Dealing Successfully with Oversupply Marie Davis, RN IBCLC.

Dealing Successfully with

Oversupply

Marie Davis, RN IBCLC

Disclosure Statement

I have a financial interest in “The Lactation Consultant’s Clinical Practice Manual” as its author and publisher.

Can a woman make too much milk?

• First described in at length in LC Series Unit 13 by Andrusiak, & Larose-Kuzenko 1987

• Woolrige and Fisher 1988• Very little has been written since• Almost no evidence based studies

Culturally Defined Expectations

• Pre-conditioned to assume low supply• “Breastfed babies don’t get colic”• An allergen in mom’s diet

Treatment •By educated deduction•Not uniformly applied•Treatment aimed at mother

Where’s the baby?

Screaming & Miserable

Blame Game

“Mom can’t make the right milk” “When is it hindmilk?”

Hence,Pump and give from a bottle…

Or

Formula must be the right milk

Colicky moms make for colicky babies

The Problem With the Internet

Google 40 K sites

Same breast for 12 to 24 hours

Cabbage to “dry up milk”

Elimination diet not working

Measured feedings

Hummingbird Effect

Nomenclature

• Inconsistent definition results in inconsistent treatment

- Almost all adjectives indicate pathology or place the blame solely on mom:

Polygalactia Foremilk/hindmilk imbalance

Overactive Letdown

Galactorrhea

Hyperlactation Hyperactive letdown

Definition remains elusive

Problem described differently

depending upon perspective

Overabundant Milk Supply and Forceful

Letdown Reflex

The main barrier to research is a lack of an objective and universally applied definition

Syndrome :A syndrome is a group of symptoms

that consistently occur together or a condition characterized by its associated symptoms

Oversupply Syndromeis a predictable sequence of symptoms in

both Mother and Baby

Once the syndrome is defined

• Treatment can be standardized

• Research can begin

• Evidence based practice results

Not a researcher

Chart Review

304 contacts

evaluation & treatment

187 who followed up

Informal Study

Protocol

Purpose—not cookbookSystematic approachAllows practitioner to see trends

Diagnostic rut?

• Allergy if -----

• GER

• 6th time you’ve seen these symptoms this week

Presenting symptom is usually “colic”symptoms

Colic rule of 3’scried for more than 3 hours a day,

and more than 3 days a week

over at least 3 weeks

True colic; defined as colic that occurs without a known cause, therefore, not the result of OSS

Differential DiagnosisPlugged ducts/ Mastitis

Sore nipples

Latch on Problems Low supply

Allergy Vomiting

Congestive heart failure

Pyloric stenosis

Sepsis GE Reflux

Medical findings

• Overlapping symptoms

• Colic

• Reflux

• High tone

Baby’s Symptoms

Excessive, early weight gain plus

Gassy, fussy Unusual stooling patterns

Short feedings Gulps or chokes

Makes popping sounds Frequent demand

Many wet diapers per day

Baby’s Symptoms• Stuffy nose

• Poor latch

• Unsatisfied sucking need

• Early ear infections

Mom’s Symptoms• Persistent sore nipples.• Linear crack across the nipple face. • Nipples reddened, bruised or purple• pc nipple:: pinched, white

– often has ridge

• Milk sprays or gushes when baby comes off the breast

• Opposite breast leaks large amounts while nursing/pumping

Mom’s Symptoms (continued)

• Problems with nipple thrush •Recurrent plugged ducts

• Early or recurrent mastitis

• Initial engorgement

– Moderate to severe

– Lasting 2-5 days

• Letdown sting or burn (about 50% say can’t feel)

• PPD

Familiar Component

• Some women appear to be genetically predisposed to excessive milk supplies

• 1/3 report sister or mom with OSS• Tends to get worse with subsequent pregnancies

unless managed early postpartum

Understand the Controls

Maternal

Initial supply hormonally driven

Local Feedback

Managing feeds

Infant

Fat slows gastric transit

Excess Lactose Fermentation

Air swallowing

Classes of OSS

1. Primary: No apparent cause

2. Secondary: result of disorder elsewhere (pituitary tumor, allergy)

3. Induced: caused by something the mother is doing (excessive pumping, galactologues)

Temporary Oversupply

Strongly recommend not to begin treatment other than 1 breast per feed until baby is 3 weeks of age unless prior history

Phases of OSS

1st Phase: relativity mild colic, easy to treat symptoms

2nd Phase: Copious amounts of milk Baby is beginning to fight at the breast, milk supply out of control, frequent plugs and or breast infections (stasis)

3rd Phase: Baby refusing the breast and loosing weight, mom's supply severely diminished

First phase treatment

• One breast per feeding 2-4 hours• Cue feeding• Posture feeding elevated clutch hold• Frequent Burping IF TOLERATED• Allow some fullness in breast• Work on latch-on problems as flow

slows

Anticipitory Guidence

• 1st 24 hours

• 24-48 hours

• 72 hours

• Change in stool usually first clue

Second Phase Treatment

More time on one breast but not beyond 4-6 hoursAddition of Sage tea and/or Pseudoephedrine

– Timing of meds is important– Dose

Mint - Aromatic oil through milk drying and may help soothe infant stomach

Suggest conservative elimination diet DairyDietary supplements

Pump out Re set milk productionConsider infant meds Nipple shield

Severe OSS

Mom Baby

Trial of BCP Gentle back to breast-self attachment

Pump and feed Rebirthing

Consider unilateral weaning

Special Situations

• The pumping mom

• Mom with twins

• Previous history

• Supply won’t down regulate

• Baby’s with huge appetites

Suggestions for further study

• Substances/foodstuffs known to decrease supply should be studied

Marie Davis RN IBCLC

[email protected]

• Extended bibilography available by request