Lea's post illustrates some basic issues that I have been encountering with assessment of growth and intake.

I started plotting weight gain several years ago when I saw a huge upsurge in failure to thrive due to increasingly severe sleep training methods adopted by a popular pediatric practice.  Often the mothers KNEW their babies were not doing well, but they were repeatedly being reassured that their baby's growth was fine, that LONGER sleep would improve their growth and that they should NOT pump.  This advice actually led to a couple of cases of permanent stunting.  In the end many of these mothers were angry because they knew that their crying frustrated babies were really hungry and their babies improved dramatically when they went back to feeding their babies with a normal feeding frequency and in some cases with a little judicious pumping.

So, in this process I've noticed that there are some pediatricians that really listen to the parents of their patients when they assess a baby's growth and take into account how the baby feeds and behaves and there are other pediatricians that only look at the numbers when they deem the weight gain to be "inadequate" or "adequate" without really understanding how babies feed.  In this fee for service environment in the United States it is exceedingly rare for a pediatrician to be able to really observe a full feeding and since they are mostly involved in making medical decisions, they simply do not have time to develop the observational skills that lactation consultants in private practice have the time to develop.  

After several years of plotting growth charts on babies whose mothers are concerned, I have found that there is a huge amount of misdiagnosis going on when it comes to growth.  I actually have found the 2/3 oz gain per day guideline referenced in this document: ILCA, 2005, Clinical Guidelines for the Establishment of Exclusive Breastfeeding to work better than the 1/2 oz gain per day used by others.  For me it is is trigger to investigate further and I find that I catch many babies who really do have an underlying problem who are gaining between 1/2 oz and 2/3 oz per day.  I do NOT use it as a trigger for intervention -- merely as a trigger to investigate and of course there are some babies who really are fine when they gain at 1/2 oz per day.  I can't tell you how many babies I have seen whose mothers knew something was wrong who were told their baby was fine because their baby was gaining 1/2 ounce per day.

In order to provide Lea with better suggestions rather than guessing what is going on, I would urge Lea to be much more specific when she provides information.  In the case she mentioned, she said that the baby was being supplemented so the growth was adequate. I'm confused about whether or not this means that the assumption is that a baby given a bottle will drink enough or if the weight gain was actually assessed.  In this case, the baby had at least one risk factor for inadequate intake from not just the breast, but also the bottle.  I've seen tongue tied babies struggle with bottle feeding and get fatigued to the point of giving up on a bottle.  Since I have had far too many experiences when other practitioners have deemed growth to be adequate when it was not (and vice versa), I would actually have wanted to know:
1) The birth weight and date
2) The discharge weight and date
3) Subsequent weights and dates

The baby in question had at least one risk factor for poor growth which was "tongue tie".  In addition, Lea speculated about reflux and I have found two patterns of growth -- the more common pattern of growth is 2 oz/day with frequent feeds.  These babies guzzle it down quickly, get uncomfortable, want to suck again and guzzle down even more milk.  I've seen many practitioners look at this growth pattern and deem it to be just fine, when really the baby is uncomfortable.  The other pattern of growth is the 1/2 oz /day with frequent feeds.  These babies simply stop feeding at a particular amount that is typically lower than the average intake.  They simply cannot drink more without experiencing extreme discomfort.  Some pediatricians will deem the upper and lower limits of this range from 1/2 oz to 2 oz to be perfectly adequate.  I know at least one pediatrician who might tell a mother of the 2 oz a day gainer to cut back on feedings, without really exploring how to make that baby more comfortable leaving the baby to continue to scream.

Of course the weight is not sufficient information -- and I can hear in my head the many varied conditions that others of you might be coming up with that can have a similar growth pattern.  This is where I am AGAIN going to urge Lea to go to Cathy Genna's workshop this summer.  She is very good at articulating how to LISTEN for the stridor of tracheo and/or larygomalacia so that you can distinguish between that and "overactive milk ejection reflex" or "oversupply" or "allegies to cow's milk proteins" etc.  And I would urge Lea to include these auditory "observations" in posts to Lactnet so that others can provide more specific advice.

The other issue "adequate" intake.  Now this gets even more tricky because many practitioners have differing criteria for what they consider to be adequate.  And they often do not take into account how long it took and how easily the baby fed.  So I would also want to know:
1) How much did the baby drink from the breast? 
2) How much did the baby drink from other devices? 
3) How did the observed feedings compare with "typical feedings", "good feedings" and "poor feedings"?
4) How long did the feedings take?
5) When was the baby exhibiting signs of distress during the feeding?

All in all, the BEHAVIOR needs to be assessed to be able to determine adequacy.  You canNOT rely on one general number.  What is ADEQUATE intake and ADEQUATE growth for one baby may not be for another.  It is ONLY when you make detailed observations that you can make sense of the numbers.  

The final issue about the case is that I have the perception, perhaps incorrectly, that you think having the frenotomy will be sufficient to fix the intake issue.  Despite what is written on some of the websites, I rarely see the miracle cures.  I usually find that babies gradually improve their intake and improve their sucking and swallowing skills post frenotomy and they and their mothers still need support as feeding improves. 

Now of all the practitioners I know in New York City, Judy Fram is the MOST THOROUGH at analysis that I have ever met.  She lives in Brooklyn.  I have learned more from her phone calls when she has referred a client to me when she was wearing her La Leche League hat than any official "mentor" I have ever had. I'd suggest Cathy Genna but she travels frequently. There is so much more than goes into an assessment than could ever describe on any electronic forum.  She is STELLAR and far too humble.

Referring clients to a more skilled practitioner and asking politely to sit in on the visit services two purposes:  a) enhancing skills and b) enhancing reputation.   There are many many competent practitioners in New York City.  They do refer frequently to other practitioners when they are busy.  These practitioners are far more willing to start sending referrals to newer lactation consultants who are willing to ask questions and refer when they are out of their depth and who really interact with the local community of lactation consultants in New York City.

Sincerely,

Susan E. Burger, MHS, PhD, IBCLC.

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