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J Am Board Fam Med: first published as 10.3122/jabfm.2016.01.150164 on 14 January 2016. Downloaded from

CLINICAL REVIEW Diagnosis and Management of Oversupply

Lauren Trimeloni, MD, and Jeanne Spencer, MD

Managing problems is an essential part of newborn care. While much is written on undersupply, little is written on oversupply, sometimes known as hyperlactation or hypergalactia. of with oversupply may have increased or decreased weight gain. Some may have large, frothy stools. They may develop a disordered . Mothers may report overly full, leaking . function should be assessed. Treatment is mostly anecdotal and includes methods to maintain breast fullness, such as block feedings. Pseudoephedrine and oral contraceptive pills may decrease the supply. Dopamine agonists such as carbergoline can be used as a last resort. (J Am Board Fam Med 2016;29:139–142.)

Keywords: Breast Feeding; Disorders; Review, Systematic

Managing breastfeeding problems is an essential Literature Search skill for family physicians. Exclusive breastfeeding PubMed Clinical Queries was searched using the provides an optimal start to an individual’s nutri- key search terms hypergalactia, breast milk oversupply, tional life, reducing their lifelong risk of many breast milk oversupply, and hyperlactation. We also copyright. devastating diseases, including obesity, asthma, di- searched Clinical Evidence, the Cochrane database, abetes mellitus, and childhood leukemia and lym- and the CINAL database using the same terms and phoma.1 The American Academy of Family Physi- the reference lists of retrieved articles. Our initial cians and the American Academy of search date was April 2015. recommend exclusive breastfeeding until 6 months, and then continued breastfeeding until at least age Clinical Presentation 1 year for optimal health.1,2 The CDC tracks Although there is a large body of literature on the breastfeeding initiation and continuation rates, as problems accompanying a , little http://www.jabfm.org/ 4 well as provider support of breastfeeding, in their has been written concerning oversupply. In addi- Breastfeeding Report Card.3 Maintaining optimal tion, the prevalence of oversupply is unclear be- breastfeeding initiation and duration should be a cause of a lack of diagnostic criteria and research on primary concern of health care providers. Although the topic. Most define oversupply as milk produc- breast milk oversupply occurs rarely and is often tion in excess of that needed for normal growth of the .4 Other terms for this include hyperga- underreported, the damage it can cause to the on 28 September 2021 by guest. Protected breastfeeding relationship can be irreparable. lactia or hyperlactation. The term is usu- ally applied only to nonlactating women or men. Early signs of an oversupply can include excessive infant weight gain (Ͼ30 g (1 oz)/day up to age 3 months).5 It is important to use the World Health This article was externally peer reviewed. Organization growth charts when assessing infant Submitted 19 May 2015; revised 30 July 2015; accepted 10 August 2015. weight gain because these are normed with breast- From the Conemaugh Family Medicine Residency Pro- feeding infants.6 Other infants of mothers with gram, Johnstown, PA. Funding: none. oversupply have poor weight gain because of exces- Conflict of interest: none declared. sive exposure to the carbohydrate-rich foremilk and Corresponding author: Jeanne Spencer, MD, DLP, Cone- 7 maugh FMRP, 1086 Franklin St, Johnstown, PA 15905 a lack of fat-rich hind milk. These infants may be ͑E-mail: [email protected]͒. fussy, particularly at the beginning of a feeding, and doi: 10.3122/jabfm.2016.01.150164 Diagnosis and Management of Breast Milk Oversupply 139 J Am Board Fam Med: first published as 10.3122/jabfm.2016.01.150164 on 14 January 2016. Downloaded from have difficulty maintaining a latch. They may cry breastfeeding, having an unhappy, uncomfort- or act averse to the offer of feeding. They may able baby and being in continual pain herself can gulp frequently and break off