This baby should be evaluated by gastroenterology if the baby's liver enzymes are abnormal, and the pediatrician is done with his/her part of the workup. The baby could have something like biliary atresia, cholestasis, cystic fibrosis, alpha-1- antitrypsin deficiency, etc, in addition to infection as possible causes. Also, make sure that the baby is not having liver toxicity from a maternal medication.
I definitely would not assume that the breastmilk is low in calories. If it was, the baby would strive to take more. Blaming breastmilk does not make sense to me.
I absolutely don't agree with adding formula to breastmilk. I don't understand why doctors do this. If a formula fed infant was not taking enough formula, the doctor would say to give more formula, unless the baby has lung or heart disease and is fluid restricted. They don't say to concentrate the formula.
So, if this baby needs more calories, the calories should be given in a physiologic manner, by giving more breastmilk, or normally reconstituted formula if there is not enough breastmilk. Here is my reasoning:
1. the baby also needs free water if the baby is not taking enough volume for sufficient growth
2. Summer is approaching, so a very bad idea to limit volume
3. Infants who take breastmilk with added formula tend to have stomach upset and don't eat as well overall (from my experience)
4. The doctor is essentially taking the baby off the breast by expecting mom to give EBM with added formula, jeopardizing her supply
5. There is no evidence that this is safe!
Anne
Anne Eglash MD, IBCLC, FABM
Clinical Professor, Department of Family and Community Medicine
University of Wisconsin School of Medicine and Public Health
Medical Director, UW Lactation Services
Medical Director, Mothers Milk Bank of the Western Great Lakes
Founder and President of The Milk Mob, dedicated to building Breastfeeding Friendly Medical Systems and Communities
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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