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.

That Innocent Little Bounty Pack...

In the UK when pregnant, your midwife/GP/relevant Health Professional will usually give you the first Bounty Pack.   There are five in total:

• Pregnancy Information Folder
• Mum To Be
• Mum's Pack
• Newborn Pack
• Family Pack

Basically you are given or collect five different carrier bags full of "stuff".

A Bounty Pack - image shared by a mum on Facebook

The "stuff" varies regionally, some mums seem to get lots of items whilst others only one or two.  A tiny tub of Sudocrem, a disposable nappy and a washing tablet seems to be pretty standard - some have had mini cans of caffeine free coke or sample of toiletries.  Discount/money off coupons/samples for everything from follow on milk and weaning foods, to fabric softeners and antibacterial spray.  Leaflets and publications such as "Emma's diary" are enclosed and then lots more advertising  - one mum noted adverts to send off for stuffed toys from both Aptamil & Cow & Gate.

Bounty's site reads:

"Embarking on parenthood is a bit like being expected to find your way in a jungle with no map and no guide.
Wonderful, yes. exhilarating, life changing, enriching; no doubt. But boy can it be challenging. It’s bewildering, exhausting and scary at times too.
When any family sets off on this incredible journey, Bounty’s there, guiding the way.
We support families in the transition to parenthood, through each key life stage, from pregnancy to birth to toddler to pre-school. We aim to be the first place new mums turn to for advice, help, reassurance and information. We also welcome them into an online community where they can share problems, worries, tips and achievements with a support network of mums who are going through the same thing.
As well as providing new mums with the timely advice and expert knowledge new mums need, we introduce carefully chosen products and services to mum that we know, as parents, can be invaluable through the different key stages. Every mum that registers with us is eligible to receive a total of five Bounty packs; filled with free samples, money-off vouchers and useful information, plus three free guides offering practical, up-to-date information, advice and guidance from pregnancy and beyond."

And there's lots of information about charitable giving and so on.

But what many forget is that in exchange for a few pounds worth of product samples and leaflets/information of varying quality - you're giving them all your personal details.  Details that are more valuable than you might think.

Let's see what website http://www.starmedical.co.uk says about Bounty:

"Bounty is one of the largest advertising and communications companies in the world. For nearly 50 years they have been providing direct marketing and support services to major pharmaceutical companies and other services that target parents of young children.
The company was founded in 1959, based in London and had 6 employees. They now employ 590 people and distribute 3.4 million bounty packs every year.
Bounty works closely with the NHS, with Postnatal Bedside Caring Distributors who communicate with new mums and Ward Midwives. This role serves to inform the new mums and also to discreetly collect useful data from them. Bounty Health Network Advisors work with Community Midwives, Health Visitors, Practice and School Nurses."

Perhaps it's just me, but that doesn't seem quite as hearts and flowers as the site for parents?

Why do the NHS allow it?

The usual reason - money.

"Bounty sales reps are given exclusive access to maternity wards by trusts" 

and

"They also try to ask women for their contact details so they can sell them to other companies that provide services for parents, and hand out free packs containing small samples of nappy cream and washing powder, but which also include official Government forms that must be filled in to claim Child Benefit.

Several hospitals and Bounty itself face investigation by the data protection watchdog, the Information Commissioner's Office, for passing on private details of this newspaper's investigation.

Last night parenting experts and patients' campaign groups criticised NHS trusts and the firm for making money from women when they are at their most vulnerable.

Belinda Phipps, chief executive of the National Childbirth Trust, said: "It is absolutely appalling. When you go into a maternity ward to have your baby, you shouldn't be subjected to commercial pressures.

"But the hospitals turn a blind eye to Bounty because otherwise they will have to ask their trusts for more money." 

Bounty, which was sold to Barclays Private Equity in April this year for £54million, has been going for 50 years. 

Almost all hospital trusts have individual contracts with the company and are paid about £1 for each pack given out after birth.

"Bounty ladies", as the firm's staff are known, also visit mothers at their bedside and ask for their addresses and phone numbers, which they then sell on to other firms." From HERE 

Now consider if Bounty pay the hospital £1 - what must your details be worth?  They generate revenue from the companies who put samples, leaflets and coupons in the FIVE packs.  Then consider they distribute 3.4 million bounty packs every year.

Then they can sell your details to generate more profit; one mum on Facebook said:

"Someone on my facebook put on her status that she'd had a phone call from Eon talking about the fact that she's pregnant and had received a pack, she didn't realise Bounty could sell her details (and not just her name and address, but the fact she's pregnant as well)"

Doesn't this mean our NHS is ultimately delivering new mothers in to the hands of a commercial company?  Doesn't the NHS have any obligation to ensure something they endorse is in line with relevant codes and that the information within is always accurate and evidence based?

Given the NHS will NOT give out details of independent breastfeeding groups or services, it seems if money is exchanging hands the rules change....

One mum on Facebook said:

"I declined the Bounty Pack (which surprised the Midwife!). Later on, the sonographer handed me some little card wallets to put my scan pictures in, guess what - sponsored by Bounty! There were so many adverts in the antenatal waiting room too, I don't understand how these companies are allowed to be so ingrained in the system."

