When a baby starts to suckle, a reflex involving nerves and hormones (a neurohormonal reflex) releases milk from the breast. This reflex is known as the milk ejection reflex (MER) and is commonly called the “let-down”. If milk is released very forcefully it is sometimes called a fast let-down or an overactive let-down. With a fast let-down, milk might be seen spurting from the breast like water from a firefighter’s hose when baby comes off the breast mid flow. Such a fast or forceful flow is not necessarily a problem for a baby—many babies love the faster pace—and it is quite normal for milk to spurt from the breast. However, some babies can seem to be overwhelmed and fussy by a very fast let-down, they may cough, choke or let go of the breast and cry. This article looks at signs that can indicate a baby is struggling with the flow of breast milk in a fast let-down and what to do about it.
What does a let-down feel like?
Not all mothers feel anything at all when milk begins to flow from the breast with the let-down reflex—but they will notice their baby starts to swallow milk more rapidly a few minutes into the feed. Other mothers will feel a tingling or prickling sensation when milk is released from the breast. Some mothers describe it as a pins and needles type feeling. If the breast is very full the sensation can be stronger and may be briefly painful.
Signs of a fast or forceful let-down
Signs that a baby is struggling to cope with the flow of milk in a fast let-down might include:
- Choking, gasping and coughing at the breast
- Coming on and off the breast during breastfeeding
- Pulling on the breast and nipples (babies can also do this when the flow of milk is too slow)
- Rapid swallowing of milk with stress cues e.g. fussing, frowning, crying, finger splaying
- Short feeds if baby gets a lot of breast milk in a short time
- Clamping down on the nipples to slow the milk flow leading to sore nipples
- Spitting up frequently after a feed (this can be quite normal)
- Making a clicking sound during breastfeeding due to losing suction with the breast. Note that babies may also make a clicking sound if they are not attached to the breast deeply (see below) or if they have a tongue-tie.
- Having trapped wind, needing to burp frequently
- Fussing or crying at the breast, unable to fall asleep contentedly
- Refusal to breastfeed
Fast let-down and oversupply
The symptoms of fast or forceful let-down listed above are often seen in babies whose mothers have too much breast milk or “oversupply” however this is not always the case—a baby may struggle with flow without oversupply. If you feel you have much more milk than your baby needs see Oversupply of Breast Milk alongside this article for management ideas. Where appropriate, reducing your supply a little can help resolve some of the difficulties. Remember that if you and your baby are coping well with the volume and flow of milk you won’t need to make any changes.
Why does my baby struggle with the let-down?
How well a baby can handle a fast let-down or forceful milk flow can depend on their latch (the way baby is attached to the breast), their positioning (the way they are held) and how well they can coordinate suck, swallow and breathe. It can be normal for a newborn baby to cough or choke occasionally with the let-down while they are still learning how to breastfeed1 and to can be quite normal to spit up excess milk (have reflux) after a feed.
Attachment and positioning
If baby has only the nipple in his mouth rather than a good mouthful of breast it is more difficult for him to control the flow of milk. Similarly certain positions can make breastfeeding more difficult for a baby. An IBCLC lactation consultant can help to identify whether a baby’s latch or positioning could be causing difficulties with managing the flow of milk.
Coordinating suck, swallow and breathe
A fast let-down is not always a mother-related problem (i.e. the mother’s let-down is too fast); it may be a baby-related issue for example a baby may have difficulty managing normal flow as well as fast flow. When a baby breastfeeds they coordinate their breathing with sucking and swallowing in a carefully timed sequence so they do not swallow the wrong way causing milk to enter their airway instead of their oesophagus. If the timing of the swallow is not quite right, fluid could enter the lungs (aspiration).
