Oversupply Syndrome Colic

Oversupply Syndrome Colic
Or
Foremilk - Hindmilk Imbalance

The reader is strongly encouraged to get the assistance of a Qualified Lactation Consultant (IBCLC) or their baby's physician in the treatment of Oversupply Syndrome.

Lactation Clinic POLICY:
A. The breastfed infant presenting with symptoms of colic or fussy baby will be observed for Oversupply (Overactive Let-Down) Syndrome.
B. Baseline infant weight must be established before starting treatment.
C. Treatment should not begin before baby is 3 weeks old.
D. Milk supply should be well established. (Initial engorgement at lactogenesis may temporarily produce the same symptoms. However, the symptoms will resolve as maternal engorgement decreases.)
E. Evaluation is based upon the presence of multiple symptoms. Most infants will exhibit over half of the symptoms listed below along with excessive weight gain.
F. All infants must be followed with serial weight checks whenever an alteration in feeding method and/or pattern is made.
G. The infant may present in the clinic as a failure to thrive despite an overabundant maternal milk supply (Woolridge and Fisher 382). Careful assessment and follow-up of the syndrome may prevent failure to thrive. Symptoms of failure to thrive may be masked by the early introduction of supplemental feedings and/or solids.
H. Syndrome may totally resolve spontaneously at 3-4 months possibly due to the normal reduction in maternal serum prolactin levels.

GENERAL INFORMATION:
A. Overactive Let-Down was first described by Andursiak and Kuzenko. Michael Woolridge and Chloe Fisher described the same symptoms as Oversupply Syndrome.
B Further study (over 500 cases in Kaiser Permanente Riverside lactation clinic in 4 years), indicates the syndrome is a fairly common cause of colic like symptoms in the breastfed infant.
C. Symptoms may be related to the infant getting too much milk too fast (excessive flow), air swallowing, the high concentration of lactose in foremilk, the volume of foremilk and/or lack of adequate hindmilk intake (Andursiak and Kuzenko 3; Nursing Mother's Association of Australia 3, 12, Woolridge and Fisher 382-384).
D. Woolridge and Fisher reported that 28% of the infants (50 babies in 18 months) referred to their clinic had symptoms of overfeeding syndrome. They classified 50% of those cases as severe. After corrective feeding management techniques were initiated 79% had partial or complete resolution of the syndrome. (383)
E. High lactose feeds are associated with rapid gastric emptying and fermentation in the infant gut resulting in abdominal distention. Lactase supply may be overtaxed resulting in lactose malabsorption symptoms. The same symptoms have been reported in toddlers who were fed skim milk by their parents to prevent later atherosclerosis. (Incorporation of milk fat in the diet alleviated these symptoms in the toddlers.) (Woolridge and Fisher 384)
F. Initial clinical impressions suggest that the condition may be iatrogenic in nature. However, recommendations for all mother's initially nursing their infants at both breast with each feeding to ensure an ample milk supply should continue (Woolridge and Fisher).
G. Persistent maternal sore nipples and latch-on problems lasting longer than 3 weeks, should also be investigated for Oversupply (Overactive Let-Down) Syndrome. The infant typically clamps the nipple to reduce the flow and does not strip the milk from the milk sinuses resulting in poor emptying of the breast (Woolridge and Fisher 383). Persistent engorgement has also been noted.
H. Recommendations here are for those infants who are symptomatic.

I. Baby's Symptoms:
     1. Appears colicky, fussy, gassy.
     2. Burps "like an adult" or burps poorly.
     3. Passes large amounts of flatus.
     4. Spits up frequently, often appears to be large amounts.
     5. May have tentative diagnosis of gastric reflux.
     6. Gains weight quickly (1-2 pounds/week).
     7. Often is 1 pound or more over birth weight at 2 weeks of age.
     8. Gulps with feedings or appears to choke with let-downs.
     9. Pulls off the breast frequently or chews at the breast.
    10. Grunts frequently between feedings.
    11. Abdomen appears full and distended especially after feedings. May have hyperactive bowel sounds.
    12. Will latch on only to the nipple or pinches nipple during feedings.
    13. Wants to nurse very frequently.
    14. Has short feedings (5-7 minutes).
    15. Nurses minimally on the second breast or refuses to take the second breast after nursing well on the first breast.
    16. Has a stuffy nose after feedings.
    17. Early or frequent ear and/or sinus infections.
    18. Has many (10-15) wet diapers per day.
    19. Has unusual stooling patterns:
       a. semi thick stools often described as "yellow cottage cheese", or "Peanut butter".
       b. Infrequent, large stools that remain liquid to soft in consistency.
       c. Frequent diarrhea like stools that may appear slimy and have and acrid smell due to fermentation of lactose in the infant gut.
20. Wants to suck hands or pacifier frequently.
21. If nursed lying down, may leave a "puddle of milk in the bed," choke or gulp less frequently.

