Thursday, 11 August 2016

Morrison P, Low Gain Protocol, 2015.

Pamela Morrison

International Board Certified

Lactation Consultant

Adapted from Handout for La Leche League Great Britain Conference, 14-15 October 2011

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 the most commonly used drug has been domperidone (10 mg, three times a day) which was available over the counter in pharmacies, but there is some concern about it’s use now – the mother should consult her doctor.  In 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

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 for healthcare staff
UK-WHO Growth Charts,
Weight chart for boys 0-4 years,

UK WHO Growth Charts for parents
UK-WHO information about the Growth Chart for parents, (contained in the Red Book) including recommendations about frequency of weighing

Positioning pictures, Robin Elise Weiss’s

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

Krugman, SD, and Dubowitz, H. Failure to Thrive. Am Fam Physician. 2003 Sep 1;68(5):879-884. available at

Walker, M.  Core Curriculum for Lactation Consultant Practice 2002 © Jones & Bartlett, and International Lactation Consultant Association.

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.


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