Q&A: could pumping be changing the composition of breastmilk?

Joyce writes:

"My 5 month old son has always been a prolific spitter-upper.  I am talking volumes.  We have always marveled that he is able to grow with the amount of spitting up that he does (17 lbs, 4 oz at 4.5 months!). He not only spits up right after a feeding, but even up to two hours afterward.  He is always in a bib, and we usually go through at least 6 bibs and four changes of clothes a day -- and we're not being overly fastidious and trying to keep him in "clean" clothes necessarily; we change him when the spit-up stink gets to be overwhelming.  I made some long-term, serious dietary changes to see if that would help (from months 2 - 4, no dairy, no legumes, no cruciferous vegetables, etc.). No dice. His pediatrician put him on Zantac to try to control the spitting up, and we thought it was helping.

I am a full-time graduate student.  Over winter break, I noticed that his spitting up declined substantially.  We even made it through several days with only one bib and no outfit changes!  I thought maybe he was growing out of the spitting up.  Either that, or it was the Zantac, since he  started it just before my winter break began.   

My classes resume tomorrow, and his spitting up has also returned.  Today we've gone through five bibs and five outfits.  I haven't changed his number of feedings, nor have I changed my diet.  The only thing different: I didn't pump during winter break, and I have gone back to pumping to build up a stash of breastmilk for his return to daycare while I am in class.  I am now assuming that the pumping is causing his spitting up. 

Have you ever heard of such a thing?  If so, what can I do?  I don't want to feed him formula while he's in day care yet, so I'd need to keep pumping.  Should we all just live with the spitting up as long as I am pumping?"

That's a gross problem. But remember that spitting up, as long as the baby isn't in pain, isn't an actual health problem. For years I've been hearing and repeating the quote that "spit-up isn't a medical problem, it's a laundry problem," and then Jamie (author of the great "Why Is It So Hard To Breastfeed A Baby?" and "What's the normal learning curve?" posts) told me the original source was  Dr. Greg White (husband of La Leche League co-founder Mary White).

My first thought was that the pumping was changing something about the amount of milk Joyce produces, or the ratio of foremilk (watery with a lot of lactic acid) to hindmilk (fatty and creamy and sticks to the ribs better). So I decided to get a second opinion from Jamie. Here's what she said:

"It could be foremilk/hindmilk imbalance with a more abundant milk supply, or it could be that her letdown is too forceful for him when she has more milk.  Gulping to keep up with the flow of milk can mean a lot of spitting up later.  A couple of ideas off the top of my head: nursing against gravity helps with overactive letdown.  She could lean back in a recliner, or in the corner of the couch, or try nursing while lying down when she's at home.  Sometimes positioning the baby so he's straddling the mother allows her to lean back more comfortably and puts his mouth higher in relation to her breast.

Alternatively, she could try pumping off some of the milk right before he nurses.  If she pumps or hand-expresses first thing in the morning (or whenever her breasts feel especially full) so she can offer the baby an empty-ish breast, it's likely to be less of a problem.  If a pumping session is too much to stomach first thing in the morning, she could try nursing with a towel handy.  When she feels the letdown begin, she could unlatch the baby for a minute, let that milk just flow into the towel, and then reconnect the baby again afterward.  It's that first letdown that will probably be the most forceful."

Those suggestions should help when Joyce is at home nursing. For the pumped bottles, it may just be the foremilk/hindmilk imbalance and there isn't anything to be done about it. (I'm assuming she's already checked to make sure there isn't that sour or soapy taste characteristic of pumped milk in women with excess lipase issues.)

Joyce, I think you're just going to have to decide which would be worse to you, to switch to formula at daycare or to keep doing so much laundry. If you start him on solids at around 6 months, that might also help him keep things down a little more. My guess is that as he gets older and that muscle at the top of his esophagus gets stronger, combined with eating more solid-ish foods, the spit-up problem will fade away.

Comments

[Jennifer Barnes]

I'm no expert by any means, but having survived nursing my son for 13 months through all sorts of weird and unusual circumstances and then reading this post, my first reaction is to blame it on stress. The break from classes and break from spitting up seem too much a coincidence to dismiss. The problem with my idea is that there is no concrete way to provide proof, y'know? I'm sorry this is happening. He'll probably outgrow it before Joyce figures out what's going on.

[hedra]

My other thought is that for me other things also affect my supply/letdown, stress included, but also diet (less rushed, better diet?), how much rest, etc.

