Has the mother done a few pre-and-post weights to get some idea of how much milk the baby is actually transferring? The amount of time on the breast tells us nothing.  Could this just be a matter of insufficient volume of her fine milk? Is she offering both sides with lots of switch nursing and compression and listening for swallows? Sometimes a baby is "coasting" on catching the initial let-down, and not patient/skilled/strong enough to dig in and drain the breast well.

Her pumping output doesn't necessarily equal what the baby is able to remove. (The good pumping output does argue against this as a primary, physical problem with milk production).  Weight gain is important.  Slow weight gain can create this difficult cycle -- the baby is on the breast all day and night (and getting wonderful touch and interaction, so they are often charming babies) but not removing milk well, so they have less energy to remove the down-regulating supply, so they remove less, and so on.  While never using the word around this mother, being in starvation mode can also cause elevated liver enzymes.

Breastmilk has a low renal solute load so perhaps one can get away with fortifying breastmilk with powdered formula (more so than over-concentrating a base of formula) -- but no one has really studied the safety of this common practice.

This baby is six months old, but there doesn't seem to be any discussion of solids (instead of the fortification).  The early months of solids are built on top of that same base of breastmilk, so they're not the major part of the diet, but nutrient-dense solids -- avocado, sweet potatoes and other root vegetables, egg yolks, meats, greens, healthy fats -- could make a contribution to calories and nutrition. 

 (When babies start solids, they also need sufficient water in the diet, which also argues against fortifying the breastmilk, which is about 90% water, with the right proportion of sugars and salts for good hydration).  Good sources of iron and zinc can also help a baby's appetite.  As several people said, this baby deserves a good workup, and checking the iron and zinc levels would be part of that.

The baby dropped a lot of percentiles, but does seem to have gained about a pound a month, and is lively -- he's getting enough to cover his basic metabolism, so just a few more ounces a day and some solids might be enough to pick up the gain.  If we put the parents on a weight chart, they might be at the 1st percentile as well.  

Older baby issues are such difficult detective work.  Good luck to the whole team.

Margaret Wills, IBCLC, Maryland, USA





> Date:    Fri, 26 May 2017 07:40:21 +0000
> From:    "Shamblin, Tricia" <[log in to unmask]>
> Subject: slow weight gain and elevated liver enzymes
> 
> Has anyone else ever encountered the situation in which an infant was otherwise healthy and growing in length and head circumference but weight gain was slow with elevated liver enzymes. Permission to post was given. The mother said she is now supplementing with formula per her Pediatrician. Weight gain is a little improved but not much. Started with full term healthy baby, 7#, 5 oz, vaginal delivery, no complications, exclusively breastfed and happy baby. Parents are tall and thin as well. Returned to work at 3 months and continued breastfeeding at home and pumping and giving bottles of breast milk. Infant almost 6 months old and 12 pounds and 13 ounces. So it is in 1st percentile. Healthy, full-term infant, born vaginally. Infant appears otherwise happy and meeting developmental milestones. Mother states he does not appear irritable at all and is usually content. Feeds frequently and practices baby-wearing when at home.
> 
> They are now giving two bottles of breast milk each day with powdered formula mixed in to increase calories daily along with breastfeeding. Baby gaining a little more weight on formula but not that much more. Usually drinks about 4 oz by bottle and spits up if drinks more 4 oz. How do you feel about adding powdered formula to breast milk? I worry about the baby's kidneys.
> 
> Her pumping output doesn't seem abnormal, usually pumps about 3 to 5 oz per pump session. Works on maternity unit with Symphony breast pump available to use when working. Has increased breastfeeding and baby wearing at home. Baby seems perfectly happy. Some possibilities on google search are epstein-barr virus, rickets, hepatitis and cytomegalovirus. Could her fat content in her milk be low? The slow weight gain has been since birth, it is not new since returning to work. For right now the Pediatrician has suggested the formula supplement and recheck liver enzymes in a month.
> 
> I did find in my research a case in which an adult had similar symptoms after receiving the Hep B vaccine. Could this just be a rare side effect of the vaccine? It's weird that this seems to not that uncommon. Found a few cases in a Google search of breastfeeding babies with this condition, but no cause is identified. On the LLL site there is a forum in which at least 5 women have reported the same thing happening with their breastfed babies and no answers as to why. Has anyone else seen this in their practice? All of them had the same advice from their doctors, supplement with formula and retest liver enzymes later. Some were offered further testing, ultrasounds and liver biopsy but none found anything. If there were 5 cases listed on the forum, I thought maybe someone else has also seen this in their practice?
> 
> http://www.bioline.org.br/pdf?gm06043
> 
> She wants to know about herbal supplements and I'm little worried about fenugreek due to possible effects on blood glucose. Told her to talk to her doctor first. I think it sounds more like something with the baby and not with her milk supply to me. We did go through all the typical ideas to increase her supply though. I also wondered about too much foremilk or fat loss due to pumping and storing milk.
> 
> Thank you,
> 
> 
> Tricia Shamblin, RN, IBCLC

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