Late onset slow weight gain

1. Late onset slow weight gain Jack Newman MD, FRCPC

2. A typical case • Mother • 29 years old, no medical problems • First pregnancy, no complications • Baby • Born at term • Healthy • Birth weight 3.5 kg (7lb 11oz)

3. Starting out breastfeeding • The baby is tried immediately at the breast. He takes it, suckles a few minutes and then falls asleep • The baby receives a little 5% glucose by cup once during the first 24 hours of life • “He wasn’t settling. The nurse said that some glucose water would calm him down”

4. Questions • Was this the best approach to dealing with a baby who wouldn’t settle? • What might have been another, perhaps better, approach?

5. Answers • No, s/he could have proceeded in a different way • The fact that s/he didn’t give a bottle, the fact that s/he didn’t use formula, does not mean that this was the best approach

6. What would have been better? • Before giving anything: • Fix the latch With a better latch, the baby gets more milk • Teach the mother how to know the baby is actually getting milk (not just sucking) • Teach the mother to use compression • Switch sides when the baby doesn’t drink any more • Do not limit time on breast

9. Video clips of drinking or not

10. Video of 10 and40 hour old baby

11. Don’t limit time on breast? • If we don’t limit time on breast, if the baby stays on the breast, usually he won’t cry or become “unsettled” • So let him stay on the breast • If the latch is good, the mother shouldn’t be sore • If necessary, give extra 5% glucose water with a lactation aid

14. After discharge from hospital • Mother had sore nipples for 10 days, then got better • Was this necessary? • Baby weighed 3.5 kg at birth • Breastfeeding exclusively, the baby weighed: • 4.5 kg at 1 month • 5.5 kg at 2 months • 6.0 kg at 3 months • 6.0 kg at 4 months

16. Video clip of a baby “jiggling” at breast

17. At our clinic, 2 days after the last weight (6.0 kg), the baby weighs 6.1 kg

18. Is this possible? • Did the baby really gain 100 grams in 2 days? • Probably not • So what happened? • Different scale • Error in writing down weights (our clinic or doctor’s office) • What does the 100 g increase mean? • Nothing • Should we be reassured? • No!

19. So why the slow gain? • Possibilities: • The mother goes on the birth control pill • The mother is pregnant • Maternal medications other than hormones • Maternal illness • Can an emotional “shock” dry up the milk?

20. More possibilities • Feeding one breast only at each feeding • Using bottles more than occasionally • Mother trying to be a “supermother”? • Other (unknown or same as 10.?) • Babies pull away from the breast when the flow slows down

21. 1. The birth control pill • Decreased milk supply with any type, even progestin only pills • Seems less common with progestin only pill, but this may be because it is less commonly used • Medroxyprogesterone (DepoProvera) cannot be taken away once given • If hormones must be used for some reason, try the oral progestin only pill first • If no decrease, maybe try DepoProvera

22. 1. The birth control pill • The decrease can be unpredictable • Not all women get this • Some have breastfed fine with it for previous babies, but start the same pill at the same time, and get a significant decrease within a week of starting • Waiting until the baby is older (4 or 5 months) does not prevent the problem

23. 1. The birth control pill • What if the mother gets a decrease while on the pill? • Stop the pill, any time; it doesn’t have to be at the end of the cycle • Start domperidone [or metoclopramide (Reglan)—less desirable, more side effects] • With domperidone, return of milk supply is often very rapid (within days)

24. 1. The birth control pill • There are other ways of conception control beside hormonal ones • Breastfeeding itself gives considerable protection • Baby is under 6 months • Mother hasn’t had a normal period yet • Baby is exclusively breastfed • Barrier methods for those not convinced

25. 1. The birth control pill • Other preparations of hormones, even estrogens, probably do not affect milk supply because blood levels achieved with these preparations are negligible • Vaginal creams • We have heard from many mothers about significant decreases in milk supply after insertion of the Mirena IUD • Skin creams

26. 2. A new pregnancy • Luckily, if a mother is breastfeeding exclusively, pregnancy before 6 months is unusual, but does occur • Thus the baby is usually eating solids, and the mother can increase the intake of solids if the baby is not content at the breast • After 6 months, formula is not necessary if the baby is eating a variety of foods in adequate amounts • Homogenized milk is perfectly adequate

27. 2. A new pregnancy • Giving bottles will not make the situation better • Milk can be given by cup or added to solids • If the baby is fussy at the breast, then give some food first, then offer breast • He is less likely to demand rapid flow, if he is not very hungry • If the baby is young (under 4 months or so)lactation aid to supplement • Even by three months, though, some babies don’t like the lactation aid

28. 2. A new pregnancy • Some babies or toddlers will refuse the breast, however, if the milk supply, and milk flow are slow, and wean themselves • There is no reason, though, that weaning is necessary if the mother is pregnant • There is no evidence that the foetus will suffer • There is no evidence for increased risk of spontaneous abortion

