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.

Why don't my breasts work at night?

Heather, a very dear friend, wrote to me asking if it was likely that she isn’t making enough milk at night because her baby fusses in the evening, won’t take the breast, and then takes 2 ounces of formula by bottle and falls asleep.  Her pediatrician suggested introducing solids as a means of solving the night time fussiness.  It got me thinking about this topic, and why that is such a terrible thing to do to mom.  Here is what I came up with in answer to her problem. 

The first thing we have to understand is that the breasts are an organ.  They work as well as the heart, the lungs, the kidneys, and the brain.  Even better, they are two mutually redundant organs so that one can compensate for the other if needed.  That redundancy is there for a reason, to help make sure that nothing bad will happen.  Breasts, like every other organ system, tend to work all the time.  They don’t function well from 9 am to noon and then suddenly and inexplicably fail for a few hours and then start back up again the next morning.  It is possible (but VERY unlikely) for them to slow down or even fail over time, but they wouldn’t work fine during the day and then fail at night.  As a matter of fact, we know that pregnancy, breasts, and infants are nocturnal.  They all work best at night, which is why contractions come from dinner to 2-3 AM, why babies are usually born in the early morning hours after a night of labor, and why babies are most awake from 9 pm to 3 am.  They aren’t hungry, they are alert and awake and frustrated that mom and dad want to sleep.  The problem isn’t the baby, it is the mom and dad that want to go to sleep and get frustrated because baby doesn’t want to go to sleep.  If you don’t want him to be awake all night, then don’t encourage him to take naps all day.  He has to sleep, but he won’t sleep 24/7.  Sooner or later he has to wake up.  I seriously doubt that night time fussiness has much to do with hunger.

Now, let’s talk about why a baby will always take a bottle.  Babies take bottles because gravity force feeds the baby and he has to take what is in the bottle, even if he doesn’t want it. They don't do it because they like it. Have you ever tasted formula? It is a rather nasty flavor and I seriously doubt a child will choose that over his mother’s breastmilk, which is incredibly sweet.  To help us figure this out, I’m going to pose a few questions that my families ask me all the time.

1) “Why do babies refuse the breast if they are hungry?”  First, I always say that if they refuse the breast, they are probably NOT hungry, they just want to suck.  You have to understand that babies are in charge of breastfeeding, they ONLY breastfeed when they are hungry.  That doesn’t mean that they won’t suckle at the breast if they aren’t hungry.  Any lactation consultant who practices pre and post weights knows that sometimes babies take the breast for 15-30 minutes and take almost no breastmilk at all, this is called “non-nutritive sucking”.   Babies suck for comfort and somehow control the flow of milk.  Another thing that babies will do is refuse the breast when the first let down happens.  They take the breasts, suck for a little bit and they pull away and cry.  Then they take the breast, suck for a bit, and pull away and cry.  It has always seemed to me that they realize that food is coming and they aren’t hungry, so they let go of the breast and cry because whatever is causing them to be uncomfortable is still there.  Their need to suckle hasn’t been met, so they cry.

 

2)  “But if they can refuse the breast, why can’t they refuse the bottle?”  Or “Why do they always take the bottle when I offer it?”  It goes back to infant development.  You may remember that all infants are born with a suck reflex.  It is instinctual, pleasurable, comforting, and helps to ensure survival.  Babies suckle EVERY TIME they are uncomfortable for any reason.  They suck when they are hungry, cold, lonely, frightened, frustrated, in pain, have a dirty diaper, they suckle EVERY TIME they are uncomfortable.  Suckling isn’t a “hunger sign” it is a “stress sign”.  Any time you put something long and hard in a baby’s mouth, they are forced to suck (fingers, pacifiers, bottles, breasts, etc...) so they will suck a pacifier or a bottle even if they aren't hungry, because it feels good, not because they are hungry.  But with a bottle filled with liquid, they have to drink because liquid is running out of it and into their mouth.

Let me explain, if you hold a bottle at more than a horizontal angle it will leak, and if you touch it the milk will squirt out all over the place.  Imagine what that does in his mouth? Let’s combine those two factors (the uncontrollable urge to suck and a readily flowing device) you get a baby who will over eat, even if he isn’t hungry.  Often he will simply push it back out and let the milk or formula drip down his chin, which is why you always need a cloth under his chin while bottle feeding to keep him from “making as mess”, but have you ever noticed that you don’t need to do that when you breastfeed?  Again, it is because he is in charge of the breastfeeding and can just let go if he isn’t interested.  But I digress, back to over eating.   When we over eat we fall asleep. This is why lions sleep on the Savannah after eating a zebra, why we sleep after our Thanksgiving feast, and why babies sleep when they are over fed. It has to do with the release of pleasurable and sedating hormones that comes with a full tummy (Gastrin and CCK, I think). 