multiple times dur- quickly lead to a determination that breastfeed- ing a feeding, and then later exhibit signs of ing will not work for her and that formula is a gassiness. Stools may be frequent, large, frothy, better feeding option. and green, especially when the infant is consum- ing inadequate protein-rich hind milk. Infants Differential Diagnosis may develop a disordered latch and move the While breast milk oversupply is often idiopathic, tongue to the tip of the to avoid being it can sometimes (albeit rarely) be a sign of seri- 7 choked by an aggressive let-down reflex. An ous underlying disorders, including pituitary ad- overactive let-down can cause the baby to pull off enomas and .11 Any cause of hyper- and refuse to re-latch, often damaging the moth- prolactinemia, including hyperthyroidism, can 8 er’s nipple. Infants of mothers with oversupply result in a breast milk oversupply (Table 1). Thy- may be misdiagnosed with gastroesophageal re- roid function tests should generally be ordered. 9 flux disease, colic, or milk protein allergies. Interpretation of concentrations in Mothers with breast milk oversupply may report breastfeeding mothers can be problematic since full, leaking breasts that are not noticeably softened lactation increases prolactin concentrations, with 7 by a feeding. In the presence of a baby who is a wide variation of concentrations among women gaining weight adequately or excessively, excess who are successfully breastfeeding.12 Women leaking should raise the question of an oversupply. with known prolactinomas can often successfully , severe engorgement, and painful milk breastfeed.13 Remission occurs in approximately ejection reflexes or let-downs are common. Moth- one third of prolactinomas during and ers may report leaking continually between feed- lactation.13 Although retained placenta is usually ings, an ability to pump several ounces after a associated with decreased milk production, a case copyright. feeding, or being awakened at night by painful report described overproduction relieved by the engorgement when the baby seems satisfied and removal of a retained placental fragment.14 Ex- not yet ready to eat. Engorgement persisting for cessive pumping, overuse of galactogogues, and longer than 1 to 2 weeks should raise a question overstimulation by the baby may also result in of oversupply. Nipple trauma resulting from a oversupply4 (Table 2). poor latch may lead to cracked, sore, fissured , increasing the likelihood of breast infec- tions, including infections with Candida.7 Incom- Management Breast milk oversupply is generally caused by plete emptying of the breast can lead to blocked http://www.jabfm.org/ ducts and , and over time it can produce either breastfeeding mismanagement, hyperpro- 7 chronic mastitis and scarring in the breast tis- lactinemia, or a congenital predisposition. Most sue.7,9 Striae on the skin overlying the breast have been reported.8 Table 1. Causes of Elevated Prolactin Concentrations Mothers experiencing oversupply often report feelings of frustration and loneliness. Breastfeed- Hypothalamic/pituitary stalk damage ing becomes very difficult, and excessive leaking Pituitary disorders on 28 September 2021 by guest. Protected and breast pain make social and professional in- Chronic renal failure Cirrhosis teractions challenging. Having too much milk is Cranial radiation often viewed as desirable, which can lead to in- Polycystic ovary disease adequate support from friends and family, as well Medications as by medical personnel who fail to grasp the Antidepressants 10 severity of the problem. Women may be ad- Antihistamines vised to wean following recurrent bouts of severe Antihypertensives mastitis or after breast abscesses, which may re- quire surgical drainage. Working mothers may Adapted with permission from Melmed S, Casanueva FF, Hoffman AR, et al; Endocrine Society. Diagnosis and treatment of hyperp- lack the time needed for increased pumping. Re- rolactinemia: an Endocrine Society clinical practice guideline. gardless of a ’s initial commitment to J Clin Endocrinol Metab 2011;96:273–88.

140 JABFM January–February 2016 Vol. 29 No. 1 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2016.01.150164 on 14 January 2016. Downloaded from

Table 2. Differential Diagnosis Breastmilk Oversupply dose may reduce breast milk production by 25% 20 Overuse of galactogogues (level of evidence, 2). Early use of - Excessive breast-pumping containing oral contraceptives may help reduce Normal engorgement in the early postpartum weeks supply and can be considered when conservative Excessive prolactin* measures fail (strength of recommendation, C). As a final resort, mothers may need use dopamine From ref. 4. agonists such as carbergoline, especially if they *See Table 1. are discontinuing nursing.4,17 interventions available for the treatment of over- References supply are anecdotal and not well studied. 1. American Academy of Pediatrics Work Group on Through complex interactions of prolactin re- Breastfeeding. Breastfeeding and the use of human ceptors and the feedback inhibitor of lactation, milk. Pediatrics 2012;129:e827–41. retention of milk within the breast decreases pro- 2. American Academy Family Physicians Breastfeeding duction.7,15 Most interventions to decrease milk Advisory Committee. Breastfeeding, family physicians production aim to retain milk in the breast while supporting(positionpaper).Availablefrom:http://www. still meeting the infant’s nutritional needs. The aafp.org/about/policies/all/breastfeeding-support. html. Accessed April 8, 2015. assistance of an experienced can be invaluable. Early interventions include 3. Breastfeeding report card: United States, 2013. Atlanta: Centers for Disease Control and Prevention, National feeding from only one breast per nursing session, Center for Chronic Disease Prevention and Health pumping from the other breast only for comfort. Promotion, Division of Nutrition, Physical Activity, Mothers often find that nursing “uphill” helps: and Obesity; July 2013. Available from: http://www. the baby is positioned so that gravity slows the cdc.gov/breastfeeding/pdf/2013BreastfeedingReport flow of milk. Moms may lean back or nurse with Card.pdf. Accessed on May 19, 2015. the infant above their nipple.16 Block feedings 4. Eglash A. Treatment of maternal hypergalactia. copyright. are also recommended (strength of recommenda- Breastfeed Med 2014;9:423–5. tion, C).4,7 In these the mother nurses from a 5. Boom JA. Normal growth patterns in infants and pre- pubertal children. UpToDate. Available from: http:// single breast for a block of time, typically 3 www.uptodate.com/contents/normal-growth-patterns- hours. She then alternates breasts for successive in-infants-and-prepubertal-children. Accessed May 18, blocks. In this way milk accumulates in the un- 2015. 4,7 used breast and should decrease milk supply. 6. WHO growth standards are recommended for use in van Veldhuizen-Staas7 reports that the complete the U.S. for infants and children 0 to 2 years of age. drainage of both breasts before beginning the Atlanta: Centers for Disease Control and Preven- http://www.jabfm.org/ block feedings reduces the excess milk supply tion; 2010. Available from: http://www.cdc.gov/ growthcharts/who_charts.htm. Accessed May 18, 2015. and thereby reduces the mother’s engorgement 7. van Veldhuizen-Staas CG. Overabundant milk sup- and the infant’s difficulties feeding with an over- ply: an alternative way to intervene by full drainage active milk flow (level of evidence, 3). Use of a and block feeding. Int Breastfeed J 2007;2:11. nipple shield may help slow the flow of milk for 8. Livingstone V. Too much of a good thing. Maternal the infant and decrease distress during an over- and infant hyperlactation syndromes. Can Fam Phy- on 28 September 2021 by guest. Protected active let-down. Topical green cabbage leaves sician 1996;42:89–99. have been described to decrease engorgement, 9. Smillie, CM, Campbell SH, Iwinski S. Hyperlacta- but efficacy has not been well documented.17 tion: how left brained “rules” for breastfeeding wreak Nevertheless, it is a simple early intervention havoc with a natural process. Newborn Infant Nurs Rev 2005;5:49–58. that could be suggested with little risk of harm pending further investigation. Nonsteroidal anti- 10. Wilson-Clay B. Milk oversupply. J Hum Lact 2006; 22:218–20. inflammatory drugs may be given to reduce in- 11. Lawrence RA, Lawrence RM. Medical complica- flammation and breast pain. Although not well tions of mothers. Breastfeeding: A Guide for the studied, sage and parsley have been reported to Medical Professions. 7th ed. Maryland Heights, 18,19 reduce milk supply. Low doses of pseu- MO: Elsevier Mosby; 2011;550–613. doephedrine (30–60 mg) may be used to reduce 12. Stuebe AM, Meltzer-Brody S, Pearson B, Pedersen supply; some studies suggest that even a single C, Grewen K. Maternal neuroendocrine serum lev- doi: 10.3122/jabfm.2016.01.150164 Diagnosis and Management of Breast Milk Oversupply 141 J Am Board Fam Med: first published as 10.3122/jabfm.2016.01.150164 on 14 January 2016. Downloaded from

els in exclusively breastfeeding mothers. Breastfeed 17. Mangesi L, Dowswell T. Treatments for breast en- Med 2015;10:197–202. gorgement during lactation. Cochrane Database Syst 13. Domingue M-E, Devuyst F, Alexopoulou O, Cor- Rev 2010;(9):CD006946. vilain B, Maiter D. Outcome of after 18. Drugs and Lactation Database. Bethesda (MD): Na- pregnancy and lactation: a study on 73 patients. Clin tional Library of Medicine (US) [last revision date Endocrinol 2014;80:642–8. December 2, 2014]. Sage; LactMed Record Number 903. Available from: http://toxnet.nlm.nih.gov. Ac- 14. Byrne E. Breastmilk oversupply despite retained pla- cessed on April 8, 2015. cental fragment. J Hum Lact 1992;8:152–3. 19. Drugs and lactation database. Bethesda (MD): Na- 15. Lawrence RA, Lawrence RM. Physiology of lacta- tional Library of Medicine (US) [last revision date tion. Breastfeeding: A Guide for the Medical Profes- December 2, 2014]. Parsley; LactMed Record Num- sions, 7th ed. Maryland Heights, MO: Elsevier ber 961. Available from: http://toxnet.nlm.nih.gov. Mosby; 2011;62–97. Accessed on April 8, 2015. 16. Forceful let-down (milk ejection reflex) & oversup- 20. Aljazaf K, Hale TW, Ilett KF et al. Pseudoephed- ply. KellyMom , Breastfeeding [blog]. rine: effects on milk production in women and esti- Available from: http://kellymom.com/bf/got-milk/ mation of infant exposure via breastmilk. Br J Clin supply-worries/fast-letdown. Accessed May 18, 2015. Pharmacol 2003;56:18–24. copyright. http://www.jabfm.org/ on 28 September 2021 by guest. Protected

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