Breastfeeding is the method of first choice for feeding any infant. Both the World Health Organization (WHO) and many leading organizations of pediatricians, as well as many governments advise that children be exclusively breastfed for a half year from birth and continue to be breastfed in combination with suitable foods for an extended time after that . Breastmilk production is an inborn capability in women, with only rare exceptions due to anatomical or physiological pathology. Even in these rare cases, partial breastmilk production may sometimes be possible. Even though these exceptions are extremely rare, a widespread belief exists that many women are not capable of producing enough, or good enough, milk for their children . Methods to treat real or perceived low milk supply are well referenced in the literature . Overabundant milk supply or hyperlactation on the other hand is not discussed in depth in the literature. There is no consensus on treatment or terminology. However, overabundant milk supply can be as devastating for the continuance of breastfeeding as underproduction. In this paper, I propose a definition, etiology and a possible "intervention" which has been found to be more effective in my practice than other common breastfeeding management solutions.
Definition of overabundant milk supply
In day-to-day language the problem of "too much milk" is mostly referred to as overproduction, overproduction syndrome or overabundant milk supply. In the professional literature the word hyperlactation is also used, but is linked to different descriptions [4
Overactive production by the milk producing glands during lactation. This is also referred to as overproduction or overproduction syndrome;
Milk production in a non-lactating woman or in a man, also referred to as galactorrhea. Some references use galactorrhea also in definition 1;
Continuance of lactation beyond the normal period.
The focus of this paper is the first definition: an overabundant supply of milk in an otherwise healthy lactating woman.
In physiological lactation fullness of the breast and galactostasis (milk remaining in the breast without removal) will lead to a decreased milk production. The accumulation of milk in the breast will reduce the binding of prolactin to its membranes. This will happen in any breast that gets overfilled, independent of the status of the other breast. The reduction in the binding of prolactin to membrane receptors will create an inhibitory effect on levels of milk production. In full alveoli lactocytes (milk producing cells) will have a lowered uptake of prolactin from the blood. If the full breast is emptied, prolactin again will bind to the membrane receptors, thus enhancing milk synthesis. The more empty the alveoli, the higher the milk synthesis rate, slowing down as the breast refills [8–10]. Evidence exists that there are two interacting mechanisms regulating the rate of milk synthesis. The first involves the Feedback Inhibitor of Lactation (FIL). "FIL is an active whey protein that inhibits milk secretion as alveoli become distended and milk is not removed. Its concentration increases with longer periods of milk accumulation, down regulating milk production in a chemical feedback loop. The inhibition of milk secretion is reversible and dependent on concentration; it does not affect the composition of the milk because it affects the secretion of all milk components simultaneously"  [p. 76]. FIL has been identified as a small protein synthesised by the secretory epithelial cells (lactocytes) that accumulates within the alveolar lumen along with other milk constituents. However as FIL is an autocrine inhibitor of milk synthesis, milk synthesis declines as FIL accumulation within the lumen increases. When milk is removed from the breast the concentration of FIL declines and milk synthesis once again increases. The other mechanism involves the interaction of lactocytes with the basement membrane to which they are attached. It is hypothesised that as the breast fills with milk, the shape of the lactocytes changes such that the prolactin receptor is deactivated and milk synthesis is slowed, and eventually ceases . Although the FIL and cell shape mechanisms likely act independently to influence the activity of prolactin upon the breast, the interaction and interplay of these two factors upon milk synthesis has yet to be fully elucidated.
Description and etiology
Hyperlactation can be caused by breastfeeding mismanagement, hyperprolactinemia or congenital predisposition. Livingstone defines hyperlactation as "mother and child hyperlactation syndrome", because in both mother and child, symptoms can lead to pathology . The hyperlactating woman will often experience a constant feeling of (over-) fullness, engorgement and tension. She may leak milk in between feedings, or leak copiously from the opposite breast during feedings, and has an increased risk for mastitis.
The infant may appear to be a greedy feeder, struggling not to choke or aspirate milk. He or she may often spit up after feedings and/or have reflux-like symptoms, and suffer from intestinal gas, colic and explosive, often green and foamy stools. The baby may show either a very low or a very high weight gain. The baby's struggle to cope with rapid flow may result in restless nursing behaviour, or even aversive behaviour, such as breast refusal or shortened feeds. Fussiness, crying and possible low weight gain can lead the mother to think that her milk is insufficient in quantity and/or quality.
An infant drinking from an overproducing breast may not be able to empty the breast far enough to obtain the fatter milk that is available in the more empty breast. The relatively high sugar, but low fat content of the diet may cause rapid gastric passage, which may lead to lactose concentrations in the small bowel too high for the infant's lactase potential, resulting in frequent diarrheic bowel movements .
A common secondary symptom in hyperlactation syndrome is a sub-optimal nursing technique in the infant. This may be the result of the child's attempts to cope with an overabundant milk flow, sometimes slipping from an optimum latch in order to clamp down on the nipple to slow the flow, often traumatizing the mother's nipple in the process. Or the infant may develop a conditioned habit of drinking but passively suckling at a breast that will give milk without any effort by the infant itself. This has the potential to lead to supply problems after 4–6 weeks when supply stimulation patterns transition from primarily hormonal stimulation to feedback inhibition mechanisms.
A treatment for overproduction commonly mentioned by lay advisors is to pump some milk directly prior to breastfeeding [13, 14]. Rationale for this option is to stimulate the surge of the milk ejection reflex and allow the peak of the overwhelming milk flow to pass, remove some of the lower-fat foremilk and to enable the child to receive the fat-rich hindmilk sooner. An argument against this approach is that frequent pumping in combination with normal breastfeeding will increase milk production and eventually increase the problem. Many professionals are now adopting an evidence-based approach to reduce milk supply by enhancing breastfeeding management. Wilson-Clay and Hoover follow Livingstone in advising to not decrease feeding frequency, but to decrease the number of times that the child will be offered "the other breast" . They advise restricting breastfeeding at one breast for a set number of feedings or a set amount of hours. The rationale for this is to produce a relative galactostasis in the temporarily unused breast, leading to a reduction of milk production due to the accumulation of the feedback inhibitor of lactation (FIL) and the change in lactocyte shape, both of which lead to a decline in the rate of milk synthesis. This practice will need close observation for signs of plugged ducts and mastitis. The difficulty in this approach is that the total pool of accumulated milk is reabsorbed very slowly. This pattern, if not carried out gradually and carefully, risks plugged ducts, discomfort and potential mastitis for the mother and may force the baby to continue coping for a long time from the start of the treatment. Berghuijs, describing complete drainage of both breasts as a treatment for hyperlactation, presented a significant modification of this method in a case discussion . She introduced the term "milk lakes" to describe the cumulative production and storage of milk due to the combination of overactive milk production, inter-feeding leakage and inefficient drainage by the infant. Berghuijs advises complete mechanical pumping followed immediately by unrestricted bilateral feeding. In her view the accumulated milk is the problem and frequent bilateral feeding will regulate milk production after the "milk lakes" have been cleared. This method does not use FIL to decrease milk production. Bilateral stimulation at every feeding session may lead to a very fast increase in milk production and new filling of the "milk lakes." The Berghuijs approach however did lead to the development of the method presented in this article where emptying the breast is followed by a way to use FIL in order to decrease milk production to more desired levels. Pharmaceutical treatment, for instance with pseudoephedrine or estrogen-containing contraception is another possibility sometimes mentioned . Both of these can lead to unwanted side-effects. Naturopathic therapists tend to advise Salvia officinalis (the culinary herb sage) as a tincture or concoction . Sage is a powerful lactation inhibitor and should be used with caution if the aim is to decrease supply, rather than lactation suppression.
What is most needed is to find a way to quickly reduce the excess of milk without increasing milk production. Most remedies focus on this reduction side while failing to take into account the infant's side of this syndrome. The optimal treatment would thus also include a way to ensure comfortable nursing for the baby, without having to drink against an overactive milk flow and without interfering with physiologic gastroenteral function. In overproducing mothers the baby tends to receive a relative overload of lactose and a relative shortage of fat. Normal gut function needs a balance between carbohydrates and fat in the food that is being digested.
In my private practice, I have developed this combination of remedies into one that I call the full drainage and block feeding method (FDBF).
Description of FDBF
The treatment sequence starts with an as-complete-as-possible mechanical drainage of both breasts. It is impossible to really empty an active, lactating breast completely, because the production of milk is an ongoing process. Emptying the breast is a major trigger for renewed production activity. Manual expression is a possibility, too, but in most cases mechanical extraction will work more efficiently and rapidly, especially if a simultaneous double pump is used. The infant will latch on immediately after drainage and will be offered both "empty" breasts to satisfaction. Many infants will fall asleep fully satisfied with high fat hindmilk, many for the first time. Subsequently the rest of the day is divided into equal time blocks starting with about three hours, initially. Every time the infant shows hunger cues or other signs of interest in the breast the same breast will be offered without any restriction in either frequency or duration of feeds. At the end of such a time block, or after a multi-hour period of sleep, baby will be offered the other breast for all feeds within the next time block. It is important that the best possible positioning and efficient latching techniques be used starting right from the very first feeding after pumping, for the sake of both the baby's improved suckling habits and the mother's comfort and future production. Depending on the seriousness of the symptoms time blocks may gradually be increased to 4, 6, 8 or even 12 hours. For less complex situations one-time mechanical drainage will suffice; for others occasional repetition may be necessary. Intervals between drainage will gradually increase as the symptoms lessen.
Mothers must be cautioned not to drain the breasts too often in order to avoid extra stimulation for milk production. Only if engorgement is becoming severe again should another drainage be carried out. In using FDBF the mother will need to be instructed, cautioned and monitored for temporarily recurring over-fullness and plugged ducts or mastitis. After the first full drainage, in some women the breasts will initially continue to produce more than asked for and thus refill. In many others just a single full drainage will suffice to decrease milk production to acceptable levels.