Pamela Morrison
International Board
Certified
Lactation
Consultant
INADEQUATE WEIGHT GAIN OR
FAILURE TO THRIVE
IN A BREASTFED INFANT
Adapted from Handout for La
Leche League Great Britain
This
protocol is written as a guide to assist mothers who intend to keep
breastfeeding while working to increase their breastmilk production in order to
feed a baby who has shown inadequate weight gain in the first 6 months of
life. It is strongly advised that their
babies should be under the care of a paediatrician who will monitor the baby's
health and provide medical care while the mother works to increase her baby's
breastmilk intake and provide supplements of expressed breastmilk (EBM) or
infant formula, as necessary. The
suggestions contained in this protocol cannot replace the information and
recommendations a mother can and should obtain from seeking the face to face
help of her own International Board Certified Lactation Consultant or
experienced, knowledgeable, skilled breastfeeding counsellor.
Babies
who are thriving and obtaining sufficient breastmilk should lose and gain
weight at the following rates
o
Loss of up to 7% of birthweight within 3 days is normal
o
Weight loss of 10% or more demands investigation and recommendations to
enhance intake
o
Thereafter, as a rule of thumb,
a full-term, healthy baby should regain and gain at the following rates:
§ Regain birthweight within
10-14 days (3 weeks at most)
§ 0-3 months 30g/day
§ 3-6 months 20g/day
§ 6-12 months 15g/day
o
The baby should double his/her birthweight by 4-5 months
o
The baby should triple his/her birthweight by 1 year.
o
Further information and more exact figures can be found in the WHO
growth charts for boys and girls shown in the references at the end of this
article.
Inadequate
weight gain has many causes, and ideally they should be identified by a
Lactation Consultant or breastfeeding specialist, and the baby should be under medical care (eg a paediatrician) so
that his/her nutrition and health can be monitored while the cause is found and
addressed. However, whatever the cause, low
weight gain shows that there has been inadequate breastmilk intake, often due
to infrequent or too short breastfeeding episodes for this particular baby. If
this poor situation continues too long the baby may be described as Failure to
Thrive (FTT). This description has no
universally accepted definition.
However, infants are generally considered to be failing to thrive when
their weight drops below the third percentile or is 2 standard deviations below
the mean on a standardized growth chart.
FTT
represents a cluster of symptoms occurring together, and is classified into 3
categories:
Organic FTT is due to physical factors
such as renal disease, congenital defects and other conditions.
Non-organic FTT is the absence of physical
evidence of organic disease; environmental factors may be inferred such as
insufficient caloric intake or a disturbance in the mother-baby relationship.
Mixed FTT is a combination of organic
and nonorganic factors, eg conditions in the baby for which the mother may blame
herself which disturbs effective breastfeeding.
Most FTT is not caused by a physical
problem, although attempts to rule out the role of illness are
appropriate. Many cases may be due to
inappropriate parenting patterns such as rigid structuring of the timing,
duration and frequency of feeding. A
frequent, and unnecessary outcome is weaning from the breast in favour of
bottle-feeding. Yet very often
supplementation of breastfeeding is possible to protect the baby's nutrition
while the mother works to increase her breastmilk supply. Sometimes a single cause of low weight gain
is never found, but often after the problem has resolved the mother may be able
to see a combination of small events that led to her baby not thriving, and she
will know how to avoid a recurrence with this baby - and with subsequent
babies.
Causes
of low weight gain which are often overlooked are:
o
Infrequent breastfeeds; most healthy babies need to breastfeed 10-20
times in 24 hours
o
Limited feeding duration; most small babies need to breastfeed with
active swallowing for 10-40 minutes at each feed, until they have had enough (as indicated by
gradually relaxing and falling asleep at the breast); many babies like to cluster-feed on and off
for 2-3 hours, particularly in the evenings, and then sleep for 2-3 hours; the use of a dummy may limit the time spent
at the breast, resulting in inadequate breast drainage thereby suppressing the
mother's milk supply. Much advice directed
at mothers ignores these basic needs of small babies, resulting in inadequate
breastmilk intake by the baby, low weight gain and - if not recognized in time
- eventual failure-to-thrive.
