Understanding Weight Loss in breastfed babies

1. Understanding Weight Loss in breastfed babies • What is normal weight loss? • Why do babies lose weight? • How to identify a concern • What to do first • All Wales Guidelines Breastfeeding Matters

2. What is a normal weight loss? • Babies born in the UK to lose weight in the first few days due to fluid loss • Many hospitals identify a 10% weight loss from birth as ok • Recent studies indicate 7% may be more normal • The time taken for the baby to regain birth weight & • The time to establish a pattern of weight gain is important Breastfeeding Matters

3. Why do babies lose more than expected? • They are not getting enough milk! A baby should have regained his birth weight by 14 days • Infrequent feeding • Insufficient milk transfer • Underlying illness Breastfeeding Matters

4. Why do babies lose more than expected? • Infrequent feeding Missed feeding cues Regime imposed Clock watching Sore nipples Equal reduction in milk supply Full breasts, Mastitis Embarrassment Misunderstanding of normal bf pattern Poor advice i.e. ‘top ups’ Breastfeeding Matters

5. Why do babies lose more than expected? • Insufficient milk transfer poor position poor latch / attachment ineffective suck /swallow pattern inhibited milk ejection Inhibited milk production Reducing milk supply Breastfeeding Matters

6. To weigh or not to weigh? • Weighing is one of several tools to assess growth & well being • Weight must be accurate, scales in good order • Recorded accurately, significance understood • Currently no nationally agreed protocol • But it should be frequent enough to pick up problems with feeding especially in first 2 weeks. NICE, BFI • Reflects what has happened over a period of time • Not the most immediate sign that feeding is not effective • Anxiety is only caused by over weighing with no help or explanation Breastfeeding Matters

7. Assessment! • Weighing is one of several tools to assess growth & well being Output V input Condition & behaviour of baby Behaviour of mum V Breastfeeding Matters

8. What are we worried about? • Extreme weight loss is accompanied by dehydration & possibly hypernatraemia( high sodium levels) • Dehydration Blood thicker, baby’s heart works harder, can clog up the blood vessels leading to vital organs; kidneys, liver or brain. • Hypernatraemia is doubly dangerous; baby dehydrated and sodium levels high. When the sodium in the blood is too high, it poisons the cells. • Brain cells are particularly at risk, which is why hypernatraemic dehydration can make a baby have fits and behave abnormally • Can be fatal Breastfeeding Matters

9. What to look out for • ‘good baby’ • Infrequent feeding – less than 8 feeds/24hours • Sleeping through the night • Mother has sore/trauma to nipples • Sleepy baby • Jaundiced • ‘constipated’, dry clean nappies • Low grade fever • excessive irritability • Weight loss of more than 12% Breastfeeding Matters

10. First things first! • Evaluate feeding by observation & discussion • Check position of mum • Attachment of baby • Assess output • Discuss pattern of feeds • Use BFI checklists • Assess weight (if not already done) • Re-visit Breastfeeding Matters

11. Signs feeding is going well ...and not well • Before attachment • Mother’s position • Mother relaxed and comfortable • Breast hanging or lying naturally • Easy access to nipple/areola • Hair/clothing do not restrict mother’s view • Baby’s position • Baby’s head and body in line • Baby held close to mother’s body • Baby’s whole body supported • Baby’s nose opposite nipple • Attaching to the breast • Baby reaches or roots for the breast • Mother waits for baby to open mouth wide • Baby opens mouth wide • Mother brings baby swiftly towards breast • Baby’s chin/lower lip/tongue touches breast first • Mother not relaxed, e.g. shoulders tense • Breast squashed or restricted • Access to nipple/areola restricted • Mother’s view restricted by hair/clothing • Baby has to twist head and neck to feed • Baby not held close to mother’s body • Only shoulders or head supported • Baby’s lower lip/chin opposite nipple • No response to the breast • Mother does not wait for baby to ‘gape’ • Baby does not open mouth wide • Mother does not move baby in swiftly • Baby’s top lip touches the breast first Breastfeeding Matters

12. Signs feeding is going well ...and not well • Observations • Baby’s chin touches the breast • Baby’s mouth wide open • Baby’s cheeks soft and rounded • Baby’s lower lip turned outwards • If visible, more areola seen above baby’s • top lip3 • Breasts remain round during a feed • Signs of milk release (e.g. leaking) • Baby’s behaviour • Baby stays attached to the breast • Baby calm and alert at the breast • Slow, deep sucking bursts with pauses • No noise other than swallowing • Rhythmic swallowing seen • At the end of the feed • Baby releases the breast spontaneously • Breasts appear soft • Nipple is same shape as before feed • Skin of nipple/areola appears healthy • Baby’s chin does not touch the breast • Baby’s mouth pursed, lips point forward • Baby’s cheeks tense or pulled in • Baby’s lower lip turned in • More areola seen below bottom lip • (or equal) • Breasts look stretched or pulled • No signs of milk release • Baby slips off the breast • Baby restless or fussy • Rapid shallow sucks • Smacking or clicking sounds • Occasional or no swallowing seen • Mother takes baby off the breast • Breasts are hard or inflamed • Nipple is wedge-shaped or squashed • Nipple/areola is sore or cracked Breastfeeding Matters

13. Identified the problem…? • You have the knowledge and skills to help • Give mum the right information to address; • Infrequent feeding Missed feeding cues, regime imposed, poor advice, embarrassment, misunderstanding of normal bf pattern • Insufficient milk transfer poor position, poor latch, inhibited milk ejection, poor swallowing Breastfeeding Matters

14. Confidence & support Mothers quickly lose confidence in breastfeeding • Your support is essential • You can give accurate information • Show confidence in her ability • You can value breastfeeding • You can develop a plan of action with her; Skin contact, feed both breasts, min 8 feeds, feed diary, re-weigh Breastfeeding Matters

15. Identified more than 10% loss? • More intensive support • Discuss with BF colleague • Check breastfeeding history • Breast compression • Switch nursing • Check for signs of illness • Pump after feeds, offer EBM via cup • Re-weigh 24-48 hours Breastfeeding Matters

16. More than 12% • Refer to paediatrician for investigation • Intensive breastfeeding support • Double pumping preferable • Supplementation is necc if bf assessed as ineffective; EBM via cup Formula feed via cup or supplementer (avoid top ups) IV fluids • Continue breastfeeding, as milk supply increases reduce formula • Continue to monitor weight 2x week until trend towards normal weight gain Breastfeeding Matters

17. All Wales Weight Loss Guidelines • Task and Finish Group • Building on comprehensive work • Compatible with BFI Best Practice Standards • For distribution this Spring • Clear guidance but will not supersede clinical judgements Breastfeeding Matters

18. To summarise • ‘Keeping your fingers crossed’ is not good enough now! • Remember the theory of breastfeeding; Good attachment, feed the baby, move the milk • Practice the skills of teaching positioning and attachment • Learn the signs of good attachment; curled out lips, round cheeks, chin indenting, swallowing • Increase knowledge • Develop practice, improve outcomes Breastfeeding Matters

19. Give a baby something to smile about! Breastfeeding Matters