Hi Laura,

I do a lot of work with babies who have a similiar scenario to the one you have posted about.  I am hospital based, but run an outpatients service as well, so get a few similiar referrals from midwives and doctors.

I am learning so much as I go.  Almost always, there is a root cause and finding that root cause can take some time.  Often, it is hard to sift through all the issues to see what comes first, "the egg or the chicken".  Is this a maternal milk supply issue and the baby became a poor feeder or is this a baby issue and the milk supply is pitched too low. I would wonder about hypotonia.  I would also wonder about urinary track infection of the baby.  Often a paediatric check with the newborn focuses on heart and hips etc, but other subtle signs can be missed in a 5 minute examination.  What is the pregnancy and birth history? Was mum on any medications during pregnancy and was there any periods of fetal distress during labour?  Were electrolytes and blood sugars taken when the weight loss was identified?  This baby would have certainly had a degree of hypernatraemia and perhaps we do not know the effects of this.

I find it useful to put a very proactive plan in place - and make it a written plan which can be adjusted as progress takes place. I find the families need to know exactly what to do to turn things around. This gives them confidence in their caregivers and themselves. In my opinion, it is really important to catch up the 20% weight loss first and foremost before expecting the baby is be able to feed normally.  The plan then needs to have a gradual sliding scale of "managed feeding" alongside baby led feeding with regular weighing (twice a week) until everyone can be sure this baby will take care of his own survivial. From all you describe, this baby cannot do this on his own right now.  

If this is low tone, have you tried a nipple shield (vacumned on)?  I would be interested to know if the baby can find feeding more effective this way. That would certainly tell you this is a tone issue for wahatever reason. I sometimes use a home made supplemental nursing system through the nipple shield and this can work well.  It can certainly shorten feed times and ensure an adequate intake.

I find it useful to base a feeding plan around the principles I have heard many IBCLC's (who post here) use (with perhaps a little variation): 1.  feed the baby, 2. protect the milk supply, 3. keep baby near the breast, 4. keep working on the issue.

Good luck,

Karen Palmer
midwife and IBCLC
New Zealand


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