Transcript Late onset slow weight gain

Late onset slow weight gain
Jack Newman MD, FRCPC
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)

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”

Questions
1.
2.
Was this the best approach to dealing with
a baby who wouldn’t settle?
What might have been another, perhaps
better, approach?
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
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
2.
Video clips of drinking or not
Video of 10 and40 hour old baby
Don’t limit time on breast?
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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
After discharge from hospital
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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
Video clip of a baby “jiggling” at
breast
At our clinic, 2 days after the last weight
(6.0 kg), the baby weighs 6.1 kg
Is this possible?
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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!
So why the slow gain?

1.
2.
3.
4.
5.
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?
More possibilities
6.
7.
8.
9.
10.
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
1. The birth control pill

Decreased milk supply with any type, even
progestin only pills
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Seems less common with progestin only pill, but
this may be because it is less commonly used
Medroxyprogesterone (Depo Provera) 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 Depo Provera
1. The birth control pill
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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
1. The birth control pill
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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)
1. The birth control pill
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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
1. The birth control pill
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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
2. A new pregnancy

Luckily, if a mother is breastfeeding exclusively,
pregnancy before 6 months is unusual, but does
occur
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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
2. A new pregnancy
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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
2. A new pregnancy
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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
3. Medications other than hormones
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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)
3. Medications other than hormones
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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
4. Maternal illness
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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
4. Maternal illness
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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
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?
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6. One breast at a feeding
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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!
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

Variation in fat content during a
single feeding
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!
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Is this possible?
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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
7. Using bottles, pacifiers more
than occasionally
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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)
7. Using bottles, pacifiers more
than occasionally
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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
7. Using bottles, pacifiers more
than occasionally
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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
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.
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.
Analysis of email
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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?
8. Trying to be a “supermother”
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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?
9. Unknown
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Sometimes the mother’s milk just decreases
3 to 6 months postpartum, sometimes
around 9 months, for no obvious reason
This is not a growth spurt, since the baby
does not drink at the breast
He may even lose weight
He may fuss at the breast
Domperidone does work well here
10. Baby’s behaviour changed
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Babies’ behaviour often changes
In the first few weeks, babies generally tend
to fall asleep at the breast when the flow
slows
After the first few weeks, they tend to pull
away from the breast when the flow of milk
slows
Some babies do not follow this pattern, but
many do
So?
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If the baby starts to pull away from the
breast when the flow of milk slows down, he
may not have “drained the breast” as well as
he could have
Most mothers will then offer the other side
The baby may pull off when the flow slows
on the second side
The baby has “half emptied” the breasts
And so?
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The milk supply decreases a little
For some babies, whose mothers have an
abundant milk supply, this may not matter
even in the long run
Over a short period of time, this may not
make much difference either, but with time,
the supply decreases more and more
Even then many babies may still grow well
But…
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For some, the situation results in the milk
supply decreasing significantly so that the
weight does become an issue
Even if there is still plenty of milk in the
breast, babies respond to flow, not what’s in
the breast
The baby pulls off before “draining the
breast”
Often in just a few minutes
Mothers will say…
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That the baby will stay on the breast only a
few minutes, and then pull off and suck his
hand
Babies of 3 or 4 months may not cry if they
are hungry, content to suck a finger
If offered the other breast, the baby may
take it for a short period of time (as long as
the flow is rapid), and then pull off
Prevention?
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Maintain flow during feedings?
A good latch results in the baby “emptying” the
breast better.
“Finish” the first side before offering the second
Mothers need to know how to know a baby is
getting milk from the breast (and not just sucking)
Use compression if necessary
Just keeping the baby there may not be enough
Observing a feeding
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This may be very difficult because most babies of 4
months, say, are distractible when breastfeeding
If the flow of milk is slow, they are even more so,
and observation of a feeding may be difficult
But…
Poor weight gain + history of short feedings +
baby sucking hand=decreased intake of milk
Email received re: baby seen in first week
(for mother’s sore nipples)

