My first ten years as a lactation consultant in the hospital, my biggest challenges were obtaining an optimal latch in a baby much too uncoordinated after a challenging birth and maintaining mom's milk supply. The next ten years as a homebirth #midwife, my challenge with clients was managing an over-abundant milk supply that didn't overwhelm the newborn gut creating weight issues or extreme fussiness.
The latter was more my own issue, when I was nursing my own littles, in spite of having pretty complicated births. My body's ability to make milk is almost unbelievable, but having fed six children and donated to a plethora to others, there is no denying this crazy little superpower.
While nursing my second child, Noah, I returned to work full-time just a few weeks after his birth. I worked 12-hour shifts and drove just over an hour each way, so I had long spans of time where I was pump dependent. While I suffered some exceedingly challenging birthing scenarios, I could sit down at my pump at work and pump off about 20 ounces per session. I certainly got some looks when I replaced the bottles that came with the pump with full size bottles and had to switch them out part way through pumping! This over-abundant supply was an excellent challenge when there was so much working against my success, but with my fourth, I was at home, nursing on demand, and my son was completely overwhelmed.
In my own case, my over-abundant supply created a super forceful let-down, but these two things don't always align. When nursing my second son, he would simply open his mouth and let the spray leak out of his mouth. It would run down my side and all over my seat, so I learned to stick a cloth diaper in there to catch the overflow. He really wasn't too bothered by this abundant supply, but when uncovered, I could squirt nearly across the room, even from the other breast. My fourth son though, just guzzled. He was utterly overwhelmed and a few weeks in, his belly was so upset he would cry all evening.
I wasn't as aware of what could result from an over-abundant supply 25 years ago and I certainly didn't know much about gut flora and foremilk and hindmilk imbalance. I don't think it was until I had my fifth child and was still nursing my fourth, that it became more clear to me that because his brother could help manage the abundant supply, my fifth didn't seem to struggle in the same way.
Might You Have a Forceful Let-Down?
When your little one is at the breast, do they sometimes gag and gulp, or do you notice your milk spraying out of their mouth? Some babies choke, cough, and gasp. Many babies will just come off the breast and let the milk spray or leak out of their mouths, but others will clamp down, almost biting, to slow the flow of milk. There are babies too who will manage it, but you'll hear clicking when they nurse as they lose their seal or they will spit up, be especially gassy, or even become exceedingly fussy. Comfort nursing may not be their preference.
This spray when you let down is called a forceful let-down and it can seem like feeding from a fire hose. As mentioned, this is often associated with a super abundant milk supply, often starting at about three-to-six weeks of age. Forceful let-down runs the gamut from a minor inconvenience to a major problem, depending upon how severe it is and how it affects the nursing relationship.
How to Help Baby Manage a Forceful Let-Down
This one is often a pretty easy fix. Move baby's airway higher than the spray of your breast, so they aren't down stream from the rushing waves of momma's milk. If you typically nurse in the madonna position, with baby cradled across your belly and your breast falling down into their mouth, then they are completely vulnerable to this spray. If you were to lean back in your recliner though, and let baby straddle your thigh and lean forward into the breast, then they have more control over the spray of milk. Chomping on the breast is greatly reduced. Side-lying and football hold are two additional options.
The other technique I often used, was to hold my breast in a scissor hold and when I felt the let-down, I'd squeeze a bit, putting a little pressure on my breast to slow the spray. If you need even more assistance, consider pumping at the start of your feeding, especially from a really full breast to reduce the pressure when your milk lets-down, but only a smidge. As your baby grows bigger, they will better manage this initial spray of milk.
Burping more frequently can be helpful, because little ones gulping at the breast are often swallowing a bit of air that may upset their bellies. Nursing more frequently can also help, so less milk accumulates between feedings. Nursing when baby is sleepy will relax their nursing a bit, and often your milk flow.
Another approach, and this really should be done in coordination with support with a breastfeeding-friendly clinician, is to adjust your milk supply. You might need to down regulate just a bit, but be super, super cautious of this in the early weeks because you can over adjust and really harm your breastmilk supply. We really try to avoid this in those first few weeks, but admittedly, I've done it on occasion.
