Permission to post:  Working with a mom of a nearly 4 mo.  BW 7lb 15 oz.  Was exclusively breastfed up until 2 weeks ago when mom returned to work full time (now BF with EBM bottles when with babysitter and dad).  Current weight only 12 lbs.  At 3 mo visit mom was told baby had lost weight, but this is hard to tell because the baby is always weighed at the ped. office with a big fat cloth diaper on (and not always the  same kind; and sometimes the diaper could be wet or dry) and different scales too (ped. has one digital and one traditional scale with the sliding weights).  Mom nursed more often after that and baby seemed to gain (however, weighed again with diaper on).  I assessed the baby.  We did a weight check before and after nursing and he seemed to transfer 3.2 oz.  Mom now pumps at work 2-3 times per 8 hrs.  She gets about 4 oz each time.  She breastfeeds baby 5 times per 24 hrs. and while she is at work, baby gets 5 bottles (every 2 hrs of 4-4.5 oz milk each time).  Before I saw this mom her babysitter was giving 7 oz of breastmilk each bottle!  (And I thought the 4 oz every 2 hours was a lot).  Of course mom is struggling to keep up with these demands and has gone through her "freezer stash".  Baby clicks at the breast, but latches well (not perfect, but good), and mom has no pain.  No nipple damage or compression.  Baby has lip tie, but it is very elastic and flanges lips well at the breast.  Able to extend tongue past gum line and doesn't "hump" tongue when sucking.  He does however spit up happily after nursing, never with the bottle.  He does have some restriction.  We talked about having him evaluated for clipping/laser if weight gain does not improve.  At first I was shocked by the amount of milk this baby was getting by bottle, but now I am wondering where it's all going.  He wets about 4-5 diapers/day.  No BM for a week, and then had 3 moderate ones (nothing huge).  With all of this breastfeeding and EBM bottles he's getting, he is only gaining .5-1oz per day (and this is only since the bottle supplementation with her return to work).  He seems happy, satisfied after nursing, meeting milestones, growing in length (4 inches from birth).  He just looks like one of those banana babies.  No plumpness.  What am I missing?  Something metabolic?  This is her second child.  She breastfeed her first without any issue and her first baby was in the 95%.  Mom and dad are both average height (not small).

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