“Our son is nearly four months old. He was
putting on weight nicely for the first two
months, but has held steady at 11.5 pounds
since then. He is cranky much of the time,
and is up numerous times at night.”
Email received re: baby seen in first week
(for mother’s sore nipples)
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“My wife has implemented three changes in the
last number of weeks to address this
problem. (cranky baby)
1.
She is nursing every three hours instead of every two
She is taking three tablets of Blessed Thistle and two of
Fenugreek, each three times a day
She is nursing on one side only at each nursing session,
to prevent the baby from ingesting too much foremilk
2.
3.
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My wife is taking birth control pills, and we have
heard that that may reduce the milk supply”
Comments?
1.
2.
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3.
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Arrrrggggh!!
Double arrrrggggh!!
I always tell mothers, whatever problem they
come in for, how to latch a baby on, how to know
a baby is getting milk, how to use compression,
etc
Triple arrrrggggh!!
This is the 3rd baby (out of 4) of this same mother
for which I have seen her at our clinic
Treatment
Formula by bottle is not the answer!
Why is it not the answer?
2.
It’s not necessary
There are other ways to deal with this
situation
There may not be such a thing as nipple
confusion, but it is interesting how often
babies started on the bottle for such a
situation, will refuse to breastfeed, usually
within a very short time (days)
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It’s not the baby who is confused
1.
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What to do?
1.
2.
3.
4.
Review possible causes of a decreased milk
supply with mother, and correct what can be
corrected (stop pill, stop other medications, feed
both sides etc)
Consider the possibility that the baby may have a
medical condition (e.g. UTI)
Follow Protocol to Increase Breastmilk Intake by
the Baby (adapted to the older baby)
If the above don’t work, and the mother is not
pregnant, domperidone will often work very well
Note
Stopping the birth control pill does not
always result in a rapid increase in milk
supply
 The same may be true with other
medications
 I almost always will start domperidone at the
same time as suggesting stopping the
hormone treatments

