/*"*//*I did get a pretty intensive history and the mother is also
working with her pediatrician and an IBCLC. *//*I didn't share full
details because I did not have her permission; *//*she said I could
share the outline of the situation for the purpose of getting the
protocol for increasing volume. *//*There is a complicated history but
pedi and IBCLC seem to feel that increasing calories is the first thing
to try. *//*She called me for emotional support and to discuss potential
ways to supplement without formula."
*/*Very short answer
Emily, if you want, I am available today and on Wednesday. You can get
in touch with me to discuss the case via e-mail
[log in to unmask] or phone 908-216-7703.
*Short answer
Yes and no. Increasing the volume and/or caloric density may work, but
not always. Without knowing the actual situation it is extremely hard to
give the appropriate advise, to say nothing about providing the so much
needed emotional support for the family. Pamela Morrison article is
great (thank you Pat, as usual, you are a such a source of incredible
information!), BUT - the that and similar protocols are dealing
specifically with inadequate intake/supply in an underfed, but otherwise
healthy and stable infant. While we do not know anything about this
particular mother's supply, we do know enough to say that the kid in
question is neither stable nor healthy.
In my opinion (and as only human, I may be wrong), rather then bringing
the family where they want to be (exclusive breastfeeding without any
supplementations and/or interventions) we have to meet this kid and her
mother where they are. And even with the little we know, they are not in
a pretty place right now.
We also have to understand the urgency of the situation, as the kid is
not just failing to thive, she critical, she is at the point of not
being able to sustain her growth and development. The problems did not
start yesterday and will not end tomorrow (unless the problem is
surgical and is reasonably easy to correct). Which brings us to several
major issues - is mother asking the right question (supplementing
without formula)? Does the kid have time and potential for simply
"stretching the stomach"? What kind of emotional support should the
lactation consultant provide in this situation?
*Long answer.
There are 3 very significant red flags here.
/*(a) losing weight, weighting 8-8 lbs at 3 mo. */That weight is waaay
below the growth chart for her age placing her at the 50% for a 2 week
old baby. We dont know how did she get there and how does her growth
curves look like for weight, length and head circumference, all we know
that she is not just not gaining enough she is losing weight. And I am
not talking about "does it look like her head is not growing either?" as
the weight would suffer first, then the longitudinal growth will stunt
and then the brain will seize to develop, thus - to grow... Almost all
malnourished babies do look the same - small bodies with realatively
large heads with the huge "hundry" eyes and huge protruding bellies.
While (with appropriate diagnosis and treatment) we can reclaim the lost
grounds in physical growth, it is much harder for the baby to catch up
in brain development (even with the good catch-up brain/head
circumference growth).
/*(b) not able to take more then 20 oz/day, spitting up when force fed.
*/To sustain herself where she is right now (without taking in
consideration her medical problems that can be energy consuming and her
already existing weight deficit) the baby is supposed to take about 22
oz/day (way less then she is able to take right now). When re-feeding
the failing to thrive babies (and such protocols are readily available
to baby's pediatrician) we should calculate the caloric intake based not
on the present weight, but on the projected weight. At 3 months the
average baby would weight about 12 lbs, which will require (again,
without addressing the medical problems) about 30 oz/day. That is
additional 10 oz/day, which no way this poor kid in her present state is
able to tolerate. Therefore the probability of successfully utilizing
protocols aimed at "stretching of the stomach" is reasonably slim, as
this intolerance is most probably not simply mechanical in nature, at
least not mechanical in a normal physiological point of view (see
example of malrotation below). Most probably the baby is not being able
to tolerate larger feedings because of her (yet undisclosed) medical
condition(s).
One can increase caloric density of her feedings with milk fortifiers,
as her doctor suggesting. "Skimming" mother's milk (the same as it is
done in the case of proctocolitis) may work as a temporary measure, but
would not work in a long run, and this kid does have a long way before
she will recover.
I personally do see the main clue to the puzzle in /*(c) "complicated
history", */but how can we help if mom does not want us to know any details?
To illustrate the importance of the/*"C"*/ - without any attempt to
provide complete differential for extreme failure to thrive in an infant
- here are some examples of such from 30 years of my checkered
experience (pediatrician and pediatric dermatologist in Moscow, Russia
and pediatrician, adoption/foster care physician and IBCLC in the US)
- first and foremost - neglect and deprivation. (most probably not a
case with your kid, but I have to start with it, as that is always on
the top of the differential diagnosis). The treatment is as you are
asking - increase the volume and caloric density and the kid will do
great. I had 8-10 lbs kids yanking over 16 oz feeds 6-8 times/day
without a second thought ( some spitting up a little bit with or without
overfeeding diarrhea).
- Eczema. I did see eczema so bad that the baby had to be restrained
because of the severe itching (not that I would recommend that measure
as a treatment option). Failure to thrive was caused by both increased
protein losses (oozing, scaling on the skin as well as intestinal
malabsorbtion), increased energy demands (stress, infections) and
decreased intake because of severe discomfort. Treating the primary
condition (eczema) and addressing secondary problems (skin infections
and infestations, severe itching and malabsorbrion) did allow the kid to
thrive physically and developmentally.
- surgical problems sometimes can be hard to detect and relatively easy
to fix - I did have a couple cases of malrotation presenting as a
moderate to severe FTT. Babies did dramatically better after the
appropriate surgeries.
- congenital metabolic problems can result in FTT as well as
neurological deterioration. Addressing the underlying problem may be
curative (had a baby with carnitine deficiency who did present as a
significant FTT and low muscle tone)
- sometimes we can not address the underlying issue... had a baby with
leucodysplasia (degeneration of the brain's white matter ) who was
slowly losing (among other skills) her ability to suck and did develop
failure to thrive. Had to fight two consultants (neurologist and
gastroentherologist) to finally put the G-tube in and to stop torturing
both the baby and her mother. All I was able to provide here was
emotional support, but that support was directed into fighting the
system, not continuing with ineffective oral feeds - no matter
artificial formula or mother's breast milk.
- anemia, impairements of internal organs (heart, lung and kidneys to
name a few) , both aquired and congential, would make the kid weak and
intolerant of feedings. Without addresing the underlying cause feeding
alterations would not work.
- neurologic and developmental issues (low mucle tone, tremors,
aversions, etc) will decrease oral intake and lead to FTT.
So, in summary, the probability of the kid'd present condition being
causes simply by inadequate intake and/or supply, is very low. Baby
needs aggressive evaluation and treatment of underlying cause(s), and
breastfeeding alone, no matter how beneficial, most probably can not be
viewed as the only nutritional solution.
Hope that was helpful
Alla
Alla Gordina, MD, IBCLC, FAAP
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