The following information is from The Lactation Consultant's Clnical Practice Manual and represents the list of symptoms and history gathering information.

It is intended for lactation consultants and interested health care providers.

In 2008, I presented my the result of my studies into oversupply syndrome at the International ILCA Conference in Las Vegas.

Portions of that presentation can be seen here: (download the powerpoint)

If you are a mother and think this may be your problem  read --- More on oversupply and Oversupply Syndrome and Colic

All treatment for Oversupply Syndrome is deliberately left off my web site. In our clinic we've seen the treatment backfire and babies lose 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" or copy from html, or download the form in MS Word and email it back to me.

Policy

1. The breastfed infant presenting with symptoms of colic or fussy baby will be observed for Oversupply (Overactive Let-Down) Syndrome.
2. Baseline infant weight must be established before starting treatment.
3. Treatment will not begin before baby is 3 weeks old, unless there is a prior history of Oversupply. Risk of down regulation may be slight but is possible.
4. Milk supply should be well established. (Initial engorgement at lactogenesis II may temporarily produce the same symptoms. However, the symptoms will resolve as maternal engorgement decreases.)
5. Evaluation is based upon the presence of multiple symptoms. Most infants will exhibit over half of the symptoms in evaluation form along with excessive weight gain.
6. All infants must be followed with serial weight checks whenever an alteration in feeding method and/or pattern is made.
7. 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.
8. Syndrome may resolve spontaneously at 3-4 months possibly due to the normal reduction in maternal serum prolactin levels. However some women continue to have over abundant supplies into the 6th month of breastfeeding

General Information

1. Overactive Let-Down was first described by Andursiak and Kuzenko. Michael Woolridge and Chloe Fisher described the same symptoms as Oversupply Syndrome.
2. Newer literature mentions that there may be an oversupply of milk with or without a forceful milk ejection reflex.
3. Further study (approx 1000 cases in Kaiser Permanente Riverside lactation clinic since 1989 and 350 cases from Internet contacts), indicates the syndrome is a fairly common cause of colic-like symptoms in the breastfed infant.
4. 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).
5. 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)
6. Initial clinical impressions suggest that the condition may be iatrogenic in nature. However, recommendations for all mother’s initially nursing their infants at both breasts with each feeding to ensure an ample milk supply should continue (Woolridge and Fisher).
7. Mothers will be taught “cue feeding” methods rather than timed feeding. Cue feeding is physiologic, based on infant’s needs and not arbitrary times and routines.
8. Current tendency is to advise mother to “block feed.” Unfortunately, this has brought mothers to the clinic that are using the same breast for up to 6 hour (or more) “block” period. Women have a tendency to increase that time without supervision. A breast could potentially be left “unused” for nearly 10-12 hours. This as serious implications for future milk supply. Arbitrary feeding times from a single breast should be avoided.
9. 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. Infant starts day out well, as lactose builds behavior becomes more and more unsettled. The same symptoms have been reported in toddlers who were fed skim milk (Incorporation of milk fat in the diet alleviated these symptoms in the toddlers.) (Woolridge and Fisher 384)
10. The addition of essential fatty acids to the maternal diet appears to help with the fat quality in breastmilk and appears to reduce infant symptoms. Maternal diets are typically low in quality fats; some women may even be following a low fat diet for weight loss. Although the amount of fat in breastmilk remains consistent studies show that the breast will take high quality fat before using lower quality fat stores. Supplementation with EFA’s changes the quality not quantity of fat.
11. Mothers with a diet high in simple carbohydrates appear to have a greater lactose load in their milk. ***
12. Recent studies suggest that the mother of a “colicky baby” is at higher risk for postpartum depression
13. We have seen women in high anxiety states because the problem is oversimplified. They appear to be in search of “elusive” hindmilk. Inform the mother of the multi- facetted nature of oversupply and that baby does need foremilk. In fact, breastfeedings are mostly foremilk.
14. Occasionally a baby may appear to be continually hungry, feed frequently followed by episodes of regurgitation and/or vomiting and crying. Unlike vomiting associated with pyloric stenosis, the baby gains weight very rapidly and is adequately hydrated. It is possible that since fat intake signals satiety, and influences infant sleep patterns baby will continue to feed until fat requirement is met.
15. Syndrome appears to have 3 distinct phases; unrelated to infant age
    1. 1st phase: relativity mild, easy to treat symptoms
    2. 2nd phase: copious amounts of milk, baby may be reacting negatively to the breast by clamping and pulling, may start showing reluctance to nurse; mother experiences nipple pain, frequent engorgement, plugs and/or breast infections from milk stasis
    3. 3rd phase Baby refusing the breast, may be loosing weight, mom's supply severely diminished
16. Poor latch and nipple pinching is common. We believe the infant is using airway protection mechanisms. Once the supply is under control mother should be encouraged to work with baby to get a deeper/pain free latch-on.
17. The infant typically clamps the nipple to reduce the flow resulting in poor emptying of the breast (Woolridge and Fisher 383). Persistent engorgement has also been noted. Mother should be educated in prevention of breast stasis and the early recognition of breast infections.
18. Mothers may also suffer from frequent plugged ducts. Use standard measures for treating plugged ducts and advice mother to monitor for breast infection.
19. Nipple Thrush is a common co-finding. Perhaps because the nipples remain continually damp and/or high sugar concentrations provide an excellent medium for c. albicans growth. Treat as appropriate.
20. Persistent maternal sore nipples and latch-on problems lasting longer than 3 weeks should also be investigated for Oversupply (Overactive Let-Down) Syndrome.
21. Very often a baby with a very rapid weight gain in the early months will appear to “fall off his growth curve” at around 6-9 months, even though he is feeding well and has adequate intake of breastmilk and solids. This is not Failure to Thrive but may be what has been called “catch-down growth.” Advise the mother to schedule serial weight checks with the medical provider. If all is well the infant’s new curve will become readily apparent.
22. We have found cases where a breast pump is complicating the clinical picture. The early agressive use of a breast pump to increase milk supply (because the mother is concerned about not having enough milk but more often so mom has a freezer stash for when she returns to work) leads to oversupply. In some mothers. if we calculate the number of ounces her baby needs and the amount she pumps each day, ithe total equals double or triple the amount her baby actually needs. We have found that these cases will take longer to get under control. This may be due to the physiology of the breast in the early post partum period.