J. Maternal symptoms:
1. Persistent sore nipples, often with a linear crack across the nipple face.
2. Nipple may come out of baby's mouth pinched, not round.
3. Mother feels that she has too much milk or complains of constant leaking.
4. Mother feels that she doesn't have enough milk because the baby appears to be "always hungry" or "not satisfied".
5. Mother complains of pain deep in the breast between feedings which may be from nerve irritation due to persistent nipple pinching. (The resulting neuritis symptoms may need to be treated with Ibuprofen 400 mg. every 4-6 hours as an anti-inflammatory for 2-3 days).
6. Mother complains of painful let-downs that sting or burn.
7. History of repeated engorgement, plugged ducts and/or mastitis.
8. Mother may have questions regarding her dietary intake as related to infant fussiness and gas.
9. Positive family history for "colic".
a. Had a similar history with a previous child.
b. Sisters who nursed report colicky babies.
c. Maternal grandmother reports problems with breastfed children
and colic.

A. HISTORY
1. Age of baby.

RATIONALE: In the first week of life neonates tend to be gassy from swallowed air and poor burping. Symptoms of "colic" are usually reported at about 2-3 weeks of age.

2. How often fed.

RATIONALE: Following the onset of mature milk, baby should be nursing on demand every 2-4 hours with an occasional 6 hour period between feedings. Fussy, gassy babies will nurse frequently to assist in soothing the gut by initiating peristalsis to pass the gas. Fat intake may control satiation and controls gastric emptying. In high lactose feeds the baby may need to nurse more frequently to have an adequate intake of calories from fat (Woolridge and Fisher 382).

3. How long at each breast.

RATIONALE: Baby may nurse well for 10-15 minutes at the first breast and not nurse on the second breast. Baby may only nurse for 5-7 minutes and appear satisfied especially when Oversupply (Overactive Let-Down) Syndrome is present because the stomach is over full. If baby does not take the second breast, mother should start the next feeding with the breast that the baby did not nurse on at the last feeding.

4. Number and type of wet diapers in the last 24 hours.
5. Baby's stooling pattern.

RATIONALE: Mother is concerned that because her infant is crying he must be hungry. After the fifth day of life baby should have a minimum of 6 very wet diapers with light yellow or clear urine per 24 hours. Urate crystals (brick dust appearance) are occasionally seen in the first few days prior to the onset of mature milk. Appearance of urate crystals after the first week suggests dehydration (Neifert and Seacat 35). Yellow, liquid to curdy stools should follow most feedings during the first month of life. Infrequent stools in the first few weeks are highly suggestive of inadequate intake (Neifert and Seacat 28 30, 35).
After 6 weeks of age is not uncommon for the entirely breastfed infant to go several days between stools. Infrequent or small hard stools may indicate malnutrition. Changes in voiding pattern are a later sign of poor intake. (Neifert and Seacat 28,34-35. Arizona Health Mothers Healthy Babies 20). As long as the stools remain soft and the infant continues to gain appropriately, the infant has adequate intake.
With Oversupply (Overactive Let-Down) Syndrome the high volume of foremilk often causes large, loose stools suggestive of a high lactose intake. Other patterns have also been seen (see above).

6. Any signs of infant illness.

RATIONALE: Rule out other causes of fussiness.

Fever, jaundice, stuffy nose etc. . .
If signs of illness are present refer to the medical provider.
7. Sore nipples.

RATIONALE: Persistent sore nipples or complaints of a pinching or biting sensation when baby is nursing are common with Oversupply (Overactive Let-Down) syndrome as the infant attempts to clamp off the flow. The nipple often comes out of the baby's mouth pinched, or misshapen or blanched white.

8. Pain in breasts between feedings.

RATIONALE: May be an indication that the nerve endings supplying the nipple and areola have been irritated.

9. Weight gain pattern for the baby.

RATIONALE: Excessive weight gain is essential to the diagnosis of Oversupply (Overactive Let-Down) Syndrome. Infants will often be one pound over birth weight at the 2 week pediatric check up. Gains of 1-1 1/2 pounds per week have been reported. Baby may have a history of rapid weight gain in the first 2 3 months followed by weight loss, lack of weight gain an/ or failure to thrive.

B. ASSESSMENT
1. Complete labor and birth history.
2. Physical exam, weight and suckling assessment of the infant.
3. Visual assessment of maternal nipples before and after nursing session.
4. Observation of a nursing session:

Assess latch-on for proper technique. Baby may only grasp nipple.
Do not attempt to correct the latch as this appears to be a coping mechanism to compensate for the fast maternal milk flow.
Listen for gulping or choking with maternal let-down.
Special attention should be given to infant cues (squirming, clicks, pops, increased respiratory rate after let-down, strength of attachment).
Express milk at let-down and observe for heavy spray.
Visual assessment of maternal let-down. (Wait for signs of let-down unlatch baby and apply light pressure to areola. Mothers with Overactive Let-Down may spray milk from multiple ports 3-6 feet).
Milk may spray from the opposite breast while baby is nursing or mother may soak bra pads loosing 1-2 ounces from the opposite breast with the initial let-down.
Observe nipple shape for signs of pinching at end of feeding.

C. TREATMENT
Goal of treatment is to reduce milk flow to a level that the infant can tolerate by reducing breast stimulation.

Note: The treatment for Oversupply Syndrome is deliberately left off my web site because in our clinic we've seen the treatment backfire and babies loose weight. It is important that the diagnosis is accurate before any treatment steps are taken. If a lactation consultant is not available to you, you may contact me via email regarding your situation. I prefer to evaluate your situation first and then send personalized treatment information. To obtain a copy of the OSS evaluation form click on the email me button below and request Oversupply Evaluation form.

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