Overactive let-down (OALD) reflex results in the forceful release of milk from the breast when the infant is suckling. It usually occurs only with the first let-down in the breastfeeding session, though in some cases the woman may have more than one let-down. Another name for this is hyper-milk ejection.

The cause of an OALD reflex is not yet known. It may be due to an abnormally strong reaction to the hormone called oxytocin which is released during suckling or nipple stimulation. It could also be that such women produce too much milk.

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Why is OALD reflex important?

When the OALD reflex is present, the rush of milk means that the baby drinks too much too fast, ingesting a lot of air during the act of swallowing. As the baby grows to expect this phenomenon, the reaction may range from reluctance to feed to downright aversion or typical colicky symptoms. Mothers may even think that the baby is ready to wean, when actually what is occurring is the baby’s display of inability to handle such a large volume of milk.

The baby may not learn to latch on properly, or may develop an abnormal latch-on. In such babies the end of the nipple may be the point of attachment, in an effort to protect against the over-abundant supply of milk during the OALD. Some babies may pull off at this time and then not latch on again. This can cause pain and trauma to the mother’s nipple.

OALD reflex can occur by itself or as part of the oversupply syndrome or oversupply colic. Other associated problems include the engorgement of the breast with overproduction of milk during lactation, as well as difficulties with breathing and swallowing patterns in infancy.

Management

OALD reflex can be managed by:

• Massaging the breast gently from the periphery to the center before nursing, so as to prevent the sudden let down of excessive amounts of milk.
• Warm breast compresses before nursing can help to get rid of some milk before the baby suckles.
• Cool compresses for a few minutes before nursing may reduce the engorgement.
• It may be wise to express the first milk by hand before beginning to suckle the infant, to avoid the difficulty of swallowing too much milk.
• In other cases, it may be possible to stop nursing for a few moments once the letdown starts, so that the initial strong flood of milk is released safely.
• The baby may also be nursed in a position in which excess milk can drain from the mouth, such as when the mother is leaning back, so that the baby’s mouth faces down to the nipple.
• Removing the baby from the nipple is advisable when the baby’s breathing sounds as if there is difficulty in swallowing. This may be done by gently putting a finger inside the baby’s mouth and easing out the nipple. Once the letdown has reduced, the baby should be allowed to suckle again.
• The breastfeeding session should continue with the same breast till the baby goes to sleep or stops drinking, so that the baby gets the hind milk as well as the fore milk. This is also called block feeding. Only one breast is used to feed the baby, once or several times, for around 3 hours, following which the other side is used. It may be wise to empty both breasts prior to the start of this practice to prevent engorgement of one breast.
• If the baby doesn’t seem to be getting enough milk with only one breast offered for 3 hours, as evidenced by less than 6 wet diapers in 24 hours, the woman may use one breast per feed rather than per block of 3 hours. She should make sure that the baby nurses long enough at the breast to get the protein-rich hind milk.
• Keeping an absorbent pad nearby is advisable to soak up the milk that leaks out with the letdown, while waiting for the flow to reduce a little. This keeps the clothing dry and clean.

To prevent the breast from becoming overfilled or engorged with milk, the baby should be nursed at least 10 times every 24 hours, leaving a gap not longer than 5 hours at night - even for a very sleepy baby. Normally, babies should be fed on demand, at least every 2-3 hours. Frequent nursing reduces the strength of the letdown reflex.

If the other breast needs to be pumped for the sake of comfort, the mother should consult a professional so that proper emptying occurs. Adequate communication with the primary care provider can be an opportunity to share all the important information and ensure necessary care for both the mother and the baby.