Thank you Pamela Morrison for an excellent description and flow chart for the undernourished infant.    You have mirrored my experiences exactly.    Eileen

On Thu, 27 Feb 2014 09:01:44 +0000
 Pamela Morrison <[log in to unmask]> wrote:
> Laura
> 
> This case must be really worrying you, and rightly so!  I've recently been scouring my books and the internet, and asking Lactnet opinion for info on FTT because I'm working currently with a similar case, though fortunately retrospectively.
> 
> So the first statement that glows red to me in your post is "Mom had just been told by a gastroenterologist to supplement with 24 ounces of formula daily and if baby didn't begin to gain more quickly, he would be hospitalized."    If you are helping mom evade medical advice you yourself could be at risk.
> 
> My experience with very low gain and failure to thrive is that the babies have a consistent set of behaviours/physical characteristics that help identify them, and help point to what to amend in their lives:
>     * Dark urine and scanty or no stools
>     * Low or no weight gain;  and often the mother has received false 
> reassurance that this is fine.  It's not.
>     * At first, there's prolonged and frequent crying, often mistaken 
> for colic, or the baby is pacified/soothed with a dummy, or a breast
>     * Later, the hungry baby may want to feed all day and sleep all 
> night;  these babies become "happy-to-starve" because they actually have so little energy.
>     * During breastfeeding, there's a very short period of 
> swallowing; and then the baby hangs out at the breast, just flutter-sucking with eyes closed, and he/she wakes again to protest only when taken off  the breast.
>     * There's usually high muscle tone;  s/he seems very strong and 
> wiry, keeping his elbows tight to the body, unlike the well-fed baby who will gradually relax during breastfeeding, uncurl his hands and fall into a deep sleep;  at the same time, the baby starts to become very watchful, and his/her face may look like a little old man or woman.
>     * The baby may continue to grow in length, but loses body-fat, 
> and in extreme cases may also lose muscle, so that his/her skin looks too loose, especially on the buttocks, arms and thighs.
>     * The gradual weight loss may first be noticed by a friend, a 
> grand-parent or a health-care provider, not the parents.
> You can find info on how babies _should_ grow, to make a comparison with how this baby is _not_ thriving by looking up the Child Growth Standards on the WHO website at 
> <http://www.who.int/childgrowth/standards/en/>http://www.who.int/childgrowth/standards/en/ 
> 
> I see you've already had lots of replies.   Most of us are saying FEED the baby, and I'll join the chorus, but I'd add a few specifics too.   It sounds as if your baby has several problems besides low gain which may have been causative, but I'd think it's a bit too late now to wait to have all these other problems addressed before immediately dealing with this baby's very compromised nutrition.  If this was my client I'd immediately start with formula supplementation (with medical approval) as follows:
> 1.  Breastfeed with breast compression and switching to keep baby swallowing as much as possible.  Stop when baby stops swallowing - may be only 15-20 minutes.
> 2.  Feed the baby 150% of what he should be receiving for the weight he should be!  So according to the WHO charts the 50th percentile for boys at 4 months shows he should be about 4.5 kg.  So that would be about 4.5 x 225ml per day = just over a litre a day, or about 125ml every 3 hours.  So the mother would offer any EBM immediately after breastfeeding, and then top up to 125ml with formula. (My apologies, I'm imperially challenged and think better in metric:  1 oz  is roughly 30g or 30ml). Adjust downwards if/when baby refuses, but expect that within a few days, his energy levels will improve, he will want it all and may become very greedy!   Reassure the mother that he'll calm down when he's caught up.
> 3.  Immediately after the baby is settled, express the breasts, switching, to the very last drop, reserve the milk for the next top-up.  This will increase the mother's supply more than any other strategy - she should be working towards making 500ml/day so that when she starts weaning foods and continues BF after the 6 month mark, the baby will receive "enough" breastmilk.
> 4.  Do this round the clock.  Feeding, topping up & expressing should take about an hour, leaving mom about 2 hours to relax/do other stuff, and baby should be very happy with all this extra food!
> 5.  Watch the catch-up gain pile on.  Watch the little man fatten up and become much, much happier.   The baby should not be expected to breastfeed _effectively_ until he's completely caught up, but mom can and should use the breast any time for comfort, and sleep-time, and reassure her a lot that her milk supply _will_ increase if she keeps this up.
> 6.  Ensure the baby receives frequent weight monitoring and medical care until he's out of the woods, and of course get the other problems addressed.
> 
> Best wishes, these kinds of situations are so challenging, and often the mom has tried her very best and is devastated to learn her baby is so malnourished - would love to hear the follow-up bulletins!
> 
> Pamela Morrison IBCLC
> Rustington, England
> ---------------------------------------------------
> Date:    Wed, 26 Feb 2014 15:30:09 -0500
> From:    Laura Spitzfaden <[log in to unmask]>
> Subject: Help needed with failure to thrive case.
> 
> PTP.
> 
> I first saw Mom and Baby three weeks ago. Baby was 4months and 11days old. He had gained just a little more than 2 lbs from birth-weight. He was content and meeting milestones. Mom was feeding him 5-6 times a day and he was sleeping through the night. He had a very poor suck, restrictive lingual and labial frenulums. He had cranial, trunk and hip asymmetry and intermittent strabismus.
> 
> Mom had just been told by a gastroenterologist to supplement with 24 ounces of formula daily and if baby didn't begin to gain more quickly, he would be hospitalized.
> 
> We started with appointments for TT and LT revision, CST and very frequent feeds (12 a day) with side switching and breast compressions.  The more frequent feeding upped his gain to 1/3 an ouce a day within 3 days. He has CST two days after our visit  day and laser revisions of tongue and lip 4 days after our visit. On day 6 he figured out how to use the supplementer and Mom began supplementing with some milk she had stored. SHe started out with 8 ounces a day and gradually reduced the amount over the next week due to his taking less from the supplementer. When she was down to just 4 ounces of supplement, she ran out of extra milk. While she was supplementing, Baby was gaining over an ounce a day but when she ran out, he only gained an ounce a day for the next two days and is now back to 2 ounces gain in 6 days.
> 
> He is still content and is gaining normally for his age but he hasn't caught up enough to be even back on the WHO growth chart. Mom is willing to consider supplementing but isn't very comfortable with donor milk or formula. Baby is now just 5 months old. This mom has worked so very hard and done everything she can to keep him on only her milk. She is also taking some herbal galactagogues that she just started a week ago.
> 
> My question is are the risks of formula greater than the risks of not catching up on the weight gain when the baby is developing normally in every other way, meeting milestones and content? My gut feeling is that supplementation would be best until he is back on the charts but I don't know if this is correct. Maybe starting solids early would be best?
> 
> Laura Spitzfaden, LLLL, IBCLC, APL
> 
> 
> 
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Eileen Ahearn Shea, BSc, IBCLC
Clinical Lecturer, Family Health Team
Department of Family Medicine
McMaster University Faculty of Medicine
1280 Main Street West, 
Hamilton, ON L8S 4K1. 
	

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