o
Oral contraceptive use; some women find that both the progestin-only
pill as well as the combined oral contraceptive pill and injectables or
implants may cause their babies to become much more fussy and demanding than
usual, indicating a possible effect on the fat/protein content of their
breastmilk and/or it's quantity.
o
Retained placenta or severe
haemorrhage; should be examined as a cause of any low
weight gain in the first six weeks after birth.
o
Mother's thyroid function; should be assessed in any case of "not
enough milk" if there is no other obvious cause.
o
Theca luteinizing cysts or polycystic ovarian syndrome should be considered if the mother’s
milk fails to “come in” within the first few days after birth.
o
Inadequate glandular breast
tissue; an
unlikely cause of lactation failure, but should be considered if there have
been no breast changes during pregnancy, if the breasts are very widely spaced
with puffy areolas, and/or assymetric.
o
Sore nipples; the cause should be assessed and addressed -
may be due either to poor positioning
and attachment of baby at breast or bacterial infection, or (less likely) a
fungal infection; the pain may be so
severe that the mother is unwilling to keep the baby at breast too long; if necessary she should feed expressed milk
until the nipples heal.
o
Tongue-tie is frequently cited as a cause
of sore nipples and/or inadequate milk transfer, but in my experience, this is the least likely cause; other causes
should be looked for and addressed first before it can be concluded that
anterior or posterior tongue-tie and/or upper labial tie is a cause of sore
nipples, or low weight gain, or failure to thrive. Following frenulotomy, the baby who is gaining
poorly should continue to be followed up
to ascertain that the procedure has been effective in reversing the previous
low gain.
Babies
who are consistently receiving inadequate intake may show certain classic
behaviours or characteristics:
o
In the newborn period there may be prolonged
jaundice, the baby loses > 10%
of his/her birthweight in the first 3 days of life and does not regain the lost weight by 10-14 days of age.
o
Dark urine and scanty or no
stools (babies
who are getting enough produce 6-8 wet nappies with clear urine and 3-5 yellow,
mustard stools in each 24 hours. After 6-8 weeks some babies produce fewer
stools. If they continue to gain well,
then this considered normal, but if their weight gain falls off, it could be a
sign of inadequate intake.
o
Low or no weight gain; many breastfeeding counsellors will offer
false reassurance that low gain in a breastfed baby is normal, but it is
not; all cases of consistent inadequate
gain lasting more than a couple of weeks should be fully investigated and only
if there is no organic or non-organic cause, and if the baby is pronounced fit,
healthy and developing normally should a mother be persuaded to feel complacent
about her baby's low weight gain.
o
At first, the hungry baby shows prolonged
and frequent crying, which is often mistaken for colic, or the baby is
pacified/soothed with a dummy
o
Later, the hungry baby may want
to feed all day and sleep all night;
well-meaning friends and advisors may inappropriately endorse either of
these abnormal situations by either urging the mother to continue breastfeeding
"on demand", and by offering congratulations that the baby is
sleeping through the night; the mother
may also reason that because she is feeding the baby all day, then s/he must be
getting enough as evidenced by him sleeping well at night; the truth, however, is that the baby becomes
so exhausted by attempting and failing to obtain enough nourishment during the
day that he is too exhausted to wake up often enough to breastfeed adequately
at night, and long intervals without drainage will deplete his mother's
breastmilk supply still further.
o
During breastfeeding, it may be observed that there is a very short period of swallowing;
thereafter the baby wants to stay attached to the breast, but mostly flutter-sucks with closed eyes, and
he/she wakes again to protest only when taken off the breast.
o
The low gain or FTT baby usually has high muscle tone; s/he seems
very strong and wiry, keeping his elbows tight to his body, unlike the well-fed
baby who will gradually relax during breastfeeding, uncurl his hands and fall
into a deep sleep; at the same time, the
baby starts to become very watchful,
and his/her face may look like a little
old man or woman.
o
The baby who is not getting enough to eat may continue to grow in length, but loses body-fat, and in extreme
cases may also lose muscle, so that his/her skin looks too loose, especially
on the buttocks, arms and thighs. Because the baby is usually well-covered most
of the time, and/or because parents are with the baby every day, and/or may be
in denial, this gradual deterioration
may first be noticed by a friend, a grand-parent or a health-care provider.
