Harriet's four-week-old breastfed baby Jamie cries a lot from lactose overload
Harriet and Jamie's story
I remember vividly the two women whose breastfed babies suffered from the most severe cases of lactose overload I've encountered in my professional life so far.
The first was the mother of three, Harriet, who saw me in desperation because her four-week-old baby showed the same signs that had caused such distress when her eldest two were babies.
The second was Carolina and her baby Sienna. You can find out about Carolina's experience of lactose overload in her baby here.
Jamie is always crying if he's not sleeping
“We're an allergy family,” Harriet explained bravely, jigging up and down on the spot, firmly patting the four-week-old baby who was curled into her body making little groaning sounds and almost invisible in the soft cloth carrier she was using.
“Both of my big boys were the same when they were tiny. They still have allergies. It's severe still with the two year old. Thankfully the eldest is starting to grow out of his, now he's five. Both of them screamed for the first year of their life, and they were both on Losec from the beginning. I know worse things can happen, but if you had any ideas to make it easier for Jamie, I'd be so grateful. If he's not sleeping - and I can assure you, he hardly sleeps - then he is crying and grizzling. Screaming, a lot of the time. I can't put him away from my body for a minute. I wear the carrier is as if it is a part of me. He's in awful pain and I feel so sorry for the little fellow.”
I paid attention to this woman as I took the history. She was a lawyer. She was pragmatic, stoic, competent. She looked exhausted but had put on make-up to come into the clinic, her mass of golden curls piled up artfully on the top of her head. Her husband was supportive but had always worked long hours as a banker and entrepreneur.
Harriet had good female friends, who cared about her. Her mother lived an hour's drive away and came in regularly to help, including to look after the older boys this morning. Her Edinburgh Postnatal Depression Scal score, which she'd filled out routinely before seeing me, was 14.
Jamie is gaining about 350 gm a week
Jamie seems to want to feed all the time and he is so little that I let him. The child health nurse said with his brothers that I should space out the feeds and I used to try that though it didn't seem to help much. I can't though, with Jamie, he starts to cry and he's in pain and …. I just feed him.” She looks at me anxiously, even guiltily.
Harriet tells me with some modest pride that despite everything, despite all that she'd lived through, despite exhaustion beyond belief, and with each little boy crying excessively well into the second half of the first year of their lives, each of her children had been breastfed until 12 months of age. They received nothing but breastmilk until about six months of age.
This really is something to be proud of. If Harriet had decided to use formula I would have completely understand. There wouldn't have been a flicker of judgement in me, how could there be? Already I feel only admiration for all that she's given. The heroism of women moves me endlessly, a quiet heroism that is still not acknowledged by the world, though these weary, hard-working, achingly generous women are nurturing the future of humanity, for the sake of us all.
Jamie starts to grizzle and cry, and as Harriet starts to take him out of the carrier, we hear a long explosion of wind and stool.
“How much stool does he pass in 24 hours?” I ask, showing her my palm to describe a palmful in the nappy.
“Oh!” She shakes her head. “Same as Sam and Aran. Huge amounts. Every nappy has some stool, even if its just a little skid. But I would say he is passing a palmful six or seven times in a 24 hour period.”
“And flatulence?” I ask.
She begins to laugh. “All the time! Same as Sam and Aran, too.” And it's true. Even as we speak he passes more noisy wind into the nappy. I take her to the nappy change mattress on the couch and she begins a practiced nappy change, talking with me at the same time, intermittently smiling at and talking to the baby, whose is grizzling and fretting all the while.
When I examine him, I notice that his tummy is distended with colonic gas. Often parents think their baby's tummy is tight and distended but it's not - little tummies can seem rounded and quite swollen, but are soft when they are happy. Baby tummies naturally become tight and hard when they are dialed up.
Jamie passes another frothy squirty yellowish green stool on the change table.
“Often it's very green,” she says. “And there can be lots of mucous. Same as the boys, allergy. The paediatrician prescribed the Losec but I'm just hanging off until I've spoken with you. I hate using medication. Though goodness knows I've had to give it to my children for years ….”
Harriet has a very generous supply of milk
And then I ask about her milk supply. She looks at me. “Milk? Oh my God. I've got enough milk for triplets. It's always been like this, all the way through. I have this huge supply and probably the world's biggest breasts. Truly, I'm huge.”
She doesn't pump, she doesn't hand express. She offers just one breast a feed. She is offering possibly every couple of hours, often more, going to the same breast over a two hour period. Much of the time her breasts feel tight and uncomfortable. I check out her breasts, and though they definitely aren't the biggest breasts in the world they are generous.
I watch a feed. Jamie doesn't stay on for long and is guzzling suck-swallow-suck-swallow for most of the time he is on. In a while he begins to fuss and pull off. But I form the judgement that fit and hold concerns are not particularly relevant for Harriet and Jamie.
Jamie has a lactose overload.
“Do you use a dummy?”
“I do. I have to. His tummy fills up so quickly but he still wants to suck.”
Ah,” I say, “a dummy really makes sense in this situation. Babies like to suck for the sensory experience of it, in addition to the desire for milk, and when there is a generous supply the tummy can fill before they've had their sensory-motor and emotional fill of suckling!”
Then we talk about strategies for managing the lactose overload.
What Harriet did to downregulate her milk production
Here are the new strategies Harriet used.
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Allowed one breast to run as full as felt safe while returning Jamie to the other
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Took Jamie off during the initial letdown and let her milk run free for the whole of that letdown. This upset Jamie, but was worth it in the end. It meant that he could suckle for longer before his tummy was completely filled up
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Trying to give Jamie as many rich sensory motor experiences outside the house during the day as possible. Jamie may have been dialling up frequently inside the home because there was not enough sensory motor adventure. Harriet was generously responding with her breast but feeling trapped inside the house when her older children were at school. A sensory motor experience outside the home may have dialled Jamie down as effectively as a breastfeed on occasions.
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Harriet made efforts to offer sensory motor experience before immediately offering Jamie the breast. This is different to a strategy of feed spacing. Harriet was using her two tools to dial Jamie down, rather than relying predominantly on the tool of milk
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Continued offering Jamie the pacifier
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Commenced a lactobacillus reuteri probiotic.
Harriet avoided
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Any attempts to feed space, though she did
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Burping or holding Jamie upright after breastfeeds, which dials babies up and makes sleep harder
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Pumping or hand expressing off milk before she fed her baby, because this would have increased her milk production
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Commencing a maternal elimination diet
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Commencing an anti-secretory medication for reflux
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Using any wind or colic mixtures.
It took about two weeks for Harriet's supply to settle down, but with each passing week Jamie became more settled. His stool remained copious but the excessive flatulence also settled. I have the view that the probiotic was the least important cause of these changes, but it was important nevertheless to add in the probiotic, given that the research has demonstrated benefit in crying breastfed babies.
You can find out about probiotics and unsettled babies here.