Recommendations here are for those women and infants who are symptomatic.

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 letdown.

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. 10-15 wet diapers per day.

19. Has unusual stooling patterns:
    • Semi-thick stools often described as “yellow cottage cheese”, or “Peanut butter”.
    • Infrequent, large stools that remain liquid to soft in consistency.
    • Frequent diarrhea-like stools that may appear slimy and have and acrid smell due to fermentation of lactose in the infant gut.
    • Blood in stools [occult or streaking] it is important to rule out other causes such as a reaction to cows milk protein—these babies usually have eczema or the “red umbilicus sign.”
    • Wants to suck hands or pacifier frequently.
    • If nursed lying down, may leave a “puddle of milk in the bed,” choke or gulp less frequently.
    • In later phases:

• May have experienced “colic” in the early months
• May be refusing the breast or mother is exclusively pumping
• May be losing weight

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, occasionally has a ridge along nipple face.
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 an anti-inflammatory medication for 2-3 days).
6. Mother complains of painful letdowns that sting or burn; [approximately 50% say they cannot feel letdown.] First letdown tends to be very painful if breast is overfull
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; or nay have begun elimination diet
9. Mother may express that baby does not like her or her milk
10. Positive family history for “colic”
• Had a similar history with a previous child.
• Sisters who nursed report colicky babies.
• Maternal grandmother reports problems with breastfed children and colic.

 

Procedure: Use the Oversupply (Overactive Let-Down) Syndrome Assessment Tool for a more complete list of symptoms and to document the problem.

History

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.

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).

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 overfull.

Number and type of wet diapers in the last 24 hours.

