Jaye
I don't know if this will help you, since your baby girl is 4.5
months old, but in one of the worst cases of FTT I ever worked with,
the baby's breastfeeding behaviour taught me a lot.
He was younger than this baby, but was about 30% below the weight he
should have been when first brought to me and I honestly thought he
might die - a little wizened African baby who was not under any
medical care, and my paed mentor who helped me with the case said
that, circumstances being what they were, it would probably be safer
for him not to be admitted to the hospital, so I more or less worked
with the mom and baby on my own at their home with occasional
supervision from the local community sister at the nearest
clinic. His father worked for the European lady who had called me,
and she had already started him on bottles (very un-PC in that
environment) but it seemed appropriate because he would at least take
the milk by bottle (you can bottle-feed a baby even when he is
asleep) and the employer made sure that all the equipment was clean
and the teats sterilized. So we started from there.
At first, the baby would take the breast, but would only actively
suck for extremely short times, and then mostly close his eyes and
fall asleep with little episodes of flutter-sucking, obviously to
conserve his energy. I had the mother express after feeding to
really drain the breasts, and feed him the EBM in a bottle. The
supplements should be worked out (to start with, read on ...) at
approx 180ml/kg/day based on what the baby _should_ weigh now, not on
her actual weight. In my case the mother had sufficient EBM (long
story), but usually with FTT what has happened is that the baby, for
whatever reason, doesn't breastfeed effectively enough to drain the
breasts well, and consequently the milk supply starts to dwindle and
eventually fall below the baby's requirements. This means that she
sucks even less effectively - mostly flutter-sucking, as described
above - and so the circle goes on, and the situation just gets worse and worse.
Anyway, what I found with this baby was that although he kept
accepting the breast and would do quite a valiant job of _trying_ to
breastfeed, he simply was not able to take all the milk he needed
until he reached the weight he should have been if all had gone
well. In fact, it took about 6 weeks of supplementation by bottle
and breastfeeding for him to reach his correct weight. Once his
intake improved, he started perking up and staying awake longer. And
once he really got going he became incredibly greedy, taking huge
quantities of milk (well over 180 ml/kg/day - all by bottle) and
gaining 70g/day! And then quite suddenly, once his actual weight
crossed the ideal weight on his chart, he seemed to be strong enough
to suck, and to keep on sucking and being really active at the
breast, and draining the breast well. It was the most amazing
thing. My heart was in my mouth of course, in case with all the
bottle-feeding he would "forget" how to breastfeed. But this case
kinda exploded all my previous prejudices about bottles and teats and
nipple-confusion.
So what I learned from this was that you can't trust an underweight
baby to breastfeed effectively - she simply may not have the
energy. I'd hold back on suggesting any other interventions for your
FTT baby, apart from supplements of ABM and any EBM the mom can
manage as you've already suggested, until she has reached the weight
she should be for her age. What weight should she have been? Well,
very roughly, take the birth weight, add on 30g/day for the first 3
months, and 20g/day for the next 3 months (in your case another 6
weeks, plus however many weeks it takes to achieve catch-up gain
...) Once she is at a normal weight for age, you may well find that
she is strong enough to breastfeed effectively. Meanwhile, it would
be important to keep offering the breast for "feeding", before the
supplements, and for comfort-sucking after the ABM supplements, so
that the baby stays programmed to the breast. It would also be very
helpful if the mother can re-build her milk supply, as you suggest.
Sometimes it's hard to know with these seriously underweight cases
whether the problem originated as a mother-issue or a baby-issue, but
the outcome seems to be the same - the mother doesn't make enough
milk and the baby doesn't take enough, possibly because he
can't. Once he's big and strong, you may well find that he has the
energy again to breastfeed effectively.
I hope this helps to add another perspective. Best wishes, and
please keep us posted, I'm really looking forward to seeing how this
one turns out.
Pamela Morrison IBCLC
(formerly in Harare, Zimbabwe)
--------------------------
Well, the first 24 hours of pre/post weighs came back: 18 ounces. That is
it. Obviously not enough for a 4.5 month old. I advised mom to start
supplementing right away. She will be coming for a pump today - she says
that after baby is done nursing, she can still hand express a bit. So - we
will be getting her pumping and supplementing with as much breastmilk as
possible and adding ABM as needed.
I did some more questioning with mom and we think we may have a baby who was
'living on let-down'.not good. Mom reports that baby's suck isn't tight and
strong - that it is very relaxed.sigh. So - how do we strengthen a 4 month
old's suck? The last baby I worked with in this scenario never got it
together - she was 5 months old when her mom called me. Interestingly
enough I got a call from another mom I'm working with whose baby, at 2.5
wks, has started to only really suck when her breasts are less full - but
when full latches, sucks once then does nothing.just swallows. Mom caught
this potential problem very early, so we can get this taken care of now.
:-)
Thanks for all input - I am not done investigating. I am not 100% that this
is only a baby caused issue. I need to look more.any other thoughts?
Warmly,
J
Jaye Simpson, IBCLC, CIIM
Breastfeeding Network
Sacramento, CA
www.breastfeedingnetwork.net
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