Treatment of maternal hypergalactia.

Many breastfeeding mothers struggle with an overabundant milk supply, or hypergalactia, beyond the first few weeks of engorgement. There has been very little research done to define, to explain, or to assist in managing this problem. Lactation specialists have identified several challenges for women with hypergalactia.1 Hypergalactia is also termed hyperlactation, oversupply, and engorgement, depending on the literature. The 10th International Classification of Diseases uses the terms hypergalactia, hyperlactation, and increased lactation. The term that is most consistently found in dictionaries to describe excessive milk is hypergalactia. Because there is not an operational definition with criteria for hypergalactia, the diagnosis would be based on the clinician's impression. A commonsense definition would be the state of producing excessive milk, which leads to discomfort and may compel a nursing mother to express and store milk beyond what the baby is taking, assuming normal infant growth. The caveat of normal infant growth is important because mothers may feel too full at times when the baby is not transferring sufficient milk. An excessive milk supply may appear to be cause for celebration by mothers with insufficient lactation, but mothers with hypergalactia are at increased risk for a fast let-down,2 acute mastitis,3 plugged ducts,4 chronic breast pain,5 exclusive pumping,6 infant fussiness,7 and early weaning.8 Many women self-induce hypergalactia by various means. Pumping in addition to nursing stimulates extra milk production. Many herbal supplements are used to increase the milk supply, such as alfalfa, fenugreek, goats rue, fennel, blessed thistle, saw palmetto, and shatavari.9 New mothers are often instructed to nurse their babies according to the clock, such as 15–20 minutes on each breast, rather than nursing according to infant feeding cues. This leads some mothers to nurse for longer periods of time than the baby needs to, raising the prolactin level further.7 This article is referring to women who persist with hypergalactia despite optimal behavioral interventions to reduce the milk supply. A mother's milk supply is under extrinsic endocrine control from prolactin and oxytocin. Prolactin is secreted from the anterior pituitary gland in response to nipple stimulation and stimulates milk secretion from lactocytes. The prolactin level is regulated by the frequency and duration of infant suckling or other forms of nipple stimulation such as pumping. Oxytocin release from the posterior pituitary gland occurs in response to several types of sensory input, such as seeing, hearing, smelling, or touching the baby. Myoepithelial cells, which surround alveoli and lactiferous ducts, respond to oxytocin stimulation by contracting to induce milk ejection. Oxytocin release is inhibited by pain and stress.10,11 A mother's milk supply is also under local control intrinsically within the breast. Fullness of the breast, within alveoli, is an important factor in controlling milk production. A very full breast is expected to slow milk production, not by simple distension,12 but by an increase in the concentration of the “feedback inhibitor of lactation,” now known to be nonneural/peripheral serotonin (5-hydroxytryptamine [5-HT]).12,13 There is a paucity of information in the literature describing the percentage of nursing mothers with hypergalactia, whereby these mechanisms of milk production don't achieve a healthy balance of milk production. In addition, there are no human studies to date that have evaluated the underlying etiology for hypergalactia. Many clinicians use behavioral strategies and antilactational substances to help reduce the milk supply. Maternal symptoms of hypergalactia include breast fullness, an inability to nurse the baby from both breasts for each feeding, and a heavy let-down reflex. The heavy let-down reflex may lead to a shallow latch by the infant, resulting in sore nipples. The mother may also struggle with excessive milk leakage, chronically tender engorged breasts, plugged ducts, and mastitis due to irregular and insufficient breast emptying. Infant symptoms include choking and gasping during the initial let-down, excessive weight gain, fussiness at the breast, excessive flatus, and explosive, green stools. Hypergalactia may be associated with a foremilk–hindmilk imbalance, leading the baby to consume a high proportion of foremilk. High foremilk intake has been suspected in some cases to be associated with blood-streaked infant stools that contain mucus.7 Evaluation of hypergalactia could include thyroid function tests to rule out either hyper- or hypothyroidism. In addition, a prolactin level could be measured to see if it is quite elevated. All successfully lactating women should have an elevated prolactin level, so it would be difficult to determine if hypergalactia is truly due to a primary hyperprolactinemia.14 The most common behavioral strategy reported to help hypergalactia is block feeding.1,7 This involves the mother nursing from one breast for 3-hour blocks (±30–60 minutes). For example, the mother nurses from the right breast from noon to 3 o'clock. Then from 3 to 6 o'clock all nursing comes from the left breast. This allows one breast to remain undisturbed for 3 hours or more at one time, so that local control from an increase in 5-HT will provide feedback to lactocytes to decrease the milk supply. Usually within 24–48 hours the mother notices a significant decline in her milk supply. Occasionally the supply will drop so much that mom will need to nurse from both sides for each feeding. If block feeding is not successful, the next step would be to try various supplements or medications to reduce the milk supply (Table 1). Common substances include herbs, homeopathy, pseudoephedrine, estrogen in the form of the combined birth control pill, and, finally, antiprolactin medications. Table 1. Substances That Reduce the Milk Supply