Baby’s stooling pattern.

Rationale: 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).

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.

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 flow. The nipple often comes out of the baby’s mouth pinched, or misshapen or blanched white or with a blanched ridge across the nipple face.

Pain in breasts between feedings.

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

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_ 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 and/or failure to thrive

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:
   1. 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.
   2. Listen for gulping or choking with maternal letdown. Special attention should be given to infant cues (squirming, clicks, pops, increased respiratory rate after letdown, strength of attachment).
5. Have mother express milk at letdown and observe for heavy spray (overactive letdown component).
   1. Visual assessment of maternal letdown. (Wait for signs of letdown, unlatch baby and apply light pressure to areola.
   2. Mothers with Overactive Let-Down may spray milk from multiple ports 3-6 feet).
   3. Milk may spray from the opposite breast while baby is nursing or mother may soak bra pads losing 1-2 ounces from the opposite breast with the initial letdown.
6. Observe nipple shape for signs of pinching at end of feeding.

Treatment (Lactation Professionals, please contact me for the complete protocol.)

The goal of treatment, based on history, is to use current techniques to relieve and/or alleviate symptomlogy

Reduce milk flow to a level that the infant can tolerate

Relieve infant GI distress

Prevent early weaning and/or breast refusal

Improve maternal comfort levels

Prevent prevent maternal complications of milk stasis (e.g. plugged ducts, mastitis, abscess)

Prevent any severe increase or decrease in overall maternal milk supply

Preserve breastfeeding

Phase I Realatively easy to treat if all the symptoms are addressed may resolve in as little as 72 hours.

Phase II May take a period of several weeks to sort out - adding interventions slowly based on symptoms.

Phase III In almost all phase 3 cases, both stage I and stage II have gone unrecognized, mother and infant have been dealing with symptoms for a period weeks or months, and have developed various coping mechanisms. The two more common presentations (in my practice) are listed as examples below. Unlike a nursing strike, these processes are gradual.

**"Studies by Prentice et al.,11 Abakada and Hartmann12 and Siber et al.13 have demonstrated that maternal diets which are low in energy,produce milk which is higher than normal in lactose. This, I have found in clinical practice, to be of great significance in treating cases of colic in instances where maternal nutrition is suboptimal, especially with respect to protein and complex carbohydrate intake; tending instead to favour a high intake of simple carbohydrate." [Hatherly, Patricia  THE MANIPULATION OF MATERNAL DIET AND ITSEFFECT ON THE INFANT WITH PARTICULARREFERENCE TO GASTROINTESTINAL DISTURBANCE… A SERIES OF CASE STUDIES Journal of the Australasian College of Nutritional and Environmental Medicine - Vol 13 No 2 - Dec 1994]

11 Prentice AM, Roberts SB, Prentice A, et al.: "Dietarysupplementation of lactation in Gambian women. Effect on breastmilk volume and quality". Hum Nutr Clin Nutr 37C: 53-64, 1983

12 Abakada AO, Hartmann PE: "Maternal Dietary Intake and HumanMilk Composition." Breastfeeding Review 13: 43-45, 1988

13 Siber H, Hachey D, Schanler R, et al.: ‘Manipulation of maternaldiet to alter fatty acid composition of human milk intended forpremature infants." Am J Clin Nutr 47: 810-814, 1989

Additional references for oversupply

© Marie Davis, RN, IBCLC     

Index/Home

The First 4 Weeks: Baby
Questions After The First 4 Weeks
Family Issues
Breastmilk Expression
Storage of EMM (Expressed Mother's Milk)
Working And Breastfeeding

Other Issues
About Me
Glossary
Works Cited

Last Reviewed: Saturday, February 11, 2012 11:14 AM

© Marie Davis, RN, IBCLC     

The First 4 Weeks: Baby

Questions After The First 4 Weeks

Family Issues

Breastmilk Expression

Storage of EMM (Expressed Mother's Milk)

Working And Breastfeeding

Other Issues

Index/Home  

About Me