3) “So what is the problem with over feeding him if it makes him stop crying and fall asleep?”  The real problem, is what it does to the mother, it is why this mother is writing to me in the first place.  She is convinced that SHE is the problem.  There could be no other explanation for why her baby is fussy at night.  Obviously her organ systems just intermittently stop working after dark and then start working again the next morning.  That is why her pediatrician suggested adding solid foods or offering a bottle….  REALLY PEDIATRICIAN?  REALLY?  It makes me angry to think that there is such ignorance out there coming from a health care provider.  What did her pediatrician do?  She took a mother who believes that fussiness is related to feeding and led her down the wrong path.  The mother has a baby who is fussy and offers the breast.  But if the baby isn't hungry, he won't take the breast for very long.  He suckles and then lets go and fusses, then suckles, and fusses, over and over again.  Mom, who is tired because it is 10 pm and she wants to sleep, gets frustrated and desperate.  Since her health care provider convinced her that she isn’t making enough milk (but only at night), and because people tend to trust physicians, mom offers a bottle and he drinks it and goes to sleep. What does that tell mom? It re-enforces the idea that he was obviously hungry and that she is just another inadequate mother who can’t do what her baby needs her to do.   

It is a terrible and frustrating myth that we in the health care field continue to spread every time we teach the mother “Hunger Signs”.  We don’t bother to explain newborn stress signs, we don’t teach a father that there is more to pleasing a baby than just feeding.  We simply suggest that every problem is a feeding problem and blame mom for not doing a good enough job.  Nonsense!  You are perfect, your breasts are perfect, your baby is perfect!  Have confidence in your body, it got you this far.  It amazes me that people, especially physicians, believe that the human body can take two cells, combine them, multiply them a couple billion times and create the most complex living system on the planet, and then for some inexplicable reason suddenly fail and not be capable of supporting that baby when they are born.  And for some reason, the fault is never the ignorant health care provider, but rather it is the helpless mother.  Okay, I have to stop or I will rant for another 100 pages. 

Hope that helps,

Sage Homme

Delayed Cord Clamping

I was recently asked to talk about delayed cord clamping (DCC) for a few friends who are due to deliver and want to know how to talk to their obstetrician about the subject.   I understand that this isn’t a breastfeeding topic, but I thought it was good information to share, so here goes. 

First, I think we should start with the professional opinion from the OB’s professional organization:

“Abstract: Delayed umbilical cord clamping appears to be beneficial for term and preterm infants.  In term infants, delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes.  There is a small increase in jaundice that requires phototherapy in this group of infants.  Consequently, health care providers adopting delayed umbilical cord clamping in term infants should ensure that mechanisms are in place to monitor for and treat neonatal jaundice.  In preterm infants, delayed umbilical cord clamping is associated with significant neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage.  Delayed umbilical cord clamping was not associated with an increased risk of postpartum hemorrhage or increased blood loss at deliver, nor was it associated with a difference in postpartum hemoglobin levels or the need for blood transfusion.  Given the benefits to most newborns and concordant with other professional organizations, the American College of Obstetricians and Gynecologists (ACOG) now recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30-60 seconds after birth.  The ability to provide delayed umbilical cord clamping may vary among institutions and settings; decisions in those circumstances are best made by the team caring for the mother-infant dyad. “  ACOG Committee Opinion # 684, January 2017.   

So what does that say?  First, I want to clear something up, it is actually, “normal cord clamping”, cutting immediately is an intervention started just before the Viet Nam War, but most OBs don’t know that.  OK, on with the show.  It says that DCC is good for almost all babies.  That it helps newborns transition from the womb to the outside world, that newborns who don’t get DCC are more likely to be anemic and suffer developmental problems (associated with newborn anemia).  It says that preterm infants are especially put at risk if you cut the cord immediately, and that there is no risk to mother or baby if you allow the cord to transfer blood to the baby after birth.  I should just stop there, but I feel like I need to help explain it to people, so here goes some physiology.