But the same response applies - work with the supply/letdown issue as a management issue - the tips provided are the ones I know. Meriel has reflux AND I had the oversupply/active-letdown issue (even with twins!), so the zantac may be helping some anyway. My kids all did learn how to cope with the supply issue on their own, not much older than yours is now. So she may 'solve' that soon! If not that, there's often a pumping/supply slump around 6 months that evens things out nicely if you had an oversupply going.

Brendan solved by sipping and letting go (complete with turning his head away to avoid being sprayed) until the intial letdown passed. Rowan learned to drink really fast. Meriel clamped down hard, then let up, clamped, then let up, let go ('done') early and then topped up a few minutes later.

[hedra]

Sorry, 'he'! :o

[AV]

If reflux is an issue, Zantac dosing is weight dependent in little ones, so as a baby grows the dose often needs to be adjusted. Some babies do better with proton pump inhibitors (like prilosec for example) than with Zantac, so might be worth a talk with the ped. if the medicine semed to work once but not now.

[caro]

M had this same frequent, voluminous spit up issue. Hers also completely cleared up around 6 months, so maybe you're almost out of the woods. Interesting info, though, about the supply stuff. We'll keep that in mind for the next one...

[Tabetha]

I would hang in there. It could be that he is beginning to outgrow the spitting up. If you are considering formula, I suggest trying formula as a test to see if it is any better before giving up breastfeeding.

[flea]

Can foremilk-hindmilk imbalance cause spitting up? My impression (based on my "happy spitter" plus too much time at La Leche League) is that spitting up is based on the baby's tummy development, plus the possibility of gulping air when feeding at either bottle or breast - which is why overproducers (like me) tend to have spitters, because of the heavy let-down. I haven't heard that the composition of the milk affects spitting up at all, and I wonder a bit about that. (I'm a librarian - I have just doomed myself to an hour on PubMed. Sigh.)

I suppose the spitting up when you're pumping could be due to oversupply at the breast, when he's nursing, and to a bad fit with the bottle nipple that lets air in, or maybe the caregiver is feeding him too fast or simply too much. And then when you're not pumping, your oversupply decreases and he's not getting bottles at all.

Anyway, my happy spitter has gotten better as he's gotten older (now 6 months, and I have definitely had a drop-off in my oversupply). I don't mind the laundry, but I do hate the guilt feeling (and feeling of wasted milk) when you nurse the baby and then he makes a small fountain at you, even if he is gaining weight and clearly not in pain. Darn those immature digestive tracts!

[flea]

Okay, back from PubMed. Note I am not a doctor, and I have only read the summaries of a bunch of articles. But the general trends seem to be: breastfed babies are less likely to spit up (=have GERD) than formula-fed babies; a significant percentage of all babies spit up a lot, and usually physical immaturity of the digestive tract is the reason; in formula-fed babies, thickening the formula made spitting up less likely.

So maybe, based on the analogy with formula, pumping IS increasing foremilk, making the milk less creamy, and causing increased spit up. Fascinating.

[Jamie]

Take a look at this article, which describes a useful method of paced bottlefeeding. Keeping the baby more upright and feeding at a slower pace might help a lot.

I would think that for your daycare providers, the benefit of less baby urp would offset the small increase in time required for paced feedings. :-)

Hope to hear how it all works out. I agree with the commenters who have said that it's likely to get better soon because of developmental changes.

Oops, no HTML in comments. Here's the link: http://www.ilca.org/pubs/jhl/j18h1l10.pdf

[tina]

How much milk are you producing from each breast when you pump? I had oversupply and was shocked when women at a LLL meeting said they get 2-3 oz per breast because I always got at least 5...and this was after I "fixed" my oversupply!

('fixing' involves pumping or nursing from one breast over and over for 4-8+ hours depending on how bad the issue is [or how long you can stand milk building up in the other breast] and then switching...gradually you'll start to produce less)

So yeah, I think maybe there is not enough fat/hindmilk overall in your baby's feedings, perhaps because you are pumping and maintaining a supply that's too high for a little belly. So when you pump or when the baby nurses, only the foremilk is coming out and this can result in an upset stomach among other things (it was the green poop that finally tipped me off). http://www.llli.org/FAQ/oversupply.html

this is all somewhat reiterative but oh well!

[hedra]

I think they meant that overactive letdown with an oversupply can cause spitting up. It isn't the foremilk amount compared to hindmilk amount that does it. It is that they get overfull and 'tip the rest back out' or they gulp to keep up with the flow and have a lot of air, which when burped tends to carry milk with it. The foremilk thing itself has no impact that I know of on the burp/spittage.

