I have worked for many years in international nutrition with failure to thrive babies.  Babies who fail to thrive are often eager and alert and active with eyes wide open in their struggle to take in enough volume. Often they simply can’t do it. The appearance of a baby with loose folds of skin, wide open eyes and an eager active look is called "marasmus" and is defined as such when a baby is -2 z scores from the median.  

Sandy reports about a baby that was born at 36 weeks and we know very well that some early babies don’t have the fat pads in their cheeks and the muscle tone to finish meals.  

Dr. Nancy Wight who is a neonatologist who headed up the Academy of Breastfeeding Medicine in the past was found of saying that fat didn't make premie babies healthy, it only made them fat.  So I don't understand the recommendation to add oil to this infant's diet without additional information.  Growth requires more than upping the fat content.  

Has anyone actually weighed this baby before and after feeding to determine if the baby can take in enough milk at a feed? If not (which seems entirely likely given the gestational age) then it seems like upping the amount of her mother's own milk should have been the first intervention that was offered until this baby gains enough fat to be able to take in enough milk?.  Also the mother has enough milk as she reports, why has no one suggested expressing milk?  Why are they offering formula instead?  

Even using a tube on the breast will lead to a diminishment of the mother's supply if she doesn't express milk. And even if this mother had a good enough supply, it might no longer be sufficient to help this baby recuperate if she doesn't express milk.

I took the liberty of plotting this baby's growth on the WHO z score curves.  The baby has dropped too low to see the curves on the percentiles, which is why I like z scores.  I had to add the -4 z score curve because the baby went from -1 z score all the way down to -3-1/2 z scores.  The baby has dropped more than 2 z scores from her initial starting curve at the -1 z score curve.  WHO recommends looking closely when a baby crosses 1 z score and definitely intervening when the baby drops more than 2  z scores. This baby is quickly approaching 3 z scores below her starting z score curve (which would be - 4 z scores) and this is where cognitive development can definitely happen.  There is still time to push this baby back up from below -3 z scores.

If this mother has enough milk she should be expressing milk every single time she supplements her baby with whatever device is deemed appropriate and the weight loss is so severe that it really should be at every single feeding.  The clinical definition by every parameter would be "marasmus" for this baby.  

It would be important to impress upon this mother that intervention is definitely needed but if she intervenes she can prevent cognitive delays.  

Of course there are many other zebras that might be involved in this case, but the simplest starting point is upping the volume of intake.

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