My baby is clicking or gagging. Is it Fast letdown? Is it oversupply? Tongue Tie?

You've got through the first couple of weeks of breastfeeding and just as you start to feel it's going ok, your baby has started gagging and choking while feeding or maybe she is latching off and on and getting her face sprayed with milk. Maybe during feeds you are hearing a clicking sound. Your baby also suddenly seems very gassy and upset. You asked your HV who suggested it could be reflux. A friend suggested it was a tongue tie. You asked "Dr Google" who popped up lots of links on Fast or Forceful Letdown / Oversupply and gives a solution of Block Feeding. This is a common scenario and a large proportion of mums and babies have this experience to some extent. Do they really all have reflux/colic/tongue tie? Do all these mums have oversupply? Could it be that again, we are just not understanding the big picture?

Is a Click a Click?

I want to start off by talking about the idea of a click. I think that 10 years ago I didn’t hear a lot of conversation about clicky feeds, but with the advent of social media, and online groups the awareness of “clicks” has massively grown, and many websites seem to exclusively link it to tongue tie. It’s almost like a diagnosis of tongue tie - “oh your baby clicks when feeding - it’s probably a tongue tie”. But is a “click” the same from baby to baby? Babies have all sorts of little noises that they make when feeding. If you are reading a website which only talks about clicks - you are quite likely to interpret the sound you are hearing as a click as well.

Would it surprise you to know that I’ve had more than a few consults for “clicks” but when I got there, the sound they were concerned about was actually a swallow sound. In fact in a couple of cases the mum was unlatching the baby and repositioning each time she heard the “click” (a swallow) - which was leading to a really fussy, frustrated baby and incredibly long feeds.

A swallow obviously happens at the back of the throat, it’s a sound of the tongue at the back of the throat so it makes a guttural type sound which can absolutely have a “k” sound to it. It might sound a bit like “kuh kuh kuh “ or a “g” sound “guh guh guh “ or even a “ck ck ck” sound. It’s understandable that you might read about clicking and misinterpret a swallow.

In fact “click” is probably not the best description of the sound that I think of as more indicative of a tongue issue. It has been described as many sounds over the years. I’ve seen a 18th century text describing it as a “chucking noise”. I actually think this is more descriptive of the sound which can be a problem. Kuh sounds are usually good. Wet sounding chucks or smacks are more of an issue. I’ve added a link to a youtube video with a baby making these sounds at the bottom of the page. You’ll hear it’s much more of a wet sound that what you think of as a “click”.

Why do we get this sound? Well it’s essentially a loss of seal. When feeding a baby needs to extend and cup their tongue around the breast. They seal their tongue around it and then move their tongue in a wave to “milk” the breast. The chuck/shuck /slurp type sound happens when the seal breaks. You can make it yourself by placing your tongue firmly against your palate and then pulling it down sharply. You will find that it makes very different sounds depending on where you are placing most pressure with your tongue. Pressing up through the centre of your tongue will cause a different sound to pressure mostly through the sides of your tongue, and this is why we can get a variety of sounds with feeding.

Why does a baby lose the seal at all though?

Is it fast letdown? It can be - but actually the letdown is supposed to be pretty fast. Having a fast letdown isn’t something you always need to fix - we can look at ways to help the baby cope better. That may be as simple as positioning.

Is it oversupply. Possibly - but in my experience many more people worry about oversupply than actually have it. Weight gain is the diagnostic factor here - if your baby is gaining 1lb a week or more then yes, you are looking at oversupply. More on that below.

Is it tongue tie - possibly. Tongue tie absolutely stops the tongue from moving as it should and can certainly cause frequent seal breaks, but so can positioning issues, engorgement, issues caused by a difficult birth, immaturity. It’s certainly not diagnostic of a tongue tie! Only a tongue tie assessment will tell you whether a baby has a tongue restriction - and that involves much more than listening to a feed. It will involve a trained professional using a gloved finger to assess specific tongue movements.

Could there be another cause - Absolutely! Lots of other possible causes - keep reading.

What about a baby gagging? Is that fast letdown/oversupply/tongue tie?

Babies have a very complex suck-swallow-breathe coordination process requiring a large number of nerves and muscles working together. The wave like motion we discussed above allows a baby to nearly continuously breathe while sucking. The basic process is as follows: Milk is transferred from the breast into the baby's mouth. Baby then takes a breath while moving the milk to the back of her throat in preparation for a swallow. As the milk reaches the back of her throat area she does a short exhale and then holds her breath while she swallows. After the swallow is complete she exhales the remainder of the held breath. It is a very complex and intricately timed process. When a baby is gagging /choking or spluttering at the breast it is generally because the smooth coordination of the suck-swallow-breathe rhythm has been disrupted and the swallow and breathe is mis-timed. As adults we still occasionally have mis-timed swallows, and we might talk about a drink having gone "down the wrong way". We can put down the glass and recover, but for babies the milk continues to flow. That leads to difficulty keeping up with flow (choking/spluttering).

Why clicking /gagging now?

Many mums and babies notice this happening around 3 weeks. A big part of the reason for the timing is the change in milk supply. Milk volume changes rapidly in the first couple of weeks. In the first few days of colostrum a mum is producing maybe a teaspoon or 2 of milk at a feed, averaging about 30-45ml over the course of 24 hrs. When her milk "comes in" there is a rapid change to large volumes of milk building over the first 2 weeks. By the time a mum gets to around 14 days she may be producing 800ml of milk over the course of a day. It is an enormous change. With the volume the letdown is a bit faster, but a fast letdown and oversupply are entirely different things. Fast milk at letdown is normal! It is normal and expected that milk will begin to spray and it makes complete sense when we think about what is happening within the breasts. Inside the breasts milk is stored in ball like structures called alveoli which are surrounded by muscle fibres. At letdown the muscles contract and literally squeeze the milk into the ducts and down through the nipples. A crude analogy would be to think of a bath toy which sprays of water when you squeeze it. This is what happens at letdown and is normal. A baby should be able to handle this ideally, but lots of things can impact on the suck-swallow-breathe coordination meaning that some babies may mistime swallows (gagging). Some babies may try to cope by breaking the seal and re-engaging again (chucking/smacking noise). A baby struggling with the flow does not necessarily mean that mum has a faster than normal letdown or that she has oversupply. It can mean that mum has a completely normal letdown and normal supply but that her baby is struggling with the normal flow.

Why would baby have problems coordinating the flow / maintaining a seal?

There can be lots of different reasons why this might happen with a normal supply. It may simply be due to immaturity. The suck-swallow-breathe coordination matures at different rates and completely mature coordination may only develop at 42 weeks gestation for some babies, or even in the weeks following birth for other babies. Gestation lengths of babies varies enormously, and that means what we think of as a 2 week old baby can vary enormously. A baby born at 42 weeks for example may have 5 weeks further development than a baby who was born at 37 weeks, even though they are both considered full term babies. Those weeks can have a big effect on a baby's coordination. Given that as adults it still happens us from time to time, it shouldn't be surprising that an immature newborn would have this experience.

It could be due to the attachment. A baby who isn't well latched to the breast won't have as good coordination of milk transfer and may splutter at the breast. This might be a simple positioning fix. It might be that the breast is really full and firm and the baby just can’t get latched on deeply. It might be that the breast is large and heavy and the baby is having difficulty holding the breast in their mouth. It may be that you lifted your breast when latching on, then let go and this is causing the breast to move in baby’s mouth making it difficult for them to maintain a deep latch.

It might simply be that babies are slightly “behind” the milk volume. When babies are born, they have done some rudimentary practising of sucking and swallowing of amniotic fluid, but that fluid is not travelling under pressure. The baby just has to open their mouth, fluid will enter, and then can swallow. When they are born, colostrum flows pretty slowly. Then suddenly milk volume increases and they need to play “catch up”. The tongue is a muscle. The jaws are moved by muscles. Imagine having muscles that you only used gently for as long as you had those muscles and then suddenly you have to use them pretty vigourously for 5 hours a day. The more the milk volume increases, the faster that milk flows and the more/faster your tongue has to work. Letdowns have extremely fast flow, between letdowns it’s slower flow. If you were doing this with your legs you’d probably call it Fartlet training or HIIT training. Muscles get tired. Sometimes they just can’t keep up in the first few weeks of training. They get stronger and a few weeks later the same activity isn’t an issue.

It could be something that happened at birth. A baby's skull undergoes significant moulding at birth in order to let it travel through the birth canal. Think of the shape of a newborn's head immediately after birth and how it changes over the first few days and weeks. Add in the impact of any medical interventions on the skull shape. Forceps, vaccum birth or cesarean section can cause different moulding to a baby's head. Any moulding of the bones affects the muscles which are attached to those bones - including the muscles which are used to latch, suck, swallow and breathe. This can be a factor in coping with the letdown. Even where structural issues aren't in play, medications can be? Studies have found that having an epidural during labour to have an effect on suck-swallow-breathe coordination for up to a month, for example. The study stopped at one month, so we actually have no idea how long the suck-swallow-breathe might actually be affected.

In some cases an anatomical issue can certainly be the cause - something like a tongue tie, which impacts on tongue movement and ability to deal with the letdown, but this needs to be fully assessed. Noisy feeding and choking/spluttering is absolutely not enough to diagnose. A small baby experiencing all this may have a much more normal sounding feed if positioned different, perhaps with some breast shaping to help form and stabilise the breast. A few weeks later he may no longer need this help.

Perhaps it's none of these things. Perhaps it's just the way breastfeeding is being managed. Maybe you are focused on feeding at certain times? Maybe you are feeling engorged? Maybe you are still in a little pain and are holding off feeding for a short time after you see early cues. Any of those factors which lead to the breasts being fuller increases the pressure in the breasts and consequently the speed of the letdown.

Is block feeding the answer?

Generally not! The basic premise of block feeding is to divide the day into blocks of time and to feed from one breast during each block thereby reducing stimulation and milk production. It works! It works very effectively and very quickly, and that means it needs caution. If your baby is struggling but not gaining excessively (which is the more likely scenario) then block feeding will mean that you reduce your supply and that may impact your baby's weight gain and growth. Block feeding should generally only be used if a baby is gaining over 1lb a week, and even then I would urge some caution. It would only be used for a few days and there are lots of other options to try before blocking.

See the big picture

While block feeding may help for true oversupply, where the issue is simply baby being an immature newborn, block feeding may hinder rather than help. It may stop the choking/gagging but at the cost of limiting that baby's source of nutrition. Milk supply is being set up in the first 5 weeks so it makes sense to be cautious about reducing milk volume in that time.

Often we need to just consider the normalcy of what is happening - an increasing volume of milk and an immature baby! Breastfeeding is a holistic process and we need to manage it in that way. Many times all that is needed is a change in position. If we have difficulty keeping up the flow of water in a glass we simply lower the glass so that it flows more slowly. The same principles apply. Shifting your body so that your baby is lying more on top of you means that gravity slows the flow. Sometimes that is all that is needed. That position can often deepen the latch, which also helps. All you need to do is lean back. If your baby is still struggling in that position it can help to just remove the letdown from the equation altogether. You can just unlatch when your baby begins to struggle and let the milk spray into a muslin or hand towel and then relatch when the flow slows again. Some babies do this all by themselves as they have worked out that it's easier that way.

It’s also important to realise that some noises are normal. The odd smacking/chucking/clicking noise is pretty normal. Most young babies will do them here and there. That’s very different to a baby feeding where you are hearing it very frequently throughout the feed. For these babies looking at breast shaping can help to get a deeper latch. If this isn’t helping I’d suggest seeing an IBCLC or breastfeeding counsellor to look at what might be happening.

For most babies, clicking/smacking/gagging is a temporary issue. Maybe it's because the baby just gets more mature each day or because any birth issues have resolved. Maybe he learns to manage the new faster volume, or maybe it's because supply and baby have just got into a better sync. In fact it's likely that in a couple of months the same baby will be wanting to get that fast flow straight away and will let you know if he isn't!

If positioning doesn't help, or getting a better attachment doesn’t help, or you are considering block feeding, look for experienced breastfeeding support. The right supporter for you will look at the breastfeeding picture as a whole, and as you and your baby as one unit. See the big picture. Our babies are still learning to feed in these early weeks and their muscles and nerves still developing. A fast letdown isn't something that necessarily needs fixed, in fact in can be a really reassuring sign that your milk supply is building nicely. Often we just need to support our babies while their feeding matures.

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