Though diet change can definitely affect degree of spillage - dairy and soy both affect massive puke episodes. Dairy is the more likely one, and you already tried that (even traces, I presume? Because traces can do it).

[Crystal]

I've gotta weigh in on this (first time posting here!). It sounds like oversupply to me, especially with the fast weight gain (typical of babies whose mothers have oversupply, but not harmful). This is the best article I've found on it:
http://www.lalecheleague.org/FAQ/oversupply.html

The extra pumping to develop a freezer stash can seriously aggravate this condition. At my worst, I could pump 8 ounces in 7 minutes. It basically looked like cloudy water because there was so much foremilk (since I couldn't pump longer to get to much hindmilk). Now that I've got things under control and we've hit 6 months, I am down to 4 ounces in 15 minutes (this is more normal).

I had to really cut back on pumping and introduce block feeding. I started out with 2 hour blocks and then went all the way to 5 hour blocks to get things under control.

I would advise her against pumping off excess before feeding. This is going to perpetuate the problem.

[Charisse]

I've only nursed/pumped for one baby, but is there any chance it could be a mechanical issue? Just swallowing a lot more air when taking milk from the bottle as opposed to the breast? It might help to change to a sippy with a more breast-like shape if that's the case. Upright feeding also a good idea--my daughter (who wouldn't take an actual bottle, but that's another story) did best when fed sitting on a caregiver's leg with her back to their stomach. We used a Munchkin First Sipper, which is totally not what's recommended at that age, but what seemed to best mimic the shape her mouth actually made when nursing my rather small breasts.

[Jamie]

Crystal makes the excellent point that pumping can exacerbate oversupply. If Joyce is trying to create a freezer stash, then ramping up the supply (a bit) is actually desirable. And if she is planning a morning pumping session anyway, then adjusting the sequence so that the pumping comes before the nursing may make for a more comfortable baby -- without telling the breasts to produce more milk than is needed.

If the baby is usually reasonably happy and his stools are normal (i.e., not green), I wouldn't worry too much about pumping first.

[Rachel]

Repeating beginning of Charisse's post, I have only nursed one baby but, in my experience, no one ever told me that pumping 5oz at a time or more was oversupply. I nursed my son through 15 months. I went back to work full-time when he was three months and pumped two or three times a day to meet his daytime needs.

At my first morning pump, (usually 5:30am so that I could then feed him directly about 6:30am), I would pump 10oz -- two 5oz bottles using Medela Pump In Style. During the day, until he was about a year old, in my two pumping day sessions, I was pumping another total of 10 oz, sometimes more. I state all this because my son actually never spit up.

I only weigh in because I'm not positive that the supply thing as measured in how much is pumped indicates a link to spit up.

More details, though, my son was born 8 lbs and gained weight at "usual" chart rate. If your child started out even a little lighter, then I think it would make sense that digestive track would be less developed. That's just a thought. Oh, I also just remembered that when he was about two months, (maybe earlier on, my memory is foggy), I stopped eating all wheat products for about a week because he was especially gassy. That helped. (I was able to re-introduce wheat back into my diet later.) In addition, from about the time he could really sit up on his own, about half the nursing times he would like to sit facing me to nurse instead of cradle hold. Couldn't do that in public but it worked when at home! Final comment, he never got the hang of any type of cup where you had to tilt your head back. He has only ever drank from the straw-type cups.

Hope some of this helps...

[Rachel]

PS: Funny thing, as I'm writing this, my boobs are beginning to feel heavy! Does anyone have experience with how long will that last that thinking/talking about/seeing a little baby will instictively get that reaction?

(Funny because my son is now 20 months and he stopped nursing in Sept.)

[Amy]

Excess lipase?? You mean there is a scientific reason why my pumped milk tastes foul almost immediately but both babies drank it from the breast without a problem? I just thought I was a freak.

[Amy]

And Rachel... I stopped nursing baby #2 over 3 years ago and I can still feel a "let down" when I think about nursing her and her older brother.

One last thing, any solutions to the excess lipase?? I'd prefer baby #3 to be on 100% breastmilk rather than the 50% he'll be on when I go back to work.

[Sadie]

It's my recent understanding that the containers in which pumped breast milk is stored can change the chemical composition pretty signficantly-- not sure if that would impact this specific issue, but thought it was worth a shout-out.

[Joyce]

Thank you, Moxie and everyone!!

