to supplement whilst bringing her supply back up to normal levels.

This really brings us full circle to an earlier entry I made discussing why information and support is much more valuable than advice.  If we're not really listening and thinking, building up a complete picture and working holistically, but instead simply dishing out standardised advice to every mum with a fussy feeder and green nappies - whether our actions are well intended or not, we risk putting the final nail in the coffin.

15 comments:

  1. Really interesting to read what you say about one breast "overproducing" - even now after more than six months of pumping, my left still produces more than my right (unless it's suffering from a blocked duct, which of course it does more often because of the relative "oversupply" and the fact that I don't have anything as efficient as a fully functioning baby to drain it). I've thought for ages that it goes back to the days when I was (trying to) feed him and he preferred the left - in fact what I think has happened was that he had established a better supply in the left breast than the right. He didn't really establish much of a supply on either side because he had an undiagnosed TT and I got crap advice but hey ho... at least I'm now reading something which backs up my own musings on this!

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  2. Very interesting piece AA. Would you say that disorganised suck corrects itself over time as baby learns?

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  3. How would you work with your baby to resolve this issue? It really sounds like an issue I had in the past with my boys.

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  4. Really interesting reading regarding the disorganised suck theory - my 7 week old has always clicked when feeding and never comfort sucks; often ends up coughing during a feed and will often cry when finished (with milk pouring down her chin - it feels like "why are you still feeding me milk when all I'm trying to do is sleep?!"). I assumed it was fast let-down due to the fact I'm still feeding my 29mo and also pumping about 100ml a day to send to a milk bank. I don't get terribly engorged so I don't think I have oversupply; and I haven't had her weighed in weeks but she seems to be gaining and is happy and alert. Is there anything you can advise to help her cope better with the flow rate?

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    1. Update - she was diagnosed with posterior tongue tie at 10 weeks and feeding has improved massively since then. Still feeding at 11 months with no plans to stop soon :)

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    2. Hi Gwennifer, my 12 week old son has the similar symptoms as yours ... clicked during the first few minutes of feeding, rarely comfort sucks, coughing during a feed and crying during and after feeding. My nipples always come out pinched with a white ridge on the top. There's no milk pouring down his chin but sometimes he has reflux/spitting curdly milk out. He is extremely gassy, hard to burp, and always crying uncomfortably when he is trying to poop.

      I don't get engorged much as well so I don't think I have oversupply. I have been battling recurrent plugged ducts for the past 10 weeks since he was 2-3 week old, having plugged ducts every few days on both breasts. I did everything I can to get rid of and prevent those plugged ducts, hot and cold compresses, cabbage leaves, hot shower/hot bath, hand massaging in the shower/before/during/after feeding and pumping to get those plugs out, varying the nursing position, hand massager/electric toothbrush to mimic ultrasound treatments, avoiding saturated fats in my diet, avoiding any pressure on my breasts, avoiding lifting heave stuffs, castor oil, lecithin supplements, echinacea/bee propolis/poke root herbal supplements ... but the plugs kept coming back!

      I have gotten discouraged and almost gave up breastfeeding several times because of the problems I and my baby have been experiencing =(

      In any case, who and how did your daughter got diagnosed with posterior tongue tie? DId you have her tongue tie clipped? I saw one IBCLC early this week and she kinda suggested that my son has lip tie and tongue tie, preventing him to have a good latch and drain my breasts effectively. But then another IBCLC I saw today during breastfeeding support group says my son is too old for frenectomy, i.e. no one will do tongue clip for 12 week old baby, they only do it for few days old/younger baby, so I am just curious to hear about your experience.

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  5. I completely agree that the cause is that coordination in most cases I'm so glad I read this article. my son is 5 months old and is very sporadic with eating and sleeping due to his gassiness. I was told when he was three months that I had a fast let down and I had to "manage" it by changing positions and the other ideas that come with that. I was hoping by now we would be on a better track. he wakes throughout the night and I'm losing my mind without sleep...I want to give up. can anyone tell me there is end in sight or a better solution?

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    1. Hiya
      Where in the world are you, have you seen an IBCLC?

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    2. hi I am I'm California and I have...I keep seeing a lactitionist and talking to a variety of groups and moms and the most common solution is manage the fast let down.

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  6. Do you have a large supply Missy ie are you becoming engorged/full between feeds to cause a fast supply?

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    1. No not really. I get a little engorged if it gets to 4 hours between feedings but that is rare.

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  7. My 6 month old has worn both the large and the one size since he was 3 months old. My almost 3 year old daughter can fit the large which is great to know because my son should be able to wear these till he's about 3! They absorb great and that yellow/green new baby poop washes out great.

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  8. Any info on how to help baby resolve this poor coordination?

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  9. how do you help baby be better coordinated?

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