Lacnetters,

I'm hoping someone will be able to shed some light on this difficult case.

Mom and baby were referred at one month post partum by pediatrician due to
slow gain.   The baby had dropped 11% of birth weight at the lowest point, at
2 weeks was a few ounces shy of birth weight, one week later, at 3 weeks had
only gained 2.5 oz in 8 days and then in the next 7 days gained only 1oz.
Mom reported lots of "spitting up" leading the doctor to do an ultrasound
that was negative for pyloric stenosis.    Mom also reported that she gave
one to two bottles of breast milk per day and that the baby seemed to reflux
more when at the breast than the bottle.  Baby had become very fussy between
almost all feedings and was keeping them up nights.  After the poor weight
gain at four weeks the referral was made to me and mom started some formula.

Prior to seeing them I was thinking maybe oversupply?   Apparently the
doctor's office staff thought so too and advised her to limit feeding time to
no more than 10 minutes.   When I saw them mom positioned baby supine in her
lap with head turned over the shoulder and allowed the baby to latch
shallowly.   After correcting and achieving a deep latch baby nursed for
about 15 to 20 minutes obtaining 22cc at the right then another 22cc at the
left, we switched  and recorded another 24 cc at the right and then 26 cc at
the left.   There was no obvious gulping, chocking, sputtering or rapid
intake of large volumes, as I would suspect with oversupply.  I thought I had
identified the slow gain as related to the suboptimal latch.  Additionally
the baby had gained 1.5 ounces from the previous day since the mom had
started to supplement.   The baby had several episodes of reguritating into
the throat and re-swallowing it and eventually spit up about 5-10cc total.

Today the mom tells me she is noticing the baby seems most uncomfortable and
spits up the most when on the breast, is a little better when given bottled
breast milk and is best when given bottles of formula.   She really does seem
motivated to breastfeed and is understandably very upset.

I definitely think this baby has reflux that probably needs some medical
intervention in the way of medications but why in the world is he doing
better with a cow's milk based formula than his own mom's milk and why the
difference between breast and bottle when there doesn't seem to be oversupply?

I am stumped.  Another LC friend suggested possibly the thicker consistancy
of the formula is staying down better, but I had thought the research on
thickening for reflux was conflicting and some schools of thought suggest
that the breast milk leaving the tummy faster was a distinct advantage over
the "thicker" formula that stays in the tummy longer.

Sorry this is so long, I am looking to my brillant friends for additional
thoughts.

Kathy Kuhn
RN BSN IBCLC
Private Practice LC
ParentsPlace.com LC

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