Wednesday, 13 May 2015

Fast letdown/choking/clicking. Is it oversupply?

You've got through the first couple of weeks of breastfeeding and just as you start to feel it's going ok, your baby has started gagging and choking while feeding or maybe she is latching off and on and getting her face sprayed with milk.  Maybe during feeds you are hearing a clicking sound. Your baby also suddenly seems very gassy and upset.  You asked your HV who suggested it could be reflux.  A friend suggested it was a tongue tie.  You asked "Dr Google" who popped up lots of links on Fast or Forceful Letdown / Oversupply and gives a solution of Block Feeding.  This is a common scenario and a large proportion of mums and babies have this experience to some extent.  Do they really all have reflux/colic/tongue tie?  Do all these mums have oversupply?  Could it be that again, we are just not understanding the big picture?
Babies have a very complex suck-swallow-breathe coordination process requiring a large number of nerves and muscles working together.  When breastfeeding a baby's tongue has a rhythmic wave-like motion which means that the baby can nearly continuously breathe while sucking.  The basic process is as follows:  Milk is transferred from the breast into the baby's mouth.  Baby then takes a breath while moving the milk to the back of her throat in preparation for a swallow.  As the milk reaches the back of her throat area she does a short exhale and then holds her breath while she swallows.  After the swallow is complete she exhales the remainder of the held breath.  It is a very complex and intricately timed process.  When a baby is gagging /choking or spluttering at the breast it is generally because the smooth coordination of the suck-swallow-breathe rhythm has been disrupted and the swallow and breathe is mis-timed. As adults we still occasionally have mis-timed swallows, and we might talk about a drink having gone "down the wrong way".   We can put down the glass and recover, but for babies the milk continues to flow.  That leads to difficulty keeping up with flow (choking/spluttering) and also commonly leads to swallowing air which later results in gas or reflux.   Gassiness and reflux are big issues and really need a blog to themselves (coming soon).  In this blog I want to solely look at the idea of the fast letdown and whether it is actually an indicator of oversupply.



Why now?



Many mums and babies notice this happening around 3 weeks.  A big part of the reason for the timing is the change in milk supply.  Milk volume changes rapidly in the first couple of weeks.  In the first few days of colostrum a mum is producing maybe a teaspoon or 2 of milk at a feed, averaging about 30-45ml over the course of 24 hrs.  When her milk "comes in" there is a rapid change to large volumes of milk building over the first 2 weeks.  By the time a mum gets to around 14 days she may be producing 800ml of milk over the course of a day.  It is an enormous change.  With the volume the letdown is a bit faster, but a fast letdown and oversupply are entirely different things.  Fast milk at letdown is normal!  It is normal and expected that milk will begin to spray and it makes complete sense when we think about what is happening within the breasts.  Inside the breasts milk is stored in ball like structures called alveoli which are surrounded by muscle fibres.  At letdown the muscles contract and literally squeeze the milk into the ducts and down through the nipples.  A crude analogy would be to think of a bath toy which sprays of water when you squeeze it.  This is what happens at letdown and is normal.  A baby should be able to handle this ideally,  but lots of things can impact on the suck-swallow-breathe coordination.   A baby struggling with the flow does not necessarily mean that mum has a faster than normal letdown or that she has oversupply.  It can mean that mum has a completely normal letdown and normal supply but that her baby is struggling with the normal flow!  


Why would baby have problems coordinating the flow?

There can be lots of different reasons why this might happen with a normal supply.  It may simply be due to immaturity.  The suck-swallow-breathe coordination matures at different rates and completely mature coordination may only develop at 42 weeks gestation for some babies, or even in the weeks following birth for other babies.  Gestation lengths of babies varies enormously, and that means what we think of as  a 2 week old baby can vary enormously.  A baby born at 42 weeks for example may have 5 weeks further development than a baby who was born at 37 weeks, even though they are both considered full term babies.  Those weeks can have a big effect on a baby's coordination.  Given that as adults it still happens us from time to time, it shouldn't be surprising that an immature newborn would have this experience.
It could be due to the latch.  A baby who isn't well latched to the breast won't have as good coordination of milk transfer and may splutter at the breast.