Lactation consultant and breastfeeding author Cathy Watson Genna2 explains that problems with swallowing (dysphagia) are not common but may be seen with some premature babies, babies who have had heart surgery, babies with neurological or anatomic issues or severe reflux and some healthy term babies. She explains that breastfeeding does not automatically protect against dysphagia or aspiration and points out that not all babies will cough or choke—some babies who are having problems may stop breathing temporarily to prevent more fluid going into their lungs. Breathing issues such as congestion or excess mucus production can also be a cause of difficulty handling flow rate at breast or with a bottle. In Supporting Sucking Skills In Breastfeeding Infants, Cathy Watson Genna, 2017, p164 explains that if a fast flow overwhelms breathing, the baby may:
- change their sucking pattern to short sucking bursts to give more time for catch up breathing
- use prolonged compression to try to stem the flow again to give time for breathing
- pull away from the breast to have a proper chance to breathe
- if the flow is too stressful some babies may refuse to suck or suck with very little pressure as a way of coping
For further reading see Supporting Sucking Skills, 3e and contact your baby’s health professional if you have any concerns about your baby’s swallowing or breathing coordination.
Tips for helping your baby with a fast let-down
If your baby coughs, chokes, gulps and gasps or lets go of the breast just after you have a let-down:
Check positioning and attachment
The deeper the latch, the better a baby can control flow. See Latching Tips and Breastfeeding Positions for Newborns for more information. Sometimes a mother or baby’s particular anatomy can make it harder to get a deeper latch eg if a baby has a tongue-tie or a mother has very large breasts or nipples. An IBCLC lactation consultant can help with suggesting the best positions to breastfeed for you and your baby.
Try leaning back in reclining positions
Breastfeeding positions with baby above the breast can help to slow the flow of milk because milk flowing uphill is working against gravity.3
Try letting the fast flow subside
If the let-down is very fast, try taking baby off the breast for a moment or two until the flow slows a little. A container or towel can catch the milk and once the flow has slowed your baby may be better able to cope with the flow. Alternatively initiate the let-down before baby comes to the breast so that the fast flow has subsided. Some mothers express a little milk before baby comes to the breast so the flow is slower. Bear in mind that regularly expressing milk before breastfeeding could ultimately stimulate your breasts to make more milk which may worsen the situation if your fast flow is connected to oversupply.
Feed frequently on demand
Avoiding long time intervals between breastfeeds will help to reduce engorgement and faster flow due to increased pressure of milk within the breast.
Look for early feeding cues
It can be helpful to avoid a baby being overly hungry which can make him less coordinated and have a stronger more frantic suck. Look for early feeding cues (sucking fingers, searching with an open mouth) or try offering a breastfeed while baby is still sleepy and relaxed.
Never hold the back of baby’s head to force him to the breast
If milk flow is fast a baby may need to let go of the breast occasionally to breathe. Avoid holding the back of a baby’s head so that he feels forced onto the breast, he needs to be able to protect his airway by taking a break.
Burp baby regularly during and after a feed
Swallowing milk quickly may mean you baby needs to burp frequently.
Nipple shields?
A nipple shield can help some babies by reducing the rate of flow of milk. However, a nipple shield can cause other problems. See Nipple Shield Good or Bad? and contact your breastfeeding specialist if you’re considering using a nipple shield for a fast let-down.
Adjust your milk supply
If a fast let-down is associated with having too much breast milk, steps can be taken to reduce the milk supply a little, and this in turn can help to slow a fast let-down. See Oversupply of Breast Milk for more information and check with your IBCLC lactation consultant before reducing your milk supply.
Try a bottle or cup
If problems continue it may be necessary to offer expressed breast milk via a slow flow teat or open cup until more help can be sought.
Seek professional help
Occasionally some babies may benefit from a referral to the Speech and Language Team (SALT) to check whether there is an underlying reason why they cannot manage the flow of milk.
Summary
Milk is released from the breast in a neurohormonal reflex known as the “let-down” at the start of a breastfeed. Sometimes the flow of milk in this reflex can seem to be too fast for an individual baby and they gulp, cough and gasp and may come off the breast crying while milk spurts everywhere. A forceful flow is often associated with having “too much milk”. How easily a baby can cope with a forceful flow of milk depends on how a baby is positioned and attached to the breast and how they can cope with coordinating sucking, swallowing and breathing through a fast flow. There are several ideas to try if a baby is struggling with a fast let-down.