Baby's
intake
The
baby who is not "getting enough" at the breast (as evidenced by
consistently inadequate weight gain) needs to receive help to breastfeed and
often supplementation, preferentially, as follows
First
choice: his/her own mother's milk
direct, at breast;
o
breastfeed at least every 2-3 hours around the clock,
o
for 30 minutes each time,
o
then STOP breastfeeding (ie don't waste time leaving a baby who is only
flutter-sucking on the breast for unlimited periods)
o
check positioning and attachment techniques
o
support the breast throughout the feed
o
use alternate massage and breast compression and switch-nursing during
breastfeeding to enhance milk flow and maximize swallowing/intake
Second
choice: Mother's expressed breastmilk, if available
Third
choice: Banked, pasteurized human
milk, if available
Last
resort: Infant formula
Are
supplements really necessary?
A
baby who is growing well on breastfeeding alone doesn't need
supplementation. However, if a mother
tries to increase breastfeeding frequency, duration and efficiency and it
results in no extra weight gain within 2-4 days, then she will need to start
supplementation.
How
much to supplement?
A
baby who is not breastfeeding effectively and/or growing well will require the
following amounts of milk:
Day 1 60ml/kg/day
Day 2 90ml/kg/day
Day 3 120ml/kg/day
Day 4
- Day 10 150ml/kg/day
Day
10 onwards 180ml/kg/day
A
baby who has been gaining only half the amount of desired weight could be
offered half the amount of supplement, above.
However, babies who are recovering from failure to thrive (very low/no
gain over an extended period) may become extremely "demanding" and
may easily take increasing quantities once they have the energy to stay awake
longer and to indicate hunger. Generally
it is better to allow the baby more supplements rather than trying to limit
them. In consultation with the baby's
paediatrician it may be appropriate to feed the baby up to 280 - 300 ml/kg/day
while s/he achieves a "catch-up gain". Once the baby has reached the weight s/he
should be for his/her age, then s/he will usually become less demanding and
will be satisfied with the quantities set out above, eg 180ml/kg/day. It is important for the mother not to feel
too discouraged if she realizes that her milk was far below what her baby
wanted - it CAN be increased while the baby achieves a catch-up and then his
appetite drops down to a more normal intake.
Method
of delivering supplements
EBM
or formula supplements can be delivered as follows:
o
Directly at breast using a supplemental nursing system
o
By cup
o
By spoon
o
By finger-feeding
o
By bottle.
Mothers
and their supporters often worry that a breastfed baby who is receiving a
bottle will become nipple-confused. My
experience is that working to maintain breastfeeding while providing
appropriate supplementation is difficult and time-consuming enough, and it
seems logical that the mother should use the easiest, quickest method of
feeding the supplements that she can find;
this may be by bottle. I have
never worked with a mother-baby pair in these circumstances where the baby was
not happy to switch between breast and bottle, and especially was not happy to
maintain breastfeeding; the key seems to
be keeping the baby very well fed and offering the breast before the baby
becomes too hungry, as well as for comfort-sucking, so that the whole mummy-breastfeeding
experience is a happy, enjoyable part of the baby's life. If, however, the mother suspects that the
baby is starting to refuse the breast, then she
should seek professional help from someone skilled in resolving latching
difficulties and in the use of appropriate aids and devices which facilitate
breastfeeding direct at the breast.
