Molly - wow, a case to get your teeth into!!

I love working with low-weight gain babies, they're so 
challenging.  But it's so rewarding when it comes right.  There are 
several pointers and inconsistencies to what might be happening with 
your new client and her baby.

1.  Fifth baby.  The low-gain ones are often the last baby in a large 
family.  Obviously with four other children this is an over-worked 
mother... she's doing her best, but it often happens that the mother 
may not think she has time to spend coaxing a happy baby to take more 
breastmilk.
2. Yes, weight gain is about one-third of what would be considered 
normal and thriving.  I convert weights to grams - this baby has 
gained an average of 11g/day instead of 30g/day which is the rule of 
thumb gain for a baby "getting enough".  Slipping from 75th to 25th 
percentile would be classified in some circles as failure to thrive.
4.  The baby is exhibiting classic symptoms of a happy to starve baby 
- ie seeming laid-back, but wanting to breastfeed all day, and 
actually taking a few swigs and then falling asleep and fluttering at 
breast, then showing hunger when taken off (because of course she is 
not getting enough and IS hungry...) - and then sleeping all night. 
Mother (and everyone else) will often conclude that because the baby 
sleeps so well at night she IS getting enough..... not true!
4.  A baby gaining so slowly needs supplements, and soon!  I do find 
that mothers often report that low-gain babies spit up extra milk 
provided, I don't know if this is a kind of denial that they baby 
might need more.  But this baby will starve and continue to go down 
the weight chart if she doesn't get more food.  I would start by 
offering 100ml after breastfeeding every 3 hours around the clock, 
and then take it from there.  As much of that as possible should be 
EBM, but top up with formula if mom cannot express this amount, and 
of course to start with she will not be able to.... Obviously a baby 
with a full tummy needs to be treated like Dresden china until some 
of the milk has gone down..... and some spit-up might be "normal"....
3.  Inconsistency:  the older children were able to successfully give 
the baby a giant pacifier, but the baby apparently wont tolerate 
anything besides mom's nipple in her mouth????  This doesn't add 
up.  Supplements could be provided with the paci and a feeding 
tube....or at breast with a feeding tube/SNS.
6.  So my care plan for a low-gain baby like this would 
be:  breastfeed with compression and switching a max of 30 minutes, 
(or a shorter time if baby keeps falling asleep) 8 times in 24 hours, 
ie every 3 hours day and night.  Immediately after breastfeeding top 
up with supplement.  Settle baby. Imeediately after this express both 
breasts.  Keep EBM for next top-up or until later in the day.  Baby 
will be calm, happy, full and mom can have two hours to do other 
things.  But three hours later (from start to start) she needs to 
commence the feeding routine again.
7. Mom should keep chart of how much EBM, formula, is going into the 
baby and how much she has expressed and when.  As the breasts are 
drained more efficiently, they will start to produce more and then 
more. It's actually more important to future success that the mother 
expresses and feeds EBM than that the baby "breastfeeds" at this 
point, because of course the baby is _not_ really breastfeeding now.....
8.  Write nice report to paed and confirm that this care plan is 
acceptable.  Ensure baby is weighed at least weekly.
9. Watch the weight pile on.  Babies finally getting enough food 
become impossibly greedy and should be responded to - if necessary 
give a whole lot more formula for a while, and when baby has caught 
up the appetite will drop back to more normal levels. This baby 
should really weigh about a kilo (2.2 lb) more than she does right 
now, and she should gain about an ounce a day once she has caught up 
to the weight she should have been if this hadn't happened.
10. Watch the mother's milk supply start to increase.  As the baby 
takes more at breast she will start to take less 
supplement.  Eventually the supplement may not be necessary.
11.  This is hard work, but it's an effective care plan if you can 
get the mother to see the value of a) not breastfeeding all day long, 
but delivering her milk via another route and b) the need for _her_ 
to drain her breasts (pump, manual expression, max 15-20 minutes at 
each session, but often...) rather than relying on the baby who 
cannot do it right now c) continuing to allow baby access to the 
breast for "practice" and for comfort/lovely mommy time - baby's 
competence will improve with weight gain.  I find it's best not to 
stop the supplements altogether until the baby has regained all the 
lost weight and is gaining normally again.
12. Good luck!  I have a care plan which explains this better if you 
want it, just let me know.

Pamela Morrison IBCLC
Rustington, England
-----------------------------------------------------------------
I am posting with permission about a baby I saw in clinic this morning.
Maybe it's just my "Monday morning fuzzy headedness" but I can't quite tell
what the problem is with her.  Baby was born February 3, and is mom's 5th
baby.   The pediatric provider suggested I see this baby as "she has
slipped from the 75th to the 25th percentile  in weight".  Birth weight was
8lb 10oz and now at 7 weeks she is 9lb 12.9oz  --baby has not lost weight
but the provider is concerned about slow weight gain and mom is feeling
very frustrated.  Of note to me right away is that the provider stated that
the baby is completely intolerant to any supplement --formula or mother's
expressed milk, she will not take supplement by cup, bottle, or syringe.
The few times they have been able to cup feed this baby she spit it right
back up.  This baby appears 'healthy' hydrated and 'happy' alert but not
fussy and mom notes that she is 'very laid back'.  Mom reports that all her
babies have been 'lip tied' but that with this baby soreness improved much
faster. She denies nipple soreness or pain while nursing at this time.  I
observed baby's latch and she latches well but comes on and off the breast
multiple times during a feeding before she falls asleep. I wondered about
supply (low or over supply) but neither appears to be the case.  Mom states
that while she had a period of 'nursing all the time' she nurses every 2-3
hours during the day and would probably go all night but mom wakes her to
feed in light of slow weight gain. Diaper count could be better, 4-5 wet
diapers a day and 1 stool a day--which ranges from yellow to green.
I see mild lip tie and no tongue tie, but this baby will NOT suck on a
gloved finger or ANYTHING except mom's breast and a 6 month + size 'mam'
pacifier which the baby only has because one of her older siblings found it
in an old diaper bag and popped it in her mouth one day. There is no
apparent oral issue here and no reason for low tone but that is the only
explanation I can think of.  THOUGHTS ANYONE?
your input is appreciated!!

Molly Scarborough McMillion RN, BSN, IBCLC, CCE, CPST
Lactation Consultant, Childbirth Educator
Special Projects Consultant - West Virginia Perinatal Partnership
Right from the Start - Direct Care Coordinator
304.667.4362   www.babylovegbv.com


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