29. 3. Medications other than hormones • Several drugs can significantly decrease the milk supply • Bromocriptine and cabergoline • Pseudoephedrine? • Antihistamines? • Diuretics? • SSRI antidepressants? • Others? (several mothers questioned the possibility that antibiotics, particularly cloxacillin, would have decreased their supply)

30. 3. Medications other than hormones • Pseudoephedrine and antihistamines are both commonly used, often in combination, in cold and allergy medicines • Look for alternatives • Vasoconstrictive nose and eye drops • Nasal and opthalmic antihistamines • Steroid nose drops, inhalers • Cromolyn

31. 4. Maternal illness • Most often associated with blocked ducts and/or mastitis • Unusual, but not rare, and in some rare cases, in both breasts, even if the mother had mastitis in just one • Why? • Prevent blocked ducts and mastitis • Good latch • “Finish” one side before offering the other

32. 4. Maternal illness • Any febrile or “flu-like” illness seems capable of decreasing the mother’s milk supply • Luckily, again, this is unusual • Due to… • Stopping breastfeeding? • Inadequate intake of fluid? • Do not stop breastfeeding for illness, take baby into bed, nurse frequently and around the clock

33. 5. Emotional shock • At first, I never believed this one, but with time one runs across situations that cannot be put down to mother’s “imagination” • Lactation consultant feeding a 3 month old baby • No problems, baby gaining beautifully • LC’s mother dies suddently and unexpectedly milk supply dries up suddenly (no drinking) milk returns within 24 hours with domperidone • Thankfully, this appears to be quite uncommon • What about chronic stress?

34. 6. One breast at a feeding • Used as a “treatment” for colic • It can help, but… • Finish one side before offering the other, and let the baby have it if he wants it • Use compression to help the baby finish • Keeping to one side is not appropriate • No more than saying to a mother you must feed both sides • No rules, puleeze!

35. 6. One breast at a feeding • “Give the baby just one breast at a feeding, so that he gets the hind milk” Secret! • If the baby is not getting any milk at the breast, he is not getting hind milk A little knowledge is a dangerous thing • “the breast is never empty” + “milk increases in fat as the baby sucks longer”error

36. Variation in fat content during a single feeding

37. Forget hind milk! • If the baby drinks enough low fat milk, he will still gain • There is no such thing as “no fat” breastmilk, even the first milk has some fat • If the baby isn’t doing the “pausing type of suck”, he is not getting milk!

38. Is this possible? • According to one mother, this is the advice she received from a breastfeeding hotline for her slow gaining 3 week old: • To make sure the baby gets the hindmilk, pump off the first ounce from each breast • How can someone even imagine this would be a good idea? • Let’s give the baby two ounces of breastmilk less at each feeding and he’ll gain better

39. 7. Using bottles, pacifiers more than occasionally • A big problem in the US and other countries where many mothers have unacceptably short maternity leaves • Even in Canada, though, mothers think babies need bottles, even if they are over 6 months old • But also mothers use bottles to stretch out feedings, or try to make the baby sleep through the night • Counselling • Help improve the “efficiency” of breastfeeding (See Protocol to increase breastmilk intake by the baby)

40. 7. Using bottles, pacifiers more than occasionally • Even young babies (<3 or 4 months old) can learn to cup feed • Mothers can find ways to combine work and breastfeeding • Some can bring baby to work • Have baby brought during breaks and lunch • Go to day care centre to feed the baby • Some babies actually will wait for their mothers

41. 7. Using bottles, pacifiers more than occasionally • Once the baby is older, there is no need for bottles • It is a measure of how pervasive our bottle feeding mentality is that we believe that babies need bottles to feed • If the baby is eating solids, milk can be mixed in with his food • The baby can learn to drink from a cup

42. From an email • I have a 10 week old daughter and have breastfeeding her since the beginning, supplementing one formula feeding per day. We have been giving her the supplement in a bottle since she was 3 weeks old, finger feeding before that. We decided to supplement her by choice, since she wasn’t gaining very well at the start.

43. Email continued • In the past day or so, she has been extremely fussy at the breast, coming on and off continuously for an hour or more, refusing it. I have really been trying to get through it, continuing to breastfeed despite her fussiness, but I’m getting very frustrated.  I have tried to change positions, feed her before she becomes really hungry and burp her more frequently, and it works sometimes, but not always. I would like to continue breastfeeding, but I don’t know how much more of this I can take.

44. Analysis of email • Was the appropriate response to “she wasn’t gaining very well at the start” to give a bottle? • Could one bottle a day really cause all this problem? • What else would be involved? • Baby’s behaviour changes with time • Milk supply decreases?

45. 8. Trying to be a “supermother” • Too easy to fall into the trap • We expect so much from mothers… • Let the housework go • Home delivery of food not such a bad thing • Laundry is for others to do • Fathers can do lots to help (and that does not mean giving a bottle) • Is it really necessary to return to work or school early?