Tricia,

It sounds like you've done an excellent job with this family. I do not agree with the dietitian. The infant is likely gaining more than an ounce a day in order to reach his genetic potential. I would just make sure they are not force feeding, which, if he is at the breast, is not an issue.

I have heard many professionals, even LCs warn families about obesity if their exclusively breastfed child is gaining too fast. One of my recent patients told me that her baby lost 13% by day 3, and when the baby gained 3 oz in 1 day on day 4 after they began supplementing, the lactation consultant told them the baby is going to become obese with that weight gain! That, of course, is dangerous advice.

The lack of education out there is frustrating.

The infant should eat according to his hunger. Forcing him to gain just 1 oz a day when he is IUGR is like forcing a poor person to stay poor by limiting the amount of money that person can make per day. He wants to reach the WHO growth curve, and he is not going to accelerate fast enough to get there unless he gains more than an oz per day.

The obesity concern with rapidly gaining infants applies to formula feeding, in my opinion, especially using high calorie formulas.

I don't usually prescribe volumes because those volumes are going to change rapidly, every few days in the first 6 or so weeks. I recommend feeding ad lib, then freq weighing to make sure it is sufficient. I only prescribe volumes if the baby is super sleepy and has weak cues, but it is a ballpark amount, not a 'limit', and again will either recommend a home scale or weigh often in the office.

Anne





Anne Eglash MD, IBCLC, FABM

Clinical Professor, Dept of Family and Community Medicine

University of Wisconsin School of Medicine and Public Health

Director, UW Lactation Services

Medical Director, Mothers Milk Bank of the Western Great Lakes

Founder and President of The Institute for the Advancement of Breastfeeding and Lactation Education (IABLE)

www.lacted.org







Date:    Thu, 1 Nov 2018 18:44:14 +0000

From:    Tricia Shamblin <[log in to unmask]>

Subject: FW: growth rate of IUGR baby



 

Hi all,

 

  

 

I have a case in which I could use your wise opinions. Permission to post. I have a first time mother with a severely growth restricted baby. He was born at 39 weeks and weighed just 4# and 4 oz, 1940 grams. He lost weight to 3# 15 oz, or 1790 grams at his lowest weight. The parents supplemented initially for 2 days with donor milk from a milk bank. Then by day 3, she was able to pump about 150 ml per pump session. The infant was a very poor feeder initially, uncoordinated suckling, and had a difficult time even bottle-feeding. We were working hard to get 10 ml by bottle on the second day, but he progressed well with bottle-feeding breast milk. He gained weight rapidly and was 5# 2 oz by his 2 week checkup. At that time, we fit her for a nipple shield (which helped him coordinate his suck better, and mom also has fairly flat nipples). Now he is 4 weeks old and mom says he’s starting to sometimes do better with the nipple shield. She’s practicing at home. Sometimes actively suckling and sometimes not. I’m going to see them again in a few days and work on breastfeeding. My gut feeling is that he’s going to get better and better over time, but it’s probably going to take another 2 to 4 weeks before he’s feeding well at the breast and won’t need the shield.

 

  

 

I found it hard to find information on what to tell the mother about volumes to feed a baby this small. I told her that he’s not preterm, but in some ways he’s going to act like a preterm infant for a while. Most of the information out there is regarding formula feeding and preterm infants and I’m not sure how valid it is for this term baby. The parents were initially very focused on getting food into him, and it was necessary. They had to work hard the first week to wake him and get him to take small volumes but then they noticed him getting more and more alert and easier to feed. I think they maybe went a little too fast and by two weeks he was taking about 60 to 75 ml on average. He did well with it. A couple times they gave him 90 ml and he spit up more. I told her to go back to about 60 to 75 ml but if he seems hungrier, they could try giving a little more. Anyway, they initially did not get any information from the Pediatrician about a specific target volume to try for. She told them to just bottle-feed when the baby seemed hungry. The mother said she was worried about that because what they were doing was working well. She felt if she left him to his own schedule he would sleep all day. Also, having a target range of about 400 to 480 ml daily was helpful for her to have a specific goal. In my experience, parents often appreciate having specific information like this when the baby is having feeding problems. If they get vague answers or no answers it is more stressful for them.

 

  

 

Anyway, they met with a dietician who told them that this volume was too high and the baby should only be eating about 360 to 400 ml daily because he’s gaining weight too fast. This I think is based on the idea of 150 ml/kg per day. She said that if the mother kept feeding the baby that much it would not give him nutrients, but only make too much adipose tissue. Have you ever heard of this? It’s been my experience that breastfed babies tend to gain more fat stores rapidly in the first 3 or 4 months and then tend to lean out. It would make sense to me that this baby would may make up for lost time and grow rapidly? Breast milk for preterm babies is specifically tailor made to help them finish development they did not get in utero, could it be the same for a term IUGR baby? The dietician told her that gaining 2 oz daily was too much weight gain. But the baby seems fine with it, is it really a problem? What do you think? I’ve never heard this theory that rapid weight gain in preterm or IUGR baby will be only fat tissue. My thought is this is probably based on the increased risk of obesity for formula fed babies.

 

  





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