I have been asked for advice by a mom in my practice who has 3 small
children.  She works full-time and her children are all cared for in a local
childcare center.  She is breastfeeding her 3rd child, an infant boy who is
now just under 3 mos old.  This baby was born at term, weighing 9 lbs 5 oz,
and has been exclusively breastmmilk fed - at the breast at home, and
receiving bottles in daycare.  His growth has been excellent, in fact he is
already 15 lbs.  He has had some issues which suggest oversupply/OMER,
especially early on when he struggled a little with fast flow, and he does
spit up a fair amount.  He is content and happy for mom though.  
The main issue surrounds the amount this baby is being fed at daycare. 
Initially, when I saw him for a 2 month old well baby check, his parents
were concerned that daycare reported he was spitting up (they said vomiting)
large volumes after every feed.  On taking a history, it turned out that the
daycare teacher was feeding this baby 8 full ounces about every 3 hours.  As
a result, he was drinking 24 ounces of pumped milk during an 8 hour day, and
spitting up all the time.  Daycare was really pushing the mom to add cereal
to the milk to thicken it, and asked her to ask me for a prescription for
Zantac to "stop his vomiting."  The baby does spit quite a bit, but he is
happy and content, growing well, and has no respiratory issues.  I
encouraged the parents to ask the daycare to feed smaller amounts, pace his
feeds, and keep him upright after feeds.  Mom called me in a week and
reported that he was doing much better, spitting less, and not using nearly
so much milk at daycare.
Today she called again looking for advice.  Daycare now reports that
although they are offering 3 ounce bottles, he is crying and unhappy all day
long, and the only way they say they can console him is to feed him.  As a
result, he is now being fed 3 ounces every HOUR!  He's back up to taking
20-24 ounces in 8 hours.  The mom wonders if he really needs this volume of
milk.  At home, she reports he is content and happy, nurses about every 3
hours, with occasional appropriate cluster feeds, and is easily entertained.
 At daycare, they tell her he screams continuously unless he is being fed,
or has just been fed. They are still wanting her to start cereal, now to
"stretch out his feedings." 
Does this less than 3 month old baby really need 24 ounces in 8 hours? 
Especially when he is averaging 5 or more feeds when with mom also?  I've
suggested that she ask the daycare providers to try some soothing behaviors
with this baby, including carrying him in a soft baby carrier or sling,
giving him time to lie on a blanket and look around (which he enjoys at
home, but can't frequently do at daycare due to several toddlers in the same
room disturbing him) or even using a swing.  He is already using a slow flow
nipple, and he refuses all pacifiers.  This mom is quite sad thinking about
her baby being so unhappy without her, but not working is not an option
right now.  She of course wants him to have what he needs to eat, but we
both have a hard time believing he needs that much, and she reports that
even when he was consuming 24 oz a day, the daycare teachers thought even
then that he needed more.
Anyone have any ideas of how to deal with this situation?

Jennifer Tieman
Family Physician
Mom to 4, including my nursling Caroline Rose, age 2 1/2

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