/*"*//*I did get a pretty intensive history and the mother is also 
working with her pediatrician and an IBCLC. *//*I didn't share full 
details because I did not have her permission; *//*she said I could 
share the outline of the situation for the purpose of getting the 
protocol for increasing volume. *//*There is a complicated history but 
pedi and IBCLC seem to feel that increasing calories is the first thing 
to try. *//*She called me for emotional support and to discuss potential 
ways to supplement without formula."

*/*Very short answer

Emily, if you want, I am available today and on Wednesday. You can get 
in touch with me to discuss the case via e-mail 
[log in to unmask] or phone 908-216-7703.

*Short answer

Yes and no. Increasing the volume and/or caloric density may work, but 
not always. Without knowing the actual situation it is extremely hard to 
give the appropriate advise, to say nothing about providing the so much 
needed emotional support for the family. Pamela Morrison article is 
great (thank you Pat, as usual, you are a such a source of incredible 
information!), BUT - the that and similar protocols are dealing 
specifically with inadequate intake/supply in an underfed, but otherwise 
healthy and stable infant. While we do not know anything about this 
particular mother's supply, we do know enough to say that the kid in 
question is neither stable nor healthy.

In my opinion (and as only human, I may be wrong), rather then bringing 
the family where they want to be (exclusive breastfeeding without any 
supplementations and/or interventions) we have to meet this kid and her 
mother where they are. And even with the little we know, they are not in 
a pretty place right now.

We also have to understand the urgency of the situation, as the kid is 
not just failing to thive, she critical, she is at the point of not 
being able to sustain her growth and development. The problems did not 
start yesterday and will not end tomorrow (unless the problem is 
surgical and is reasonably easy to correct).  Which brings us to several 
major issues - is mother asking the right question (supplementing 
without formula)? Does the kid have time and potential for simply 
"stretching the stomach"? What kind of emotional support should the 
lactation consultant provide in this situation?

*Long answer.

There are 3 very significant red flags here.

/*(a) losing weight, weighting 8-8 lbs at 3 mo. */That weight is waaay 
below the growth chart for her age placing her at the 50% for a 2 week 
old baby. We dont know how did she get there and how does her growth 
curves look like for weight, length and head circumference, all we know 
that she is not just not gaining enough she is losing weight. And I am 
not talking about "does it look like her head is not growing either?" as 
the weight would suffer first, then the longitudinal growth will stunt 
and then the brain will seize to develop, thus - to grow... Almost all 
malnourished babies do look the same - small bodies with realatively 
large heads with the huge "hundry" eyes and huge protruding bellies. 
While (with appropriate diagnosis and treatment) we can reclaim the lost 
grounds in physical growth, it is much harder for the baby to catch up 
in brain development (even with the good catch-up brain/head 
circumference growth).

/*(b) not able to take more then 20 oz/day, spitting up when force fed. 
*/To sustain herself where she is right now (without taking in 
consideration her medical problems that can be energy consuming and her 
already existing weight deficit) the baby is supposed to take about 22 
oz/day (way less then she is able to take right now). When re-feeding 
the failing to thrive babies (and such protocols are readily available 
to baby's pediatrician) we should calculate the caloric intake based not 
on the present weight, but on the projected weight. At 3 months the 
average baby would weight about 12 lbs, which will require (again, 
without addressing the medical problems) about 30 oz/day. That is 
additional 10 oz/day, which no way this poor kid in her present state is 
able to tolerate.  Therefore the probability of successfully utilizing 
protocols aimed at "stretching of the stomach" is reasonably slim, as 
this intolerance is most probably not simply mechanical in nature, at 
least not mechanical in a normal physiological point of view (see 
example of malrotation below). Most probably the baby is not being able 
to tolerate larger feedings because of her (yet undisclosed) medical 
condition(s).
One can increase caloric density of her feedings with milk fortifiers, 
as her doctor suggesting. "Skimming" mother's milk (the same as it is 
done in the case of proctocolitis) may work as a temporary measure, but 
would not work in a long run, and this kid does have a long way before 
she will recover.

I personally do see the main clue to the puzzle in /*(c) "complicated 
history", */but how can we help if mom does not want us to know any details?

To illustrate the importance of the/*"C"*/ - without any attempt to 
provide complete differential for extreme failure to thrive in an infant 
- here are some examples of such from 30 years of my checkered 
experience (pediatrician and pediatric dermatologist in Moscow, Russia 
and pediatrician, adoption/foster care physician and IBCLC in the US)

- first and foremost - neglect and deprivation. (most probably not a 
case with your kid, but I have to start with it, as that is always on 
the top of the differential diagnosis). The treatment is as you are 
asking - increase the volume and caloric density and the kid will do 
great. I had 8-10 lbs kids yanking over 16 oz feeds 6-8 times/day 
without a second thought ( some spitting up a little bit with or without 
overfeeding diarrhea).

- Eczema. I did see eczema so bad that the baby had to be restrained 
because of the severe itching (not that I would recommend that measure 
as a treatment option). Failure to thrive was caused by both increased 
protein losses (oozing, scaling on the skin as well as intestinal 
malabsorbtion), increased energy demands (stress, infections) and 
decreased intake because of severe discomfort. Treating the primary 
condition (eczema) and addressing secondary problems (skin infections 
and infestations, severe itching and malabsorbrion) did allow the kid to 
thrive physically and developmentally.

- surgical problems sometimes can be hard to detect and relatively easy 
to fix - I did have a couple cases of malrotation presenting as a 
moderate to severe FTT. Babies did dramatically better after the 
appropriate surgeries.

- congenital metabolic problems can result in FTT as well as 
neurological deterioration. Addressing the underlying problem may be 
curative (had a baby with carnitine deficiency who did present as a 
significant FTT and low muscle tone)

- sometimes we can not address the underlying issue... had a baby with 
leucodysplasia (degeneration of the brain's white matter ) who was 
slowly losing (among other skills) her ability to suck and did develop 
failure to thrive. Had to fight two consultants (neurologist and 
gastroentherologist) to finally put the G-tube in and to stop torturing 
both the baby and her mother. All I was able to provide here was 
emotional support, but that support was directed into fighting the 
system, not continuing with ineffective oral feeds - no matter 
artificial formula or mother's breast milk.

- anemia, impairements of internal organs (heart, lung and kidneys to 
name a few) , both aquired and congential, would make the kid weak and 
intolerant of feedings. Without addresing the underlying cause feeding 
alterations would not work.

- neurologic and developmental issues (low mucle tone, tremors, 
aversions, etc) will decrease oral intake and lead to FTT.

So, in summary, the probability of the kid'd present condition being 
causes simply by inadequate intake and/or supply, is very low. Baby 
needs aggressive evaluation and treatment of underlying cause(s), and 
breastfeeding alone, no matter how beneficial, most probably can not be 
viewed as the only nutritional solution.

Hope that was helpful

Alla
Alla Gordina, MD, IBCLC, FAAP


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