How
to maximize breastmilk intake and supplement to improve the baby's nutrition
Mothers
are often advised that supplementation with formula in a bottle will decrease
their breastmilk supply, but this need not necessarily happen as long as they
maximize breastmilk production. Mothers
are also often persuaded that they must either breastfeed or bottle-feed, or
that it is not worth continuing to breastfeed if the amount of breastmilk
produced is quite small; this is not
true; breastmilk is so valuable to the
baby that even 50 ml/day will keep him/her healthier than none; in addition, breastmilk production can nearly
always be increased and can eventually replace the supplement. Furthermore, as the baby's nutrition improves
so will his energy; my experience
working with failure-to-thrive babies indicates that once the baby has reached
the appropriate weight he should have been for his age, then he will almost
certainly be able to breastfeed effectively, but probably not before. It may take quite some time to resolve a low
weight gain/failure to thrive difficulty, but if a mother is motivated enough
to put in the time and hard work of breastfeeding, expressing her milk, and
supplementing, then the rewards are very great. In addressing the problem of inadequate
intake while maintaining and enhancing
breastfeeding and breastmilk intake, there are only two rules:
o
Feed the baby
o
Drain the breasts
The
easiest method of feeding the baby enough milk while maximizing breastmilk
production is as follows;
At each feed:
1. Breastfeed for 20 - 30 minutes, using breast
compression to increase swallowing, and switching breasts as necessary when
breast compression no longer results in more sucking/swallowing bursts. Stop after a maximum of 30 minutes.
2. Supplement the baby with any expressed
breastmilk available, and if necessary top up to the right amount with formula
(eg if the baby needs 60 ml of supplement, and there is only
20 ml
expressed breastmilk available, then feed the EBM first, and then feed 40ml of
formula).
3. Settle the baby (cuddle, comfort, allow the
baby to fall asleep on the breast with flutter-sucking, or use a dummy/pacifier
- whichever is quickest)
4. As soon as possible after feeding, express both
breasts at least twice (hand-expression or pump, whichever is most efficient)
for a maximum of 10 - 15 minutes or until there are only small,
"creamy" drops of milk being produced. The key to milk production is frequent and efficient breast drainage,
so it is important to express to the very last drop! Over time, this - more than anything else -
will stimulate the breasts to produce more - and more …. Expressing after feeding can also indicate to
the mother how effectively her baby has breastfed; if she is able to express jets of milk after
breastfeeding, then this shows that the baby has not drained the breast
well. If she is only able to express
creamy drops, then this is an indication that the breast is well drained.
5. Store
any expressed breastmilk in the fridge;
feed it after the next breastfeed.
If the quantities are very tiny, then store several expressings in the
same bottle and feed them to the baby all at once at, say, after one breastfeed
of the day, instead of dividing up them up into several feeds.
Each day:
1. Keep a chart of breastfeeds, supplements fed
to the baby (EBM and formula), and the time and amounts of expressed milk. In this way, the mother can track the baby's
intake, and her own breastmilk production, eg it is important to drain the
breasts at least 8 times in 24 hours, and over time she will see that her
breastmilk supply increases. EBM can
then be used to replace formula.
2. Also on the chart note the baby's urine and
stool output. A baby who is getting
enough breastmilk should produce 5-8 wet nappies with clear urine in each 24 hours. He should also produce 3 - 5 yellow, seedy
stools. A baby who receives formula
supplements may produce fewer darker stools, but should still produce clear
urine.
3. At the end of the day total up the number of
breastfeeds (should be at least 8) the amount and type of each supplement, and
the times and amounts of breastmilk that were expressed. These figures can be used over time to assess
progress, or to show where something needs to be altered or improved.
Each week:
The
baby should be weighed.
Using
the chart she keeps, the mother should assess the baby's increasing breastmilk
intake and - over time - her success in reducing the quantity of formula
supplements needed for the baby to achieve a catch-up gain and then to maintain
adequate weight gain.
The
baby's doctor should be consulted regularly to monitor the baby's health while
the mother works on increasing her breastmilk production, and then ensuring
that the baby has ample opportunites to take the milk she is making.
Additional
help:
1. Apart from baby-care, the mother should try
and rest as much as possible; unload all
other responsibilities, accept help from the baby's father, friends, family and
neighbours with all other tasks. It may
take as long to build up the milk supply as it took to fall below the baby's
needs, so the mother will need to be kind to herself, to be prepared to put in
the time to express her milk, and to wait for her baby to grow stronger.
2. The mother should consider discussing with
her doctor the adviseability of taking a galactogogue to increase breastmilk
production. In UK Southern Africa , the most commonly
prescribed galactogogue is sulpiride (50 mg three times a day until breastmilk
production is sufficient to exclusively feed the baby, then taper off very gradually,
eg twice a day for a week, then once a day for a week, to avoid a sudden drop
in milk production).