It could be something that happened at birth.  A baby's skull undergoes significant moulding at birth in order to let it travel through the birth canal.  Think of the shape of a newborn's head immediately after birth and how it changes over the first few days and weeks.  Add in the impact of any medical interventions on the skull shape.  Forceps, vaccum birth or cesarean section can cause different moulding to a baby's head.  Any moulding of the bones affects the muscles which are attached to those bones - including the muscles which are used to latch, suck, swallow and breathe.  This can be a factor in coping with the letdown.  Even where structural issues aren't in play, medications can be?  Studies have found that having an epidural during labour to have an effect on suck-swallow-breathe coordination for up to a month, for example.

In some cases an anatomical issue can be the cause - something like a tongue tie, which impacts on tongue movement and ability to deal with the letdown.

Perhaps it's none of these things.  Perhaps it's just the way breastfeeding is being managed.  Maybe you are focused on feeding at certain times?  Maybe you are feeling engorged?  Maybe you are still in a little pain and are holding off feeding for a short time after you see early cues.  Any of those factors which lead to the breasts being fuller increases the pressure in the breasts and consequently the speed of the letdown.

Does this mean it is never oversupply? No - of course a baby having difficulty can be a symptom of an oversupply of milk but in that case your baby's extra weight gain is also an indicator.


Is block feeding the answer?



The basic premise of block feeding is to divide the day into blocks of time and to feed from one breast during each block thereby reducin stimulation and milk production.  It works!  It works very effectively and very quickly, and that means it needs caution.  If your baby is struggling but not gaining excessively (which is the more likely scenario) then block feeding will mean that you reduce your supply and that may impact your baby's weight gain and growth.  Many IBCLCs now urge caution with block feeding, suggesting it should only be used if a baby is gaining over 1lb a week.


See the big picture

Rather than jumping to a solution of block feeding it makes sense to look for the cause of the feeding issue.  While block feeding may help for true oversupply, where the issue is simply baby being an immature newborn block feeding may hinder rather than help.  It may stop the choking but at the cost of limiting that baby's source of nutrition.  Milk supply is being set up in the first 5 weeks so it makes sense to be cautious about reducing milk volume in that time.  

Often we need to just consider the normalcy of what is happening - an increasing volume of milk and an immature baby!  Breastfeeding is a holistic process and we need to manage it in that way.  Many times all that is needed is a change in position.  If we have difficulty keeping up the flow of water in a glass we simply lower the glass so that it flows more slowly.  The same principles apply.  Shifting your body so that your baby is lying more on top of you means that gravity slows the flow.  Sometimes that is all that is needed.  That position can often deepen the latch, which also helps.  All you need to do is lean back.  If your baby is still struggling in that position it can help to just remove the letdown from the equation altogether.  You can just unlatch when your baby begins to struggle and let the milk spray into a muslin or hand towel and then relatch when the flow slows again.  Some babies do this all by themselves as they have worked out that it's easier that way.  

Usually within a short time the gagging/choking is no longer an issue.  Maybe it's because the baby just gets more mature each day or because any birth issues have resolved.  Maybe he learns to manage the new faster volume, or maybe it's because supply and baby have just got into a better sync.  In fact it's likely that in a couple of months the same baby will be wanting to get that fast flow straight away and will let you know if he isn't!

If positioning doesn't help, or if your baby is having difficulty through all of the feed, not just letdown, look for experienced breastfeeding support.  If you feel you do have oversupply and want to check if block feeding is actually the right route for you look for good breastfeeding support like a breastfeeding counsellor or lactation consultant.  Oversupply may be the result of excessive pumping, or inflammation /infection in mum?  The right supporter for you will look at the breastfeeding picture as a whole, and as you and your baby as one unit.   See the big picture.  Our babies are still learning to feed in these early weeks and their muscles and nerves still developing.  A fast letdown isn't something that necessarily needs fixed, in fact in can be a really reassuring sign that your milk supply is building nicely. We just need to support our babies while their feeding matures.


Further Reading
http://www.nancymohrbacher.com/blog/2014/8/25/coping-with-fast-milk-flow.html
http://www.nancymohrbacher.com/blog/2013/10/9/block-feeding-dos-donts.html
http://www.beststart.org/events/detail/bsannualconf04/Smith_First-Feedings.pdf
http://dianaibclc.com/2012/06/15/understanding-oversupply/



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