Managing Slow Weight Gain in the Breastfed Infant Assessment & Management Strategies

1. Managing Slow Weight Gainin the Breastfed InfantAssessment & Management Strategies Elaine Webber DNP, PPCNP-BC, IBCLC

2. Weight Gain Concerns • Approached in orderly diagnostic process • Complete history and PE • Details of feeding • Observation of feeding • Appropriate labs • Data organization • Will help identify factors that appear under maternal and infant cases separately

3. Failure to Thrive(as defined by Ruth Lawrence) • Weight loss after 10 days • Birth weight not regained by three weeks • Rate of weight gain below 10th% beyond one month of age

4. Slow Weight Gain • Weight gain slow but consistent • Weight, length and HC proportional • Developmental milestones normal

5. Differentiating Slow Weight Gain and Failure to thrive Infant who is slow to gain weight • Alert • Good muscle tone • At least six wet diapers/day • Pale, dilute urine • Stools frequent, seedy (or if infrequent, large and soft) • Eight or more nursings/day of active feeds • Weight gain consistent by slow Infant with failure to thrive • Apathetic or crying • Poor tone • Poor turgor • Few wet diapers • “Strong” urine odor • Stools infrequent, scanty • Fewer than eight feedings, often brief • No evidence of milk-ejection reflex (no swallowing noted) • Weight erratic, may be losing weight

6. Normal Growth • Initial weight loss • Normal 7-10% of birth weight • What might impact excessive weight loss? • Expected weight gain • “Normal” