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From the perils of block feeding to the magic of a milkshake: addressing the
challenges of hyperlactation
Dear Dr Smillie,
Thank you for a very interesting talk! please have a look at the study, An Evaluation of the
Left-Brain vs. Right-Brain Hypothesis with Resting State Functional Connectivity Magnetic
Resonance Imaging. It explains left/right brain is a myth? looking forward to your reply!
Kind regards,
Leana
South Africa
Hi Leana, thanks for asking this question, because I get it a lot. The concerns about being left-
and right-brained expressed in the article you reference, as well as other places is a legitimate
and real concern. As talk about left and right brains migrated from the realm of neurobiologists
into the popular literature, some people began to talk about individual people being "left- or right-
brained". And this study showed that this type of generalization about people is exaggerated. We
all have a corpus collosum, the neurons that connect the left and right brain and allow them to
communicate, and everyone uses both sides of the brain all the time.
The whole discussion about "exploding the myth of left and right brains" appears to primarily be
written in the language of psychologists about an issue framed in the terminology of popular
psychology. And that language used by the psychologists, as well as the purposes and aims of
their studies, appear to me to be quite different from what neurobiologists are looking at when
they examine real difference in brain function using neuro-imaging. I am however not either a
psychologist nor a neurobiologist, so I try to be very careful when I read the literature of other
specialties. What I will say is that it appears to me they are speaking different languages about
different phenomena.
So declaring in the popular press that there is no such thing as left brain or right brain dominance
does not mean that this question is actually settled. Because as far as I can read in the
neurobiology literature, there is much to refute the conclusions of the 2013 PLOS study. But
again, outside my area of expertise.
What I can say, however, is that regardless of the validity of that article's conclusions, the subject
of left or right brain dominance as a personality type is not what I am talking about when I
discuss left and right brain activity of mothers and babies. That is, that whole debate about
personality types, exploded myth or not, does not mean that that there are not known established
differences between how the left brain and right brain work, what they do, and how different
people use the different sides or their brain in different circumstances.
And it does not even mean that individual people have neuronal pathways that often lean in one
direction or another. These differences are well established over the decades by multiple studies,
including many neuro-imaging studies.
For a summary of some of these studies as it relates to mother infant communication, you can
read Allan Shore's work. Effects of a secure attachment relationship on right brain development,
affect regulation, and infant mental Infant Mental Health Journal 2001. Available free online. This
is key to my understanding of this subject.
You can look at the work of W Thomas Boyce, research on both monkeys and children. Or a
recent review article, On the Role of asymmetric frontal cortical activity in approach and
withdrawal motivation: An updated review of the evidence Harmon Jones et al. Psychophysiology
2018. (Review article of just one detail of this issue).
Well you can see we could go on about this. Shore's article is the most helpful to me because it
addresses exactly what I am talking about, the mother baby relationship.
Thanks for an important question.
Tina Smillie MD
Hi Christina,
I really enjoyed your talk. My question is about lecithin and whether you have any
experience with it. A client of mine had initial hyperlactation and baby was getting quite
fussy, then blocked ducts so tried lecithin which really helped all aspects and had no
further blockages, she fed on demand, offered both sides, what was interesting was that
she said her baby's bowel motions changed to more smother consistency and he was
more comfortable in the belly once she took lecithin. Have you heard anything similar in
your experience?
Stefanie
New Zealand
We certainly see mothers who have used lecithin, some see results and others don't. It is all over
the internet, and taking a pill is often what mothers try first, looking for a quick fix, so we mostly
see the mothers for whom her previous strategies didn't work, so that includes lecithin. I'm not
sure how or if it would really get into the breastmilk to perhaps make the milk more slippery? I
can't imagine how it could affect the baby's stools, it would be so dilute by the time it's gone
throughout the whole body for some of it to, so that seems unlikely to be anything other than
coincidence. Remember that whenever you have ONE patient with a particular story, that
coincidence is always the most likely explanation for the change you saw. There just is no
literature on either the physiology of how this works, or the efficacy of this management. Most of
what we know is anecdotal and we certainly can at least say it's safe, but whether it works or is
just placebo effect is still up for grabs. Not that I don't use all sorts of therapies in my clinical
practice that haven't been well studied. I just can't say from the mothers in my practice that I
have even anecdotal support over 20 years that lecithin is actually helpful.
The main thing for me is that taking a capsule or granules doesn't get at the root cause of
plugged ducts, which is milk stasis. The hands on approach is much more effective in letting
mother understand her own body, and why plugs develop, so she can prevent them in first place.
Taking a capsule has the potential to leave the cause of plugged ducts a mystery, and then she's
destined to more plugged ducts for which she then takes lecithin her entire lactation. I prefer to
empower mothers with an understanding of the relationship between what they feel - comfort or
discomfort and the prevention and management of plugs.
But that's just my personal experience. You have had your own valuable experience with this
mother. As you see more mothers, repeat things you have seen work, to refine your
understanding: learn more to find out who this works for, under what circumstances, and what
situations, if any, it doesn't work for. Learn from your experience. The mothers and babies have
so much to teach us.
Tina Smillie MD
Can you speak to the development of milk blebs in Mom's who have abundant milk?? Do
you have any suggestions how to advise these mothers?
Maureen
USA
Milk blebs represent one form of plugging, right through and at the end of the nipples. This
happens with mothers who have a lot of milk because of milk stasis. That is, the milk does not
move for a long time. This can happen if there is a long time between feeds, especially when it is
longer than is usual for that mother and baby for that time of day. Or if there are always very long
intervals between feeds on that side, as happens frequently with block feeding. If a mother is
typically feeding every 3 hours or so, but on only one side at a time, then each breast has 6
hours of no milk movement. That may be no problem if it is that long once a day if the mother is
lucky enough to have a baby sleeping 5 or 6 hours at night. But if the breast is making a lot of
milk and also going 6 hours between all feeds, for some mothers this can be a problem. For
other mothers it is not a problem.
We are all different, and no one rule fits everyone. This applies to EVERYTHING about
breastfeeding and lactation.
For a mother who has lots of milk and gets blebs and plugs, this clearly has been a problem.
For her, prevention is the best strategy.
1. Try to avoid strict one sided feeds all the time. Try to encourage the baby to nurse on the
second side after most daytime feeds.
2. Whether she gets to nurse on that second side or not, after nursing, use the fingers right
behind the nipple to check for tender areas and to move just a little milk to keep the breast and
nipple comfortable.
3. BEFORE each nursing, with two hands, gently but firmly massage each breast, to
"homogenize" the milk and get the milk dripping and check behind the nipple to clear any tender
area and assure comfort.
4. Lecithin capsules or granules might also be helpful.
As far as treatment once a bleb has developed, I would recommend the above strategies, (if it is
too painful to nurse, hand expression must be included in addition to pumping).
PLUS, use a very tiny amount of a steroid ointment, perhaps 2.5 % hydrocortisone or a bit
stronger if a doctor will prescribe for you (I use 0.1% triamcinolone, but another doctor might
choose a similar moderate strength), and put a very tiny amount just on the little bleb and avoid
the rest of the nipple as best you can. (A little won't hurt but daily over time it can add up, and if
you used big amounts all the time on the rest of the nipple, it could be a set up for a different
nipple problem. Don't get too crazy worried about this! ). What strength you can get over the
counter without a prescription varies from country to country.
So use that little amount of steroid ointment, rub in well, about 3 times a day for 2 to 4 weeks.
Depending on the size of the bleb it can take a long time to clear.
Once a day, cover this with a piece of clear plastic kitchen wrap if you have that available, to get
deeper absorption of the ointment.
This ointment is not absorbed by the baby's gut and will not hurt the baby whether breastfed
directly or drinking pumped milk. No need to scrub it off before feeding or pumping.
If this does not help, consult a dermatologist who is sympathetic to mother's issues.
Tina Smillie MD
Not a question just a big thank you for an amazing presentation.
Regards
Lynda
South Africa
I enjoyed your presentation very much, thank you!
Agata
Poland
Fantastic presentation. I have always been concerned with the blanket recommendations
for rapid milk production. Now I have science based tools which work well. I have been
doing a more modified block approach for a while on my own. It does work.
Ann
USA
I'm glad you all found the presentation helpful.
Tina Smillie MD
Hi. I found your talk on the Breastmilk 'Milkshake' fascinating and very relevant for all of
my clients to use to 'homogenize' the breastmilk before a feed. I am looking everywhere
for graphics that would show this, do you have a source for any illustrations I can show to
clients to help them understand the process/rationale for doing this massage before
feeding (and pumping)?
Thank you!
Dottie
USA
Dottie, the only illustration I have is the little graphic I made up that is in the powerpoint you
viewed, with an alveolus and a duct, and little dots representing the milk fat globules. But that's
not how I explain it to mothers, because that's way too scientific. I just explain that the cream is
there at the same time as the watery fraction, but that our milk is not homogenized, and the
cream is 'sticky' and clings to the lining of the ducts. And when we massage, we loosen the milk
fat, so it gets mixed into the milk. (I avoid talking about 'foremilk' and 'hindmilk' because these are
fake scientific terms that are not used by mammary physiologists themselves, and completely
misrepresent what is going on. Nevertheless mothers are often quickly made familiar with these
terms they had never heard until their baby was born, so I will sometimes use these terms to
explain both how she can 'homogenize' her own milk, and also to explain why these terms are
just plain wrong. Which I think I explained in the talk.
Because I'm on a vendetta about this, I will elaborate, even though this is not your question:
Milk is not divided neatly into two kinds of milk. This simplistic view leads to a lot of bad advice.*
Milk transitions quite gradually from the thinner milk that is available sitting in the ducts before
milk has been released to the richer milk that can be left behind if baby, hands or pump have
removed milk while breast was continuously making more milk and releasing it with milk
ejections. How much thinner or richer it is from beginning to end varies for a lot of reasons by
time of day, mother, baby, feeding patterns and rhythms, whether they are staying on one side
for a long time, switch nursing, long or short intervals between feeds, etc. And of course, if a
mother massages her breasts, as Jane Morton's studies show, she can get creamier milk in the
first place.
* For example, block feeding, as I explained in the talk. Or, another example, for a sleepy slow
gaining baby, frequent bad advice is to "stay on one breast so you can get to the hindmilk," when
in fact an underweight baby who is flow dependent will fall asleep as the flow slows down, and
will not "get to the hindmilk" and such advice only aggravates poor milk transfer, poor weight
gain, and further compromises maternal milk production.
Tina Smillie MD
Are rosemary and thyme also anti galactogogues?
Gabrielle
Australia
YES. That's why some of my talks on galactogues will reference Simon and Garfunkle's "Parsley,
Sage, Rosemary and Thyme." But hard to take enough of these last two by themselves. Doesn't
mean a mother whose production is not overboard, or who is building production, can't have a
little rosemary bread or use thyme to season a meal here and there.
Tina Smillie MD
From your lecture about the effect of massaging the breast to get the proper fats in the
case of hyperprolatemia i totally agree with you but what about the over supply for the
mother what to do to avoid mastitis and other problems as you are not agree with block
feeding and pumping ? Thanks in advance. I really enjoyed your lecture.
Dinka
Croatia
I'm sorry if I was not clear. Block feeding may possibly be ok if limited to a single day or two of
short 3 hr blocks for a mother with very mild hyperlactation. This is what some providers mean by
block feeding and I have no quarrel with that, because it will work quickly if we are nipping the
situation in the bud.
However many mothers have taken block feeding to an extreme, staying on the same side for 4,
6, 8, 12 or even 24 hours at a time, and then sticking with this unnatural plan for weeks or
months at a time. (By "unnatural," test the idea against the cave woman or the mother monkey).
Longer and longer blocks continuing for weeks moving into months, why? because the original
plan didn't work.
With a mother who has full blown hperlactation, who is making milk way faster than her baby or
babies require, block feeding for longer and longer blocks of time is DANGEROUS because it
makes the mom ignore her breast comfort in the face of an exterior rule, creating milk stasis on
the alternate side and setting her up for plugged ducts and mastitis. Comfort should always
trump rules, as that's how physiology works best. Think less about volume of milk and think of
hyperlactation as very FAST production. This is why it is too late for FIL to work very well for
these mothers, so the premise behind block feeding falls apart. Block feeding allows the
unnursed breast to rapidly fill with milk. For some women the letdowns from stimulation from the
other side can allow cream into the unnursed side, but for many mothers it means thinner and
thinner milk on that unnursed side, and hours to allow the milk to separate further. These
situations do NOT necessarily respond to the rules you think FIL follows because when mothers
make milk super rapidly they can have lots of receptors responding to the rapidly emptied alveoli,
and not much chance for FIL to work.These mothers are then in a more extreme situation than
the mechanisms of FIL will address.
Massaging is not just to get "the proper fats" but to protect the breast from plugging by keeping
the ducts open and averting the milk stasis that leads to plugging.
Creamier milk also helps satiate the baby so the baby will not keep driving up the rate of
production by hungrily staying on or returning to the breast frequently. Faster rate of production
means thinner milk, means hungrier baby.
Also if she is making tons of milk, pumping and storing 200 ml or more over and above what her
baby is taking, I certainly wouldn't tell her to stop pumping cold turkey, again she needs to
maintain comfort. But to use antigalactogogues and limit pumping to comfort, followed by manual
pressure over uncomfortable areas, so she keeps breasts comfortable, prevents stasis and
plugging, but gradually reduces the amount she takes off to maintain comfort.
Tina Smillie MD