Inadequate growth in the newborn

It's been a while since I've written on this blog.  No excuse, I just write when I can.

Today I got a message from a mom who was told by her pediatrician that she was making “skim milk” and that she needed to add more fat to her diet.

“Today the pediatrician told us our two-week-old baby is underweight. He was born at 8lbs 2oz and Now weighs 7lbs 4oz.

I feel like he’s eating well. He eats every 3 hours, sometimes he’ll go 4 at night. It used to be for around 45 minutes but the last 3 days or so he’s done between 20-30 minutes. He definitely empties my breasts when he feeds. I can feel the difference. I’m also pumping once or twice a day and get between 20-35mls per session if 10-15 minutes. He doesn’t seem hungry. He sleeps well after feedings but he’s not gaining his weight back.

He was jaundice and in NICU for 5 days getting supplemental feeds with donor breast milk in addition to my 20-minute feedings every 3 hours. He lost some weight in NICU but lost more the week he’s been home.”

Here was my response:

I want to let you know that your experience is VERY common.  It is nearly impossible for a mom to judge how well their baby is eating.  In fact, it seems that it is impossible for pediatricians too.  As a lactation consultant, I find it very difficult as well.  The only way to know how much your baby is eating while breastfeeding, is to weight him before and after each feeding.  IF you do that for 24 hours in a row, you can know how much he eats.  Of course, I don't recommend doing that, it would drive you crazy.  As such, you must use other ways, to get hints as to what is going on. The only way we know that a baby is transferring enough milk is to follow his weight over time. I strongly recommend close follow up for the first 2-4 weeks after birth.  If I were there, I would see you every 48-72 hours for a couple of days to check on intake and growth.  Since I am not there, and you don't have access to an IBCLC, we will have to work on other ways to check this.  You mention a few helpful signs that suggest Baby is eating well, the emptying of the breast, the frequency and duration of his feeds.  But you also suggest that he has a feeding problem that needs attention. 

First, he has not regained birth weight at two weeks old, which is a red flag.  It isn't dangerous right now, but it is a marker for problems in the future.  You also say that he was eating for 45 minutes at a time.  Both of these suggest that he is/was having trouble emptying the breast.  The average baby can empty the breast in 12-20 minutes. Since you say that he has started feeding for shorter duration, he may have figured it out and turned the corner, but we will have to watch for that. 

Another issue that I see is that he eats every 3-4 hours (that is 6-8 feeds per day), which is not common in newborn.  We expect him to eat every 2 hours for most of the day with an occasional 3-hour stint when he is really sleepy (that is 8-12 feeds per day).  I know how exhausting it is to be a new mom, but it really isn't helpful when a newborn sleeps “well”.  There is a rare group of moms and babies who manage to sleep for long periods of time and still grow, but they are few and far between.  Again, I recommend that you offer him the breast every two hours for most of the day, and every 3 hours if he is really sleepy.  You will notice that I don't say "Day and Night".  Babies don't understand the clock or your sleep cycle.  Most of them are most alert from 9 pm to 3 am, so that is closer to "day" for them.  They sleep most from 9 am to 3 pm, so that is where you will get the best sleep.  Don't fight it, you can't.  Just roll with the punches. 

Now let’s talk about other ways that you can judge how well he is eating.  While he is eating, try to listen for his swallowing at the breast.  A baby who is two weeks old, is usually swallowing loud enough for mom to hear.  You might have to get close to his neck to hear it, but it should be audible.  The harder it is to hear, the less likely it is that he is swallowing.  Another subjective way to know that he is eating, is by tracking his stools.  Most babies will poop 3-4 times a day.  They should be good sized poops, not "sharts", I generally ask if the poop is more than a teaspoon worth.  You see, all humans have a “gastrocolic reflex”, which means that when we eat, our bowels move and dump stool into our rectum.  Adults ignore it, until it is a good time to go, but not babies, they just let it go.  As a general rule, a baby who is eating well, will poop well.  It isn't an exact science, but it is a good rule of thumb. 

 So, what do I recommend:

 

First, get in to see a lactation consultant.  If you go to google and type "find a lactation consultant" you will find the nearest IBCLC.  You can also find help through La Leche League International (www.llli.org)  They have helpful volunteers in almost every corner of the western world and beyond.  An IBCLC is a breastfeeding specialist with certification in assessing and counseling the breastfeeding family.  They can assess his mouth for structure and ability, they can measure food intake with special scales, they can tell more in one visit than the average pediatrician can tell in a month. I do not recommend pediatricians or nurses as a source for breastfeeding information unless they have specific training in lactation (and the vast majority do not).  Contrary to popular belief neither medical school, nor nursing school teaches breastfeeding.  The only people I trust are IBCLC and La Leche Leaders.  It’s sad, but true. 

Second, offer the breast more often.  Every two hours is NORMAL feeding behavior for a newborn.  It will stretch out over time, as his belly and your breasts finish developing, but the average mom and baby transfer very little milk in the first 2-4 weeks and as such they have to feed VERY FREQUENTLY. 

Third, listen for swallowing and track his stool.  They aren't perfect, but they are the most reliable sign that a new mother has, to reassure her that the baby is eating well at the breast.  Believe it or not, babies often go to the breast and suckle for long periods of time and do not transfer breast milk.  Sometimes it is because they aren't hungry, and they suckle because instinct tells them to.  Other times, it is because they can't transfer breast milk due to an oral problem.  I worked with a baby two days ago that sucked for 21 minutes and didn't take any breast milk, then an hour later, he suckled for 11 minutes and took 50 mL.  The difference between the two feedings were his audible swallowing. I use a scale to tell me how much the baby eats, but mom could tell by his behavior at the breast that he wasn't trying to eat the first time. 

Fourth, I would recommend supplementing him with your expressed breast milk (EBM).  You baby was born at 3,628 grams and now he is 3,288 grams.  That is a loss of 340 grams (9.3%).  That is a significant loss, particularly in a two-week-old infant.  He needs more than he is capable of eating right now.  I can't tell you why he is struggling to eat over the internet, I would need to assess him and his feeding behavior.  But it is pretty clear by the weights you gave me, that he isn't getting enough calories to sustain growth.  If he doesn't start getting more, he will not be significantly higher next week when you see the pediatrician.  You mention getting 20-35 mL at each pumping session, that is FANTASTIC for a new mother.  I would suggest that you pump 3-6 times a day and give that to him right after you pump it.  For a baby who is inefficient at breast, it doesn't really matter to me if you give it to him in a bottle, or a cup,. or a syringe.  The problem isn't how you offer the food, it is that he can't use your breasts very well just yet.  But that is a secondary problem right now.  Rule number one is "feed the baby" everything else can come later.    

Fifth... get in to see an IBCLC ASAP.  I know that I've already said it, but I can't stress the importance of seeing a competent health care provider. Ann mentioned to me that the pediatrician said you were making "skim milk" because you didn't have enough fat in your diet.  If that is the case, your pediatrician does not understand the synthesis of breast milk.  You can't make skim milk, you just can't.  Ignore that response.  Your diet will not allow you to make skim milk.  Look at the dairy industry.  Skim milk doesn't come from skinny cows.  They have to remove the fat from the cow.  If they could alter milk components by diet, they would. I don't want to say that your pediatrician is a fool, he is simply a victim of an educational system that did not teach him what he needs to know. 

let me know if that helps.  Feel free to write to me any time you like.  I love to help new moms with breastfeeding issues.