Protocol to Increase Breastmilk
Intake by the Baby
1.
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Get the best latch possible.
The better the latch, the more of the
mother’s milk the baby will get
However, a baby of 4 or 5 months may not
want to change what he does
It’s worth a try, but don’t force the baby if
he’s reluctant
Protocol to Increase Breastmilk
Intake by the Baby
2.
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Know how to know the baby is getting
milk
If the baby is not drinking at the breast, it
doesn’t help for the mother to try to keep
him there longer
Watch for the pause in the baby’s chin
(video)
Protocol to Increase Breastmilk
Intake by the Baby
3.
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Use breast compression when the baby no longer
drinks on his own
Begin fairly early, as soon as drinking slows,
before the baby pulls off the breast
Compression is like pumping, but instead of
pumping into the bottle, the mother “pumps”
milk directly into the baby
May not work that well or quickly enough, if the
milk supply is very low (just as pumping may not
work that well)
Protocol to Increase Breastmilk
Intake by the Baby
4.
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When the baby no longer drinks even with
compression, or starts to pull off the breast,
switch sides and repeat
Sometimes, though the baby will not take the
second side and will prefer to suck his hand
Less likely to happen if the mother takes him off
before he pulls off
Try switching back and forth, but do not force
the baby to the breast
Protocol to Increase Breastmilk
Intake by the Baby
5.
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Breastmilk production should be increased
Herbs (fenugreek and blessed thistle) do
not usually work at this age, but
occasionally they do
Domperidone is far superior to the herbs
Domperidone can avoid need to add
calories
Protocol to Increase Breastmilk
Intake by the Baby
6.
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If extra calories are thought to be necessary
The baby should receive food off a spoon
There is nothing magical about cereal (banana,
avocado, mashed potato, meat are fine if the
baby is over 4 months of age)
Breastmilk or other milk can be mixed with the
solids
Formula is not necessary if the baby is over 6
months of age and is getting breastmilk and a
variety of solids as well
Protocol to Increase Breastmilk
Intake by the Baby
7.
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If, and only if, it is urgent (rare) to increase the
baby’s intake:
A lactation aid can be used to supplement
Many babies this age will not accept the lactation
aid
Often, the cup or spoon will work
Remember mixing milk with solids
It is important to avoid the bottle, so if there
appears to be no choice, stop bottle as soon as it
is practical
What about pumping?
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Nothing wrong with this, but it takes time,
and often doesn’t work
Better to use compression, if it works
Pumping also doesn’t always achieve the
hoped for results
If the mother expresses, the milk should not
be given by bottle (it usually is feasible not
to use bottles)
What about feeding more?
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Many of these babies are sleeping through
the night
Certainly it may not hurt to wake the baby
during the night for more feeds
But, feeding very little more frequently may
not help
Like pumping, it doesn’t always work
Some mothers will not follow this advice
Domperidone
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Prescribed to increase breastmilk is an “off label”
use
Available in Canada as a prescription
Available in some countries (UK, Netherlands,
Belgium)
In the US, available at compounding pharmacies,
with a physician’s prescription
No drug is 100% safe, but domperidone is much
safer than most
Domperidone
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We usually start with 30 mg 3 times a day
We now go up as high as 40 mg 4 times a day
Expect, in this situation, a response within a
couple of days
Continued increases may occur for several weeks
Mothers should continue on it as long as necessary
to increase their milk supply and maintain the dose
for several weeks
Weaning off domperidone
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Start when milk supply is well established again,
and baby is drinking well at the breast, and has
been for a couple of weeks (verify by following
weight gain as well)
We usually suggest dropping one 10 mg pill every
4-7 days
If the mother gets down to no domperidone,
without a decrease in her milk supplyideal
If milk supply decreases again, up the dose to the
previous effective dose, and wait a couple of weeks
before trying to wean down again
Domperidone
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Some mothers may have to use
domperidone long term
Can be used for long periods of time
(months or longer)
Metoclopramide (Reglan) may be used, but
has more side effects, especially with long
term use and so is less desirable
Still, it can be used temporarily until mother
can get domperidone
Getting domperidone in the US
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Some compounding pharmacies will still provide
domperidone if the mother has a physician’s prescription.
You can find compounding pharmacies by clicking
http://www.iacprx.org/. Click “For Patients, Pet Owners”
in the red box on the left side of the page , then click
“Finding a Compounding Pharmacist Near You”. You will
need to sign in and then you can find your nearest
compounding pharmacy. Please note, however, that not all
compounding pharmacies in the US carry domperidone.
If not, it can be had over the internet.
For the latest information, check www.asklenore.info
In House Pharmacy
http://www.inhousepharmacy.com/general/motilium.html (for
getting domperidone without a prescription)
Case study (continued)
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Two weeks after first visit
The mother believes the baby is
breastfeeding better and longer (careful)
The baby still sucks his hand after feeding
Weight today is 6.3 kg (increase of 200
grams in 2 weeks)
Observation shows the baby does, in fact,
nurse better and longer
Case study (continued)
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Two more weeks later
All the previous signs that things were going
better were there (stays on breast longer,
better, etc)
Weight today is 6.8 kg (6.3 kg two weeks
before)
Observation shows he drinks well and is less
distractable when nursing
What about the baby who won’t eat?
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1.
2.
Based on my experience, there are two
groups of babies over 6 months who refuse
food
Those who are gaining well
Those who are not gaining well
1. Those who are gaining well
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There is no reason to do anything with these
babies except monitor their weight gain and make
sure they continue to gain adequately
Pushing these babies to eat rarely works, and can
actually make the situation worse
They eventually start eating, usually by a year or so
If there is any concern about iron (interestingly,
though, they rarely show iron deficiency), they can
be given medicinal iron
2. Those who are not gaining well

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These babies often spend long periods of time on
the breast
Observation of a feeding (not always easy) shows
they are rarely drinking, but most of the time
“nibbling” at the breast
The mother’s milk supply has usually decreased
significantly for various reasons
Suckling at the breast without actually getting milk
can substitute for eating food
2. Those who are not gaining well

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Approach to fixing the problem
Eliminate any reason the milk supply might have
decreased
Follow the Protocol to Increase Breastmilk Intake
by the Baby (see information sheet)
Let the baby stay at the breast (both sides) as long
as s/he drinks, but do not allow the baby to
“nibble” at the breast without drinkingtake baby
off the breast and offer food
Sometimes offering food before the breast may be
helpful
2. Those who are not gaining well

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Drug treatment?
Domperidone can be helpful to increase the
mother’s supply (30 mg tid to start)
I use it frequently (if the babies eat more,
then they often eat more)
Does zinc deficiency aggravate the problem?
Maybe
Treatment with zinc may help, won’t hurt