There are excellent articles in journals about infant weight gain in
breastfed children, and anyone counseling mothers about infant growth should
be familiar with them.  I will a good one below at the end of this post.  In
my experience, there are many reasons why some babies grow poorly, and why
their pediatricians might be concerned about them.  Better breastfeeding
management is my preferred way of reversing poor early growth, but certainly
there are times when the growth is so poor and the milk supply is so
depressed that one might temporarily advise supplementation with formula to
improve growth or promote some catch-up growth.

In general, breastfed babies grow most quickly in the early months of life.
They should lose less than 10% of birth weight and  ideally will double
their birth weight by 4-6 months pospartum.  Early weight gain is typically
about 30g/day (1oz) for little girls and a bit more than that for boys. At
the lower end of normal (5%tile), boys and girls are growing at about 20
g/day. Growth slows down as the infant's energy intake requirements decrease
around the 6th month mark.  One looks for the birth weight to triple by 12
months.  Everyone has a genetically programmed growth pattern, and sometimes
very big babies with excellent early growth curves will "catch down" to
match the physical stature of their parents.  But this is very different
from those babies who struggle to put on weight in the early days, and who
take weeks to regain birth weight and thereafter maybe gain a pound a month.
There is no virtue in over-feeding, and you don't necessarily get an A+ for
having a baby in the 99%tile.  Neither is it good to brush off the chronic
underfeeding of a baby who might well be happier and grow better on more
calories.

Some reasons for this problem:
    * Over-scheduling of the infant and not enough opportunity to feed (this
leads to fuller breasts at each feeding and an over-delivery of low-fat
milk.)
    *  Understimulation of early milk supply due to a variety of factors inc
luding disruption of early breastfeeding, poor management of early
engorgement,  leading to down-regulation of supply.
    *   Mothers with some kind of primary milk production issues (related to
their health in some way) whose marginal nature goes relatively undetected
and is never managed in a way that might maximize their lactation capacity.
    *  Infants with marked poor growth who continue to present with failure
to thrive after 1 mo. typically have some organic cause for this problem.

Other possible factors include:  previous breast surgery, maternal milk
suppression due to hormonal imbalances or medications, stress, inverted
nipples, inappropriate and un-monitored use of nipple shields, insufficient
glandular formation, psychosocial factors, smoking, maternal infection,
infant reflux or allergy, tongue tie, non-specific neurologic problems, etc.

An excellent article is:  N Powers, Slow Weight Gain and Low Milk Supply in
the Breastfeeding Dyad, Clinics in Perinatology 1999; 26(2):399-430.

Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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