Smaller babies can really become overwhelmed but can catch up quickly so the above tricks can be implemented while they are growing in those early weeks posing no risk to your supply. These first few weeks is when all effort is put forth to make milk and the more the merrier most of the time. Your body starts to better regulate this closer to six weeks, so between baby growth and milk regulation, this soon corrects itself without much adjustment.
Milk makers, like myself, sometimes really benefit from block feedings. My kids were chubby to the point that people would ask if my kids were okay. They were huge fast and my pediatrician would recommend reducing their feedings. When I donated to surrogates and even toddlers with significant syndromes that caused them to grow exceedingly slow, most all of them nearly doubled their weight in an exceedingly quick period of time. For this reason, my children typically nursed from only one breast per feeding and sometimes the same breast for several feedings at a time. If your little one isn't gaining though, block feeding may or may not be a wise approach, so certainly you'd want to work with a breastfeeding-knowledgeable clinician.
How to Manage an Over Abundant Supply
If appropriate to block feed, then invite your little one to nurse on either breast just as you would offer them dinner. Allow them to eat until satiated. If they want to nurse more after a burp or after dozing off for a moment, offer the same breast again. If the unused breast is uncomfortably full, express just enough to be comfortable. You could even try cool cabbage leaves which are both cooling and can reduce milk production.
Some mommas will return their child to that same breast for blocks of time, maybe two hours, four or at the extreme end, closer to 8 hours of time. This really should be managed with a knowledgeable breastfeeding support person though because the risk here is dramatically losing your supply and even clogged ducts, mastitis, or worse your little one not consuming enough nutrition. This is a tricky approach, that works incredibly well when managed just right, but there is a good amount of complexity here. Admittedly, if my client were to do this without my involvement, I would be a bit nervous, unless we had done this together previously with great outcomes.
Ultimately what block feeding does is let one breast become a bit more full, which signals the brain to reduce production. The breast being nursed is not becoming as full so the milk provided your baby will have a higher fat content which is quite soothing to their belly. This strategy can be a lifesaver, but what many are not aware is that milk is squirting in your baby's mouth does equate exclusively to an oversupply. There may be other causes or these two variables may be completely independent, so block feeding with anything less than an over abundant supply is going to harm the breastfeeding relationship.
What really may be the case is you have a little one still learning to coordinate the suck, swallow, breathe pattern and so occasionally they are pulling away to get their breath. Sometimes it is all about positioning and just bring them above the spray of milk offers them more security and the comping or gulping is reduced. More often I think of block feeding when I have little ones presenting with some level of dysbiosis, because a higher degree of foremilk from those fuller breasts can create a bit of an imbalance in the gut for which many babies do just fine, but some may have a bit of colitis, and at the extreme, some do lose weight because in spite of an abundance of milk, their belly is so inflamed and therefore excreting mucous, they are not absorbing nutrients well.
Other Tricks from My Old Midwifery Bag
A few more tricks that seem counter-intuitive is to completely drain each breast with a great pumping session and start from scratch. Sometimes this can sort of reset that supply and demand, and sometimes you will have to return to block feeding, but the edema is less significant and you feel a bit caught up and not so overloaded. Other women though, have more success with switching more frequently during a single feeding, as opposed to block feeding. This isn't a method I've used a lot because it can aggravate baby.
Be mindful of plugged ducts and mastitis, which are not one in the same. When you load up on milk and it sits for a bit, you can get a sort of knot in your ducts where milk stagnates a bit. The milk isn't bad per se, but this can inflame your tissues. This is more common if you feed in the same position most of the time because some ducts will drain better than others. Vary those positions. If you haven't tried side-lying, this is a must-do. Massage your breasts a bit while you nurse to help work out milk in every corner. Plugs are also more common when you are fuller for longer periods, especially at night, so again, be mindful.
Don't over-stimulate your breasts. If you use a pump and express more than you need to for comfort, regularly, you will make more and more milk. Keep in mind though that babies tend to grow into the abundance of milk and will eventually handle it quite well. Three months tends to be a turning point for many moms, but some, like myself, find block feeding to be their norm.