I am thinking that oversupply could be the issue. Baby's poops are normal & not green, and he doesn't actually spit up after taking bottles -- it's only when he's breastfed. We actually had to give him only bottles for two days last week because I was on a muscle relaxer for a wry neck. I pumped and dumped, and we decimated my freezer stash. He barely spit up in the two days he was on the bottles, and when we went back to breastfeeding, back came the spit-up.

Soooo....based on all the great suggestions:

I am going to try nursing in different positions and pumping off a bit before nursing him to see if I can counteract that first letdown a bit. I'm also going to work on being more patient as his little tummy grows to handle the deluge.

Off to do laundry... ;)

[Brooke]

I believe you can scald milk to deactivate the lipase. But I'm not positive about it.

[Amanda]

I have to comment on this. Having a baby that has/had SEVERE reflux, that's exactly what this sounds like, and just because a baby is gaining weight, that doesn't mean reflux isn't the issue. Reflux babies are typically one of two things, overeaters or undereaters. It sounds like she has an overeater and a happy spitter, meaning they don't seem to be in pain. And solids is not the answer to vomiting. It just makes for a nastier mess. The idea behind that is that solids are heavier, and therefore, harder to throw-up. But some reflux babies could spit up concrete.

I also think that it's a horrible idea to give mothers of spitters the false hope that 6 months is the magic age that their baby will stop spitting up. Reflux, of any degree (meaning the most painful to the happiest), peaks from 4-6 months, and then starting at 6 months, most babies will grow out of it because their lower esophagal sphincter develops.

What it sounds like to me is that the Zantac was working, and the baby outgrew it's dose. Zantac is very weight sensitive, and it takes about 2 weeks for it to kick in. PPIs are much more effective medications for reflux anyway.

[Josie]

My baby is also a major spitter and only spits up after nursing, not after a bottle. My LC said it was oversupply combined with overactive letdown. Starting when she was three weeks old and continuing through now(she's 6.5 months), I only nurse her from one breast each feeding (so she gets the hindmilk). We also nurse with her sitting up as much as possible. Ironically, my daughter didn't spit up once while we visited my in-laws in New England over the holidays and I nursed her the whole time. I have no clue how to explain that one. I guess if I lived there all the time, I might have to do less laundry. Good luck figuring it out and keeping up with the laundry!

[O]

One other thought: It could still be allergies, too. I know you are probably not eating *that* differently on break but it can sometimes be devilishly hard to trace, and different allergens can take different amounts of time to get out of the system... One of my best friends came to LLL meetings as well as local bf group meetings with her prolific spitter-upper, with no help anywhere. Turns out eventually that Zantac and a no soy, no nut, no wheat, no something else diet solved the problem but that took a lot of teasing out. I hope that the positioning, etc., helps but don't rule out the allergy route if it doesn't. Good luck!

[swimmermom]

My first baby was a prolific spitter-upper, just like you describe your baby. We also went through multiple bib & clothing changes (his and mine) daily for the first 6+ months. My baby gained beautifully, hit all the developmental milestones, and was generally a cheerful sweet guy -- didn't seem bothered in the slightest by these humongous blurps. (The dog remembers those days fondly, lol.) (also Ew, lol) I tried a lot of things but what finally worked for us was totally eliminating dairy, soy, and nuts from my diet. I had made a half-hearted attempt early on which was unsuccessful, so I had to really commit and do it right before it worked. I realize you already did a pretty thorough elimination diet but is is possible you missed a main allergen? For example, soy is nearly as allergenic as cow's milk, and it's in *everything* these days. Maybe you eat energy bars (Luna bars etc) when you are in school but not at home -- those have a lot of soy. You wouldn't need to start from scratch with an elimination diet, just try cutting out different things than before.

The combo of elimination diet and just waiting for him to grow out of it was what worked for us. Around 12-15 months I could start adding the offending foods back into my diet without triggering the spitting up, and later he was able to eat those foods himself with no problems.

[Hilary]

I tried to post earlier but got interrupted. I hope I am not repeating what someone else said. Is your baby drinking the pumped milk out of bottles, and only spitting up when he has used a bottle?

Milk comes out of most bottle nipples much faster, and a breast fed baby may suck too hard. You can get newborn nipples, which have restricted flow, and the baby may gulp less and spit up less.

I may have misinterpreted when he spits up, but if youa re only concerned about the pumped milk, it may be the nipple, not the milk, that is more different.

[Tabetha]

Just curious. Do you pump into glass or plastic bottles? I know that glass bottles can change the composition of breastmilk. Just a thought. :)

[ergo baby carrier]

This cannot be possible how can this effect the composition of your breast milk.

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