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Late onset slow weight gain


... The baby still sucks his hand after feeding Weight today ... If the baby drinks enough low fat ... no complications Baby Born at term Healthy Birth weight 3 ... – PowerPoint PPT presentation

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Title: 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
  • The baby receives a little 5 glucose by cup once
    during the first 24 hours of life
  • He wasnt settling. The nurse said that some
    glucose water would calm him down

  1. Was this the best approach to dealing with a baby
    who wouldnt settle?
  2. What might have been another, perhaps better,

  • No, s/he could have proceeded in a different way
  • The fact that s/he didnt give a bottle, the fact
    that s/he didnt 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 doesnt drink any more
  • Do not limit time on breast

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Video clips of drinking or not
Video of 10 and40 hour old baby
Dont limit time on breast?
  • If we dont limit time on breast, if the baby
    stays on the breast, usually he wont cry or
    become unsettled
  • So let him stay on the breast
  • If the latch is good, the mother shouldnt be
  • If necessary, give extra 5 glucose water with a
    lactation aid

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After discharge from hospital
  • Mother had sore nipples for 10 days, then got
  • 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

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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?
  • 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
    doctors office)
  • What does the 100 g increase mean?
  • Nothing
  • Should we be reassured?
  • No!

So why the slow gain?
  • 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
  • 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
  • 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
  • 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
  • Waiting until the baby is older (4 or 5 months)
    does not prevent the problem

1. The birth control pill
  • What if the mother gets a decrease while on the
  • Stop the pill, any time it doesnt 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
  • There are other ways of conception control beside
    hormonal ones
  • Breastfeeding itself gives considerable
  • Baby is under 6 months
  • Mother hasnt had a normal period yet
  • Baby is exclusively breastfed
  • Barrier methods for those not convinced

1. The birth control pill
  • Other preparations of hormones, even estrogens,
    probably do not affect milk supply because blood
    levels achieved with these preparations are
  • 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
  • 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
  • Homogenized milk is perfectly adequate

2. A new pregnancy
  • 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 dont
    like the lactation aid

2. A new pregnancy
  • 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
  • Several drugs can significantly decrease the milk
  • 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
  • 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
  • Most often associated with blocked ducts and/or
  • 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
  • Any febrile or flu-like illness seems capable
    of decreasing the mothers 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 mothers imagination
  • Lactation consultant feeding a 3 month old baby
  • No problems, baby gaining beautifully
  • LCs 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?

6. One breast at a feeding
  • 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 isnt doing the pausing type of
    suck, he is not getting milk!

Is this possible?
  • 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
  • Lets give the baby two ounces of breastmilk less
    at each feeding and hell gain better

7. Using bottles, pacifiers more than occasionally
  • A big problem in the US and other countries where
    many mothers have unacceptably short maternity
  • 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
  • Even young babies (lt3 or 4 months old) can learn
    to cup feed
  • Mothers can find ways to combine work and
  • 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
  • Once the baby is older, there is no need for
  • 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 wasnt 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 Im 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 dont know how
    much more of this I can take.

Analysis of email
  • Was the appropriate response to she wasnt
    gaining very well at the start to give a bottle?
  • Could one bottle a day really cause all this
  • What else would be involved?
  • Babys behaviour changes with time
  • Milk supply decreases?

8. Trying to be a supermother
  • 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?

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9. Unknown
  • Sometimes the mothers 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. Babys behaviour changed
  • 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

  • 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?
  • The milk supply decreases a little
  • For some babies, whose mothers have an abundant
    milk supply, this may not matter even in the long
  • 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

  • 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 whats in the
  • The baby pulls off before draining the breast
  • Often in just a few minutes

Mothers will say
  • 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

  • Maintain flow during feedings?
  • A good latch results in the baby emptying the
    breast better.
  • Finish the first side before offering the
  • Mothers need to know how to know a baby is
    getting milk from the breast (and not just
  • Use compression if necessary
  • Just keeping the baby there may not be enough

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Observing a feeding
  • This may be very difficult because most babies of
    4 months, say, are distractible when
  • 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 handdecreased intake of milk

Email received re baby seen in first week (for
mothers 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
mothers sore nipples)
  • My wife has implemented three changes in the
    last number of weeks to address this problem. 
    (cranky baby)
  • She is nursing every three hours instead of every
  • 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
  • My wife is taking birth control pills, and we
    have heard that that may reduce the milk supply

  • 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

  • Formula by bottle is not the answer!

Why is it not the answer?
  • Its 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)
  • Its not the baby who is confused

What to do?
  1. 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)
  2. Consider the possibility that the baby may have a
    medical condition (e.g. UTI)
  3. Follow Protocol to Increase Breastmilk Intake by
    the Baby (adapted to the older baby)
  4. If the above dont work, and the mother is not
    pregnant, domperidone will often work very well

  • 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

Protocol to Increase Breastmilk Intake by the Baby
  • Get the best latch possible.
  • The better the latch, the more of the mothers
    milk the baby will get
  • However, a baby of 4 or 5 months may not want to
    change what he does
  • Its worth a try, but dont force the baby if
    hes reluctant

Protocol to Increase Breastmilk Intake by the Baby
  • Know how to know the baby is getting milk
  • If the baby is not drinking at the breast, it
    doesnt help for the mother to try to keep him
    there longer
  • Watch for the pause in the babys chin (video)

Protocol to Increase Breastmilk Intake by the Baby
  • 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)

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Protocol to Increase Breastmilk Intake by the Baby
  • 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
  • Breastmilk production should be increased
  • Herbs (fenugreek and blessed thistle) do not
    usually work at this age, but occasionally they
  • Domperidone is far superior to the herbs
  • Domperidone can avoid need to add calories

Protocol to Increase Breastmilk Intake by the Baby
  • 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
  • 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
  • If, and only if, it is urgent (rare) to increase
    the babys 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?
  • Nothing wrong with this, but it takes time, and
    often doesnt work
  • Better to use compression, if it works
  • Pumping also doesnt always achieve the hoped for
  • If the mother expresses, the milk should not be
    given by bottle (it usually is feasible not to
    use bottles)

What about feeding more?
  • Many of these babies are sleeping through the
  • Certainly it may not hurt to wake the baby during
    the night for more feeds
  • But, feeding very little more frequently may not
  • Like pumping, it doesnt always work
  • Some mothers will not follow this advice

  • Prescribed to increase breastmilk is an off
    label use
  • Available in Canada as a prescription
  • Available in some countries (UK, Netherlands,
  • In the US, available at compounding pharmacies,
    with a physicians prescription
  • No drug is 100 safe, but domperidone is much
    safer than most

  • 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
  • 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

  • Some mothers may have to use domperidone long
  • Can be used for long periods of time (months or
  • 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
  • Some compounding pharmacies will still provide
    domperidone if the mother has a physicians
  • You can find compounding pharmacies by clicking
    http// 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
  • If not, it can be had over the internet.
  • For the latest information, check
  • In House Pharmacy http//
    eneral/motilium.html (for getting domperidone
    without a prescription)

Case study (continued)
  • 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)
  • 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 wont eat?
  • 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
  • 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
  • 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 mothers 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
  • Approach to fixing the problem
  • Eliminate any reason the milk supply might have
  • 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

2. Those who are not gaining well
  • Drug treatment?
  • Domperidone can be helpful to increase the
    mothers 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, wont hurt

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