3. The baby should be under the care of an
experienced, breastfeeding-friendly GP or paediatrician. It is important to rule out all medical causes
of low weight gain, treat any health conditions in mother and baby, and
continue follow-ups to monitor the baby's nutrition and development. If a doctor advises complete weaning from the
breast, then the mother should consider seeking further medical advice or a
second opinion from a doctor who has wide experience in working with breastfed
babies.
Measuring
success
While
the first weeks can be discouraging, the mother will be able to see from her
chart that her breastmilk supply is increasing.
Eventually she should be able to gradually reduce the amount of formula
supplements by replacing them with breastmilk.
As the baby starts swallowing more milk during breastfeeding she will
notice that his/her urine and stool output remains adequate even though s/he is
taking less supplement. Finally, as the
baby's strength improves she should be able to maintain breastfeeding and
eventually gradually eliminate all
supplements if the baby's rate of weight
gain remains normal. If the baby still
requires supplements by the age of 6 months, then solid foods can gradually
replace the formula offered, and the mother can continue breastfeeding with
solid foods for as long as she and the baby want and according to current WHO
recommendations that breastfeeding should continue for up to 2 years and
beyond.
© Pamela Morrison, IBCLC
Updated
October 2011, November 2013 and January 2014
Acknowledgements:
My deep appreciation
goes to the hundreds of mothers of low weight gain/failure to thrive babies I
have worked with, for their resolve and motivation to maintain breastfeeding
and re-establish a full milk supply; and to their gallant babies, most of whom went
on to exclusively breastfeed following what was often a very difficult start in
life.
My gratitude goes to the
baby-friendly paediatricians in Harare, Zimbabwe; Dr John Sanders, Dr Greg Powell and Dr
Charles Bannerman, who not only referred babies to me, but were so
knowledgeable about the health benefits of breastfeeding that they were willing
to monitor the babies' health while the mother, the baby and I worked to
fine-tune and maximize breastfeeding, and who were so generous with the facts, figures
and knowledge they shared with me that I could not have wished for better
mentors.
References and Sources:
Desmarais L and Browne
S, Inadequate weight gain in breastfeeding infants; assessments and resolutions. Lactation Consultant Series Unit 8, La Leche
League International.
Neifert MR. Prevention of breastfeeding tragedies. Pediatr Clin North Am
2001;48:273–297, available at
Riordan J & Wambach K, Breastfeeding and Human Lactation, Fourth
Edition, 2010, Jones & Bartlett Pubs
Walker M, Breastfeeding management for the
clinician; using the evidence; published by Jones & Bartlett 2006.
WHO 2006,
Weight for age percentiles for girls, birth to 2 years
WHO 2006, Weight for age percentiles for
boys, birth to 2 years
UK-WHO Growth Charts, http://www.rcpch.ac.uk/growthcharts
Weight chart for boys 0-4 years,
the charts in the format mothers receive
them (A5):
http://www.rcpch.ac.uk/sites/default/files/asset_library/Research/Growth%20Charts/Chart%20Images%20April%2009/A5%20Boys%20UKWHO.pdf (boy's chart)
http://www.rcpch.ac.uk/sites/default/files/asset_library/Research/Growth%20Charts/Chart%20Images%20April%2009/A5%20Boys%20UKWHO.pdf (boy's chart)
UK-WHO information about the Growth Chart
for parents, (contained in the Red Book) including recommendations about
frequency of weighing http://www.rcpch.ac.uk/sites/default/files/asset_library/Research/Growth%20Charts/Chart%20Images%20April%2009/A5%20UKWHO%20foldout.pdf
Positioning pictures, Robin Elise Weiss’s
About.com
Hand expression of breastmilk, video, Jane
Morton, Stanford University
Images of hand expression, see Real Baby
Milk website
Brusseau R
1998, Analysis of refrigerated human milk following infant feeding
Lawrence R, (Chapter 12, Normal growth,
failure to thrive, and obesity in the breastfed infant) Breastfeeding: a guide
for the medical profession, 5th edition 1999, Mosby publishers.
Wilson-Clay B, Hoover K, The Breastfeeding
Atlas.