First, you should know that I wrote my master’s thesis on delayed cord clamping and that I was lucky enough to study under one of the world’s foremost experts on the topic, Dr. Judy Mercer CNM, when I was in midwifery school.  I know the concepts VERY well.  So here is how it happens.  In the uterus, the baby does not send much blood to the lungs, in fact, only 8% of the baby’s blood goes to the lungs before birth.  This is because the baby is not breathing air and doesn’t need his lungs yet.  There is just enough blood to help them grow and develop.  30% of term baby’s blood and 50% of the preterm baby’s blood is in the placenta at all times.  That amazing organ is actually an organ that is outside the baby’s body and it is where he gets his oxygen and his food, and where he sends his waste products for mom to get rid of.  At birth however, he has to start using his lungs and when he takes his first breath, the lungs require 40% of the cardiac output.   So when he is born, umbilical cord changes from a two-way street to a one-way street and begins to pump blood to the baby very quickly (8%+30%=38%, which is amazingly close to the 40% of his blood that he will need when he begins to breathe air).    

If the physician (I say physician because EVERY midwife learned this in school for the last 30 years and the doctors are incredibly far behind on this one), if the physician clamps and cuts the cord immediately, they do some horrible things to the baby.  First, they cut off that blood transfusion and force the baby to take the blood from their arms and legs.  Hello blue hands and feet!  If you took 30% of my blood away, I would also have blue hands and feet.  That means that baby no longer has the resources needed to do much and they sleep for the first day or two because a sudden and profound loss of blood volume will make you very tired.  Have you ever given blood?  Imagine you gave 4 times in 10 minutes, how would you feel?  How would you look? You would look like a newborn, exhausted, with blue hands and feet, pale face and red eyelids.  These babies also don’t breastfeed as well, partly because they don’t have the energy to eat. 

What is even worse than a pale baby is that when a baby doesn’t have enough blood he doesn’t have the ability to carry and use oxygen.  That means that well-meaning physicians who want to cut the cord and pass the baby to the waiting team to help the baby breath, have accidently made it worse.  When you leave 30% of his blood behind, all the oxygen in the world will be of little help, because without blood he can’t use the oxygen.  This is why immediate cord clamping is so very dangerous to preterm babies.  First, they lose 50% of their blood, and they are weak and vulnerable to begin with.  They really can’t afford to lose the blood, and shifting all that blood from the arms and legs to the heart and brain leads to brain bleeds (intraventricular hemorrhage), and loss of blood to the intestines causing them to dye (necrotizing enterocolitis). 

So why did physicians start doing it in the first place?  In the 50’s there was a high rate of baby’s having too many red blood cells (polycythemia).  The assumption was that the babies had too much blood, but they didn’t, they had too many red blood cells (there is a difference).  So the physicians assumed it was because blood was flowing into the baby after birth from the umbilical cord.  They were wrong and no one has asked why they were wrong, but that was what I wrote my thesis on, so I’ll tell you what it was.  In the 1960 census they reported 97% of women of childbearing age smoked >10 cigarettes a day.  We know that mothers who smoke cause polycythemia in their babies.  So, what actually happened, was that we had a VERY HIGH-RISK population, but no one knew it.  No one knew that smoking was bad for you back then, and so the scientists never thought to look at smoking as a cause of the problem.  As so often happens, they made an assumption (the wrong assumption), things got better, and they used that as evidence that they were right.  There weren’t, but then again, that happens all the time. 

Now there are times when immediate cord clamping may be a wise idea.  If the baby, God forbid, is born without a heartbeat, then there will be no transfer of blood to the baby after birth.  That baby needs immediate attention, and there is little value in waiting to start working on him.  That doesn’t mean every baby born in trouble, only the babies born without a heartbeat.  If a mother has high blood pressure, is diabetic, is a smoker, or a narcotic drug abuser, those babies have all had to compensate for those stresses, like the babies of the 50’s, they will probably benefit from immediate cord clamping. 

So there you have it.  Immediate cord clamping is bad for your baby, delayed cord clamping is the physiologic norm, and your physician should be told to read their professional policies and put them into practice.  Once in a while I get someone who tells me that their physician won’t practice delayed cord clamping.  I always say the same thing, FIRE THAT PROVIDER!!  Do you really want a physician caring for your baby when you know that they are 30 years behind the evidence?  Their own professional organization came out in 2012 and said it was most likely safe and effective, then 5 years later they put out the statement I quoted above.  If the provider is that far behind, what other things are they doing wrong?  I have no patience for health care providers who are not up to date on their own professional organization’s rules. 

Okay, that got a little harsher than I wanted it to get, and I’m sorry.  But I’m not going to change what I said.  I urge you to ask your physician about delayed cord clamping and ask them what their professional organization recommends on the topic.  If they won’t educate themselves, maybe they will listen to you?

Reference:

ACOG (2017) Committee Opinion #684.  Delayed Umbilical Cord Clamping after Birth.  Obstetrics and Gynecology; 129: e5-10.