Two six-week-old breastfed babies with severe functional lactose overload of breastfeeding + what happened next
Caroline and six-week-old baby Sienna
When I first saw Carolina she was offering Sienna the one breast over a three hour period, applying 'block feeding' as her International Board Certified Lactation Consultant had advised. Her firstborn baby Sienna was a dark-haired six-week-old, whose little tummy was distended with wind when I examined her, due to lactose overload of breastfeeding. Carolina who was doing all she could to manage her extremely generous milk supply.
Carolina came in to see me intermittently after that, throughout the next couple of months. Sienna continued to grow beautifully.
During this time, Carolina's breasts were always tight and netted purple. She had recurrent 'blocked ducts' and two bouts of mastitis. You can find out about 'blocked ducts' here and mastitis here.
Sienna was rarely completely relaxed and happy, though she didn't have crying bouts often at all. Still, the baby's rather dialled up behaviours at times distressed Carolina, who was exhausted.
“I just want her to be happy!” Caroline explained to me, repeatedly. I understood. It hurts our heart to see our tiny child in distress. This is a normal biological response. And whilst I aimed to share with Carolina some psychological tools for managing these painful feelings and the painful thoughts that accompany them, I also consider it my first task as a clinician to deal with the underlying clinical problem - because once that's dealt with, most women's sense of wellbeing returns.
Parents try all sorts of manourvres (such as pedalling their little legs) to help baby relieve herself of gas. But really, these manouvres are more likely to be an interesting sensory motor experience for the baby, which dials her down for that reason. If baby has a true lactose overload and gas-related distension, pedalling baby's legs is not part of the treatment.
It's not our job as parents to make babies pass wind. Their little guts do this perfectly competently themselves, over time. Our job is fill the baby's days with rich and changing sensory motor nourishment outside the home, using milk frequently and flexibly. This approach is best for baby's gut, and best for baby's developing motor system.
Most babies might have some periods especially in the early days when their needs are calibrating a woman's supply, and there is some signs of a mild lactose overload. As health professionals, we are best not worrying about this. It is too easy to tip a woman into low supply by having her use strategies that are really only suited for a true and significant lactose overload. Most often a baby's fussiness has other causes.
Many women with a generous supply, whose baby has a true lactose overload, have been told that the baby has a medical condition. The baby is then treated in a way that increases the risk of a true medical condition, when all that was required was skilful breastfeeding management.
I often said to Carolina: “You're the one who is able to best calibrate your supply to meet your baby's milk needs. My job is to make sure that I'm communicating information to you in a way that makes sense, so that you can then go home and experiment.”
Sensory nourishment is an important part of the management plan. Women tend to feel locked into the home when they have a crying baby or feeding problems, and this worsens infant crying due to baby's inadequate environmental experience.
In recent years, breastfeeding support professionals have become more aware of lactose overload. Unfortunately, it is now overdiagnosed, and babies can quickly switch from crying due to a lactose overload, to crying because of hunger which results from 'block feeding' and resultant low milk supply. Some women are even being told in hospital to offer one breast a feed so that they prevent a lactose overload, which is a receipe for low milk supply!
What can happen when there is a health system blind spot about lactose overload of breastfeeding
I remember one woman with severe postnatal depression, and her devoted partner, who came in with their very unsettled six-week-old baby, who had a severe lactose overload. I patiently worked through what this devoted breastfeeding mother needed to do to bring her baby relief. She was beside herself with worry and exhaustion because of the baby's constant crying.
“Anything we do to decrease your milk supply today will take at least a couple of days to have an effect,” I explained.
But they saw the paediatrician the next day, who diagnosed severe reflux, commenced a proton pump inhibitor, stopped the breastfeeding, and put the baby on extensively hydrolysed formula. Needless to say, within 48 hours the baby's crying had stopped. This, the paediatrician wrote, confirmed the diagnosis of cow's milk allergy.
I sighed deeply when I read that letter in my intray. Of course if you stop breastfeeding, the symptoms caused by lactose overload of breastfeeding stop! It's just that it can usually be quite simply and almost as quickly managed with breastfeeding changes.
Within a couple of weeks, the psychiatrist to whom I'd referred this woman had admitted her to a residential parenting unit, where she and her baby began sleep training the same day. A week later, after a couple of nights of severe crying, the baby was crying less overall, and still waking at night but not crying so much in the night.
This woman did come back to see me, finally, a month after she began sleep training, when the baby was waking every 40 minutes to an hour throughout the night. I considered this a predictable outcome of the sleep training methods she'd been asked to implement. You can find out about sleep training here.
“At least we dealt with my baby's gut pain,” the mother said to me. “At least we caught the allergy early.” I can't say to her that both treatments (the proton pump inhibitor and the extensively hydrolysed formula) will increase her child's risk of allergy.
"My baby was allergic to my milk," she continued. "She was very sensitive. Even the smallest bit of dairy or soy in a biscuit set her off.” I knew she thought I'd missed the cow's milk allergy, but was being polite and not blaming me.
I nodded carefully.
Some paediatricians I know prescribe anal suppositories for babies who have an abdomen distended with colonic gas. They X-ray, see the colon distended with gas, and consider it to be due to air swallowing, or allergy, or random aerophagia, and believe they should eliminate it with a suppository. This, however, results in further random gut contractions, which can make babies scream with pain. I remember a baby who was hospitalized the night after the paediatrician prescribed a suppository for what was in fact a severe case of lactose overload, due to the screaming. "Allergy," the paediatrician diagnosed (again). "We have to stop the breastfeeding."
That baby was kept in hospital for a week on amino acid formula, while the woman pumped her breasts to prevent engorgement and mastitis, and within days the baby was transformed. The baby was sent home with a dramatically increased the baby's risk of true allergy down the track. No-one in hospital had diagnosed the lactose overload, which is a breastfeeding management problem.
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