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

"There are little normative data regarding weight gain for exclusively
breastfed infants in the first 1 to 4 weeks of life.  Clinicians generally
agree that the thriving breastfed infant loses less than 10% of birth weight
and regains birth weight by 2 weeks.  Nelson's et al data show that between
14 and 42 days of age, girls average 34 g/d gain whereas boys average 40
g/d.  At the lower end of normal (fifth percentile), both boys and girls
average around 20 g/d."
Based on Lawrence's definitions of FTT:   Concern is warrented when:  Day
1-7 Loses > 10% of birth weight.  Day 14 Still under birth weight, Day 14-42
gaining at < 20 g/day.

Powers:  "Concern must lead to thoughtful assessment and problem solving
during the first 1-2 weeks after birth.  Watchful waiting at this stage may
be inapprppriate because unidentified problems often become more difficult
to manage over time."

We need to remember that milk supply is calibrated in weeks 1-3 (Hill and
Aldag, 1999 and P. Hartmann's work).  In my opinion, it is important to
evaluate in person an infant still under birth weight at Day 21 gaining only
17 g/d.  While
things may be just fine and be improving, I would NEVER take that for
granted.  Infants who have not recovered birth weight by this time seldom
have sufficient strength to empty the breasts competently.  This impacts
milk supply as well as intake. The issues may well be mismanagement of time
or relate simply to latch.  Solutions may be as simple as changing position
and latch and using breast compression.  Supplementation can hopefully be
provided with mothers own pumped milk after some of the daily feedings.
Improvements in behavior may indeed reflect that the situation is turning
around, but direct observation and history taking are important to make sure
that no underlying illness of mother or baby, or anatomic mismatch that
needs assistance will hamper normal growth.

Robust weight gain and more than enough milk for one baby is what normal
looks like in the developed world.  I suspect that if the mother is not
terrifically malnoursished this is also what normal looks like in more
marginalized areas.  Gently, with encouragement and skill, my job is to
figure out what is going on if this is NOT happening.  I am ethically
charged to discover why and come up with a plan to help feed the baby and
help the mother recover to the place where all interventions cease and she
and her baby feed normally (which is defined for the baby as feeding at the
breast and growing better
than reference i.e. formula, counterparts).

Barbara Wilson-Clay BSEd, IBCLC
Austin Lactation Associates
http://www.lactnews.com

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