ABM Clinical Protocol #32: Management of Hyperlactation

Abstract

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breast-feeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Introduction

THE AIM OF THIS PROTOCOL is to review the diagnosis of hyperlactation and describe management recommendations. Throughout this protocol, the quality of evidence based on the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (Levels 1–5) is noted in parentheses.

Hyperlactation, also termed hypergalactia or “oversupply,” is the production of breast milk in excess of the volume required for growth of healthy infant(s) based on international standards. No precise definition for this term exists, so reported cases constitute a wide spectrum of excess volumes. An average term infant consumes 450–1,200 mL daily (Level 4), and production volumes higher than this may represent hyperlactation.

Multiple factors regulate milk production homeostasis (Levels 3 and 4). These include the following:

• Amount of mammary glandular tissue in an individual breast

• Alveolar distension in the breast

• Degree and frequency of milk emptying

• Complex neuroendocrine pathways

In addition, the complex signaling of serotonin and possibly other bioactive factors may mediate some of the actions previously attributed to a single substance termed “Feedback Inhibitor of Lactation” (Level 4).

Patients with hyperlactation may experience multiple breastfeeding complications, including breast pain, plugged ducts, and mastitis. Dyads are at risk for early weaning and/or exclusive pumping due to latch difficulties and/or forceful letdown. Maternal and infant signs and symptoms of hyperlactation are summarized in Table 1 . If medical complications and/or psychological distress occur, women with hyperlactation may be advised to decrease their milk production. Behavioral interventions, herbal therapies, and prescription medications have been used to treat hyperlactation, with varying success rates and levels of evidence. As the effect of each intervention may vary between individuals, determination of optimal therapy regimens, such as dosage and frequency, remains challenging.

Differential Diagnosis

Hyperlactation may be self-induced, iatrogenic, or idiopathic.

• Self-induced hyperlactation occurs when the mother stimulates production of more milk than the infant requires. This may occur from excessive pumping in addition to breastfeeding. Mothers may fear not having sufficient milk in the future, desire to donate milk, or misunderstand that they do not need to store high volumes of milk for return to work. Women who exclusively pump may produce more milk than needed for the infant(s). Women also may self-induce a rate of milk production higher than needed by their infant(s) by taking herbal substances and/or prescription medications that may increase milk production.

• Iatrogenic hyperlactation occurs when health professionals contribute to excessive milk production. Providers may advise women to take galactogogues (i.e., substances that increase the rate of human milk synthesis) without close follow-up and/or guidance regarding cessation. In addition to prescribing metoclopramide and/or domperidone, other medications such as metformin may increase the rate of milk synthesis (Level 4). Health professionals also may advise expressing milk in addition to direct breastfeeding. While this may be appropriate in certain situations, it also may lead to persistent overproduction of milk if not closely monitored.

• Idiopathic hyperlactation is a term reserved for mothers who struggle with high rates of milk production with no clear etiology. It is normal for healthy mothers to experience breast fullness in the first several weeks postpartum, as their milk production adjusts to the demands of their infant(s). However, if fullness and high production persist, idiopathic hyperlactation represents a diagnostic consideration.

Although hyperprolactinemia has been suggested as a cause of hyperlactation, no evidence exists that correlates prolactin level with rate of milk production (Levels 3 and 4). In fact, mothers with a history of pituitary adenomas have been reported to have insufficient milk production (Level 4).

No consensus exists regarding how early in the postpartum period a diagnosis of hyperlactation can be made. Hyperlactation can be distinguished from engorgement by lack of interstitial edema and persistence of symptoms beyond 1–2 weeks postpartum (Level 4). Mild cases of hyperlactation may never be formally diagnosed, as they may resolve spontaneously within a few months as prolactin levels decline and regulation of milk synthesis shifts from predominantly hormonal to local control (Level 3).

Management