Double plus for Bounty is that this means their information also appears Government endorsed - the packs are given out by Health Professionals and Health Establishments, one pack contains a form required to claim child benefit and so on.

Bounty also released a statement according to  http://www.lancashirechildrenstrust.org.uk/:

"Bounty’s statement (October 09) that it will no longer promote weaning foods or
toddler milks from early 2010"

Yet when I ran a quick poll here on the blog - out of 147 mothers that had responded at the time of writing this blog, 53 (36%) said they did receive such marketing in 2010.  More worryingly 61 (41%) replied yes in 2011.  Only 33 (22%) of respondents said they didn't receive any.

This means either a lot of mothers made a mistake, or Bounty continued to supply such marketing materials after early 2010.

Furthermore, whilst Bounty stated they would stop promoting these items - does this mean they will stop selling details to these companies too?  I suspect not....

The document from Lancashire Childrens Trust, summarises the many issues with the NHS being associated with Bounty and is well worth a read.  So I want to move on to the issues parents raised on Facebook.

1.  Insensitivity from Bounty photographers:

"My daughter was badly bruised on her face from the very traumatic birth she had - the Bounty rep selling photos came round the ward and then when she got to me looked at my baby's face and said "Oh you wont be wanting any photos of her for a long time will you" and promptly left. I was very very upset, I should have complained. Disgusting that they allow sales reps for Bounty near very vulnerable ladies :-("

and

"I was in the middle of having an extremely uncomfortable procedure done on day 2 (you really don't want to know the details trust me!) when the Bounty lady came round. My husband who was outside the curtains took my pack on my behalf, but refused to give her my email address. She then tracked me down the next day and stayed in my room until I gave her an email address, I had just had a blood transfusion and was too tired and weak to tell her where to go. In the end I gave her an email address I don't use any more, have just checked email account I gave her and I have received an outstanding 211 bounty emails in 3 months! Madness!"

and

 "Very unimpressed that my husband wasn't supposed to be on the ward with me and our newborn (visiting hours for Dads is 12 noon until 8pm only) and we got a lot of hassle and bullying because he had got in at 7am and wouldn't leave (because I would burst into floods of tears at the mere mention of it) yet the Bounty woman was there handing out packs and taking photos - for sale, of course. How is she allowed to be there and not the father of my baby?!?!"

and

"How annoying! I've just been harassed by a Bounty Pack woman. A bit of background info for you-i'm in hospital on complete bedrest after PROM at 22 weeks. I'm now 24 weeks. Anyway, she came in asking if i'd had a pack. I said i'd had one off my midwife when i had my booking in appointment. She said that i needed the next pack and she needed my details. I said i wasn't interested but she kept going on telling me if i didn't have the pack i wouldn't be able to claim child benefit as i woldn't get the form." 

2.  Getting out of the "Bounty System" once you're in:

Despite the close NHS links, it is the responsibility of the parents to advise Bounty if they no longer wish to receive packs due to miscarriage or stillbirth. At a difficult time this can be the last thing parents remember to do.  Mums on Facebook said:

"I found it very upsetting that bounty still sent me vouchers to get their packs when I lost my baby. You would think they would get the idea when I didn't collect a hospital bag but they still sent me the voucher for it months after our baby had died."

and

"Bounty failed to remove me from their mailing list when I let them know our first baby had died in utero at 17 weeks- which meant I received (amongst other things) a tiny nappy sample through the post a few weeks after we had lost him.  I am not ashamed to admit that wee nappy had me weeping on my knees in the hallway."

and

"I lost my first son 20 weeks into pregnancy and the constant emails and post from Bounty and associated companies almost pushed me over the edge."

Again a problem that doesn't seem new - in a large discussion about Bounty on Mumsnet a few years ago one mum said:

"Bounty still sent me a pack every 3 months or so after my stillbirth and it was pretty upsetting to be honest. Once you are on their list it's virtually impossible to get removed."

3.  Environmental Issues?

I'm not a hardcore green activist but the one thing mums say over and over again when discussing Bounty packs is "I took out the samples and binned the rest".

Just a couple from the many on Facebook/online:

"I didn't mind the bounty packs, got a couple of fairy/persil coupons/samples and binned the rest, along with alot of the leaflets re bf, cosleeping, pnd etc

and

"We were all handed one in the waiting room for one of mu appointments. I kept the comfort pure samples and binned the rest"

and

"A load of stuff that I threw in the bin and some advertising material thinly disguised as 'parenting literature'. Seriously though, I really can't remember as it was all stuff I didn't want to use."

Even if every single person recycles, how much recycling does 3.4 million Bounty packs generate?

There is an alternative!
Blackpool PCT are currently trialling Mama Packs.

Mama Packs are cotton bags [RRP£2] & the United Kingdom's ONLY ethically influenced, trade marked Mum & Baby sample pack.
Mums get better freebies, no advertising bumf and no selling of details to third parties.

If you're pregnant or due to receive packs, I hope this helps you make an informed decision as to whether to sell your details to Bounty.

UPDATE July 2014: Mumsnet found 82% of those surveyed felt it was unacceptable for commercial companies access to patients. Therefore they've campaigning for a ban on Bounty sales reps in postnatal wards. Click here for details.