“You’ve got so much milk! You’re so lucky!” “No, I’m bloody not”: oversupply, ‘colic’ and ‘reflux’

When we’re so used to new mums worrying about low milk supply, it’s easy to forget what life is like for women at the other end of the spectrum.

Imagine a baby with the natural urge to come to the breast but when they get there they find it overwhelming, distressing and unsafe.

Imagine a young baby who chooses NOT to breastfeed when they need comfort and reassurance.

Oversupply can be miserable for everybody concerned and it doesn’t help when you’re surrounded by people telling you how lucky you are.

It’s important that we know what oversupply can look like, what to do about it and what it’s not. There is an epidemic of confusing oversupply and its accompanying symptoms for ‘colic’ and ‘reflux’. There are many babies right now being dosed with infacol, lactase drops, Gaviscon and reflux treatments, when the issue is simply that mum has too much milk or that improvements can be made with an adjustment to positioning.

It’s not clear why some mums seem to produce more milk than their babies need. In some cases it might be as a result of expressing with powerful modern electric breast pumps (and mums getting the message that regular pumping is part of normal breastfeeding). Perhaps they have more prolactin than average or large amounts of glandular tissue. Often there’s no obvious cause.

The problems will normally start to show themselves after the first week or so. It may be that some feeds are less of a problem (perhaps nights are easier) or that every feed is a struggle. A baby will look like someone dealing with a large volume of liquid being pushed down their throat which is not surprising as that’s often what’s happening. You may hear spluttering and choking. A baby may break off to take a breath (and mum may notice a spray of milk). A baby may cry or be obviously distressed and grumpy.

This baby will probably not feed for long. They may not need to because they are getting what they need in such a short time. As a result, these are the babies of mums who really don’t need the ‘advice’ to ‘feed for at least 20 minutes or baby won’t reach the fattier milk’ and a great demonstration of the fact that you can’t make rules about how long a feed should last.

Sometimes a baby may break off prematurely when actually they could have done with a bit more. If this is going on it will be reflected in the baby’s weight gain and these are the babies who are more likely to have mucousy green frothy nappies or have some digestive discomfort. These are the babies who are going to develop the symptoms that look a lot like ‘colic’.

Colic isn’t a very useful word. It’s a term used as a threat to new parents. It’s the thing we fear but we don’t really know what it is we are fearing. Unhappiness and lots of crying seems to be the basic summary but normal healthy otherwise happy newborns will have periods in an ordinary day where they are fussy and unsettled. It’s normal for a baby to cry on and off for most of an evening. It’s normal for a baby to only be calmed on the breast and want to feed almost constantly for several hours. It’s normal for parents for feel desperate and confused and perhaps worry that either there’s a problem with milk supply or their baby is behaving unusually because something is wrong. If they are calmed on the breast (even if only for a short time and they don’t actually appear to be swallowing much) then that sounds like normal evening fussiness.  One definition of colic (Wessel’s definition) is three hours of crying,  three days in a row,  three weeks in a row. By that definition, no one can say that a week old baby has colic or even a two week old baby. Normal evening fussiness may not develop in the first couple of weeks. A common call to the helpline goes like this: “Help! When we first got home from the hospital, our baby slept in the Moses basket in the evening and we ate dinner and watched TV and then we all went to bed together at 11ish. Now my baby cries most of the evening. He wants to feed constantly from about 6pm to 10pm. I haven’t even got time to eat dinner or go to the toilet. Is this colic?” That doesn’t sound like colic but normal cluster feeding or growth spurt behaviour and normal behaviour for a baby in the first few weeks of life. The parents who get the evening shift are luckier than the ones who get the 1am-4am slot.

It’s also normal for babies to be windy. The reality is that a large group of mums perceive their babies to be windier and fussier than average but we can see that statistically that doesn’t make sense. If lots of babies have periods of being fussy and windy and unsettled, that IS normal. We need to check latch and positioning because when there’s a problem that means an opportunity for air to get in. It’s surprising how many babies struggling with wind and digestive pain are more comfortable once changes are made: the gape has improved;  the tongue is placed correctly on the breast; the head is tilted with the chin burying into the breast and once that cheek is touching the breast (on both sides). It's also normal for babies to be grumpy just before they poo. You'd think this natural process would be nice and easy but no.

However beyond what’s normal, babies dealing with oversupply and overactive letdown are more likely to be windy and more likely to be dealing with digestive discomfort.

How would we know it was due to oversupply? We’ll see that classic behaviour on the breast of the bobbing on and off and struggling with faster flow. We may also find a baby who is more likely to get hiccups, get trapped wind, produce explosive poos and bring up milk after a feed.

Bringing up milk after a feed isn’t the reflux we worry about. The word reflux just means ‘a flowing back’. It’s normal for some milk to come back out when little babies have immature sphincter muscles at the top of their stomach. If they take in too much milk, a bit comes back up again. That’s not a negative, that’s a safety mechanism that prevents stomach stretching and overfeeding. Plus the baby gets breastmilk with all its lovely growth factors and immunological factors sliding past on the way down and on the way back up again! When an air bubble comes out, sometimes milk comes out. The milk surrounding the trapped air bubble will come out too. All perfectly normal. Messy but normal.

When it’s not just milk coming out but acid too and a baby is in pain, that’s the reflux that we might worry about. A baby bringing up with a look of surprise on their face rather than a look of pain doesn’t need medication. These are the babies with a “laundry problem” rather than a “medical problem”. Unfortunately it’s the laundry problem babies that are sometimes still finding themselves in the GP surgery. Parents are worried that too much milk is coming up and they want to stop it happening. Sometimes these are parents focused on intervals between feeds and believing that that the small amount of milk coming out is preventing them from reaching the 3 or 4 hours their baby book says should be the aim. GPs may provide Gaviscon – a thickener that stops the stomach contents from lifting up through the oesophagus – but as we already know this may not be the ideal if this process is actually a safety mechanism. Gaviscon has other side effects: the thickening continues through the system and these babies may start to develop constipation and certainly have firmer stools. We end up seeing babies in genuine pain with constipation due to medication that was trying to solve a problem that wasn’t actually a problem in the first place. When you give a baby infant Gaviscon, you are giving them sodium alginate and magnesium alginate which form a gel in the stomach when they come into contact with stomach acid and thickens the stomach contents. Let’s not do that unless we really need to, not to avoid normal posseting.

When babies spit up, it can look a lot. Mums talk about ‘the whole feed’ coming back up. This is unlikely to be the case. If you get 1 fluid oz (30ml) of cow’s milk out of the fridge and spill it down the front of a baby gro, I think you’ll be surprised how far it will go. They will be drenched. If a baby is taking in 60-80ml and even 20 mls comes out, that’s still going to look like a lot but the majority is left happily behind. It can be normal for a baby to posset after EVERY single feed. This still isn’t a baby in need of medication.  Another problem with giving Gaviscon is delivering it to a breastfeeding baby. The manufacturers suggest mixing the powder with cooled boiled water to make a paste and then giving it AFTER a feed using a syringe or spoon. I worry that many mums will be tempted to give a bottle (with potential impact on latching or milk supply) just to deliver this medication. Plus giving a young baby something in a spoon when they will usually still have a tongue thrust reflex is an impossible mission. Syringe feeding a sleepy baby (breastfeeding contains hormones like oxytocin and cholecystokinin which encourage drowsiness) is likely to be an aspiration risk. This may well mean feeds end early and babies are broken off before the right amount of high fat content milk has been reached.

So please let’s not give Gaviscon to babies that bring milk back up but aren’t in pain doing so.

If ‘colic’ or ‘reflux’ is to do with oversupply, it can be fixed. Colic is usually used to describe babies with digestive discomfort. They may raise their legs while crying or we may hear their tummies rumbling. They may be red in the face or rigid with discomfort. It has been suggested that these babies have issues with their gut flora and probiotics may help. They may have hypersensitivity of nerves in the gut and the underlying cause is not known, though babies will usually grow out of it between 3 and 4 months. Some of these babies may have food intolerances. A reaction to dairy protein is a possibility though that will usually be accompanied by other symptoms such as a skin condition, unusual stools (which may even be blood flecked) and weight gain issues.  Mums who smoke are more likely to have babies with colic.

Increasingly, companies are marketing products at these understandably desperate mums. Gripe water is an old-fashioned remedy which historically contained nearly 4% alcohol (and various herbs, bicarbonate of soda or ginger).  We now realise giving babies a raft of mysterious untested ingredients seems like a bad idea when we know so much more about gut flora and the relationship of our vital friendly bacterias to the Ph of our gut. Most of us know now that it’s not wise to give young babies herbal teas or plant extracts but if the product is being made by pharmaceutical companies then we inherently trust it.  Mums are being told to use ‘colic drops’ that often contain lactase. The theory is that babies are reacting to lactose and need help digesting it. Lactose is the sugar naturally found in all breastmilk (it’s not about dairy intake) and true lactose intolerance is very very rare. To give lactase drops, we’re spoon feeding those young babies with the tongue thrust again. This time when they are hungry and hoping for breast.

At least if a mum gives Simeticone drops (which help air bubbles to clump together to leave the body more easily) it can come directly from the dropper. Although I’m not sure we have research on giving babies ‘natural orange flavour’ several times a day.

I know there are mums who find some of these products useful. Of course, babies with genuine acid reflux find thickeners helpful.  I know there are mums who like giving droppers and other products. They feel it helps. I’m not down on everything on the shelves in Boots the Chemist.

I’m just saying that if you suspect oversupply or positioning and attachment might be your issue, get some breastfeeding support before going down to the pharmacy or to the GP. Let’s try and solve the underlying problem rather than fiddling around with spoons and exposing our babies to unnecessary chemicals.

Chemicals can be wonderful but let’s save them for the babies who can’t have their issues resolved after a fifteen minute chat with a lactation consultant or breastfeeding counsellor.

If your baby is gulping and choking and it appears to be about the volume of liquid going down their throat; if your letdown pain is quite strong; if you pump a large amount in a very short time; if you get extremely engorged and uncomfortable inbetween feeds – these could be clues that oversupply is an issue. You may hear baby clicking which indicates a loss of seal and can be associated with a large volume of milk. Baby may slip off or attempt to shallow the latch to cope with the flow.

What can be done about it? First of all, let’s check that some of these issues aren’t about positioning and attachment problems rather than oversupply. Babies may protest, shallow their latch, be fussy, slip off and wiggle around when mums just need to position them in a different way. We’ll assume you’ve had positioning checked and it’s clear there’s too much milk. Let’s also check you haven’t been removing your baby from the breast prematurely which can also result in some of the lactose overload problems and fussiness associated with oversupply. Ideally baby will come off the breast when they choose to do so or when they have stopped actively feeding and swallowing. If you are not sure what swallowing looks like, this video can help: https://www.youtube.com/watch?v=7giyNvlCW18 It's also true that babies with tongue ties (especially posterior tongue ties that are often missed by healthcare professionals) are sometimes the babies struggling at the breast - bobbing on and off and choking and spluttering. Babies with tongue restrictions will have problems grooving the tongue and swallowing the bolus of liquid effectively. If your baby is fussy, it's a good idea to get their tongue assessed alongside a general check of latch before you start any kind of supply adjustment.

How old is baby? If baby is under six weeks, you might be in a group of mums who start off with overproduction but things settle down as the body gets used to your baby’s natural levels of intake. Your body regulates from the higher prolactin baseline to the one that will become the norm for the rest of your time breastfeeding. So it may well be that your supply eases without you having to do anything at all. If we fiddle around with your supply in the early weeks and then you experience this shift, things might go too far the other way so it may be wise to hold on and see. That doesn’t mean that you can’t do anything though if your baby is really struggling with fast flow.

Milk comes out because of your milk ejection reflex (the oxytocin arriving in the breast and contracting muscles to push the milk down through your ducts) and your baby’s ability to remove milk using their tongue and create negative pressure inside their mouth. It’s not much about gravity. But if liquid is flooding into your throat and you are UNDERNEATH the flow, that’s more likely to be overwhelming. You won’t feel safe taking a breath. You are more likely to feel out of control and feel the need to break off. When we feed babies in a cradle hold, cross-cradle hold or rugby hold and they are under the breast, it’s understandable they feel more overwhelmed. If we lean back so the baby is more above the breast, this is likely to prevent the milk pooling in the back of their throat and hopefully they will feel less out of control.

You could get them on in their usual position but then scoot your bottom forward and lean back – just make sure you have back support for yourself. You could also use positions where the baby is seated, perhaps with one leg astride each side of yours and their mouth level with the breast. By changing position, we’re hopefully going to result in the baby staying latched on properly throughout the feed. This is going to mean less air getting in and less windiness, colic and possetting.

I’ve heard of mum pumping before every feed to take off the faster milk. This really isn’t sensible as you’re stimulating your supply and telling your body to keep production at this level. One option might be to get the letdown started and then you could let the faster milk flood off into a muslin cloth before reattaching baby but this wouldn’t be fun in the long term. Some mums also get results by pressing on their breast with the side or heel of their hand at the begnning of a feed and blocking off a section of their breast but again this isn’t wise in the longer term and it could increase your risk of blocked ducts.

If changing positioning doesn’t help things and your baby is a couple of months old, it could be time to consider reducing your supply on purpose. We know that when the breast is full, this slows milk production. A fuller breast stretches the prolactin receptors in the alveoli so more prolactin can’t be received. A fuller breast accumulates a whey protein known as FIL (feedback inhibitor of lactation) and this seems to slow milk synthesis.

Before we play around with supply, we want to make sure that this isn’t a baby struggling with other issues such as weight gain. It is true that some mums with significant oversupply could still have a baby with weight gain problems. If a baby is taking in a large volume of milk, they may be filling up before they get to the higher fat content milk. They may have frothy green mucousy stools and be particularly gassy from getting the larger doses of lactose which we find in the lower fat content milk. When lactose is in large quantities, baby may not be able to digest it all effectively. It may travel through the gut undigested and this faster transit can result in greener poos. Undigested lactose can move into the large intestine and start to ferment and produce extra abdominal gas.  Good bacteria are important part of digestion so it makes sense that we are concerned that babies with digestive problems are potentially struggling with gut flora issues. If we take the edge off your supply, they should hopefully start to receive proportionally more of the higher fat content milk.

However it’s not sensible to intentionally reduce your milk supply without proper supervision if your baby has green stools and weight gain problems. This can also be a sign of insufficient milk supply. A baby may also bob on and off the breast and protest when the flow is too slow. This is a time to talk to a lactation consultant or an experienced breastfeeding supporter. It’s important to note that green poo can be a normal coloured poo for a happy healthy baby. We’re only going to worry if it’s frothy, mucousy and accompanied by other symptoms.

A way to reduce supply, when we are confident that is the problem, is to use a technique called block nursing. This means the baby stays on one breast for a block of time. This isn’t because we aim for them to have slower milk for a few feeds in a row but because it means the neglected breast will accumulate milk and the body will receive signals to reduce production. If you aren’t already doing single-sided feeding (offering only one breast for each feed), you can start with that. If that doesn’t improve things, you could then spend 24 hours experimenting with two feeds on each breast. That’s going to mean something like 4-6 hours with all the feeds being on the same side. The neglected breast may become engorged and even a little bit uncomfortable and this will send messages to reduce production. Then you swap and the other breast gets its turn to be fed from for a block of time. After 24 hours of blocking, you could then return to single sided feeding and see if things are any easier. In some extreme cases, mums may need to block on one side for three feeds or even more.

This technique can mean that mums are more at risk of blocked ducts or even mastitis. Once you come back to the neglected breast after a gap of time, flow may be particularly overwhelming so this is a good time to use that technique where the first milk floods off into a cloth before the baby attaches properly. After the first feed back on that side, it’s a good idea to check that no firm areas remain and the breast has been drained effectively. You may have firm areas before a feed and even lumps which may just be the glandular tissue full and distended under the skin. All the way along, let’s use our instincts. If a baby is indicating that they aren’t happy staying on one breast and they need more, this may be a time to abandon this method and try something else and check our thinking.

If mums have a history of mastitis (and that may not be unusual if mums have a history of overproduction), the idea of block nursing can be a scary one. An alternative option is to use natural remedies that reduce milk production. Applying cabbage leaves to the breast can reduce supply (which is one reason we want to be cautious in recommended this to brand new engorged new mums). Sage is also a useful herb. I once spoke to a breastfeeding supporter who claimed she spoke to more mums with supply problems after Thanksgiving and Christmas and all the sage and onion stuffing. That sounds a bit unlikely unless they are serious stuffing fans but sage does appear to have an effect. If you are not ending breastfeeding, you’ll need to be cautious. Kellymom.com (http://kellymom.com/bf/can-i-breastfeed/herbs/herbs-oversupply/) recommends taking ¼ teaspoon of dried sage three times a day for up to three days. It can be combined with food or drank with vegetable juice.

Some mums also reduce their milk supply using pseudoephedrine, an ingredient in decongestant and cold and flu medicine. Birth control pills containing oestrogen can also reduce supply. However I hope no one is starting off with decongestants and hormonal contraception without proper guidance and having tried other remedies first.

Sadly there aren’t fixes for every baby with colic symptoms or reflux symptoms. Some of these families are going to need medication and all the support they can get. However let’s just check that babies we know aren’t part of the trend of misdiagnosing colic and reflux when actually the problem is latching and positioning or oversupply and it can be sorted with some skilled help. I have known many mums and babies who have had ‘colic’ and ‘reflux’ disappear overnight with after a short conversation on latching or a couple of days of supply adjustment. But that doesn’t make the pharmaceutical companies any money, does it? And our GPs may not have the 15 minutes to spare nor the training in breastfeeding to resolve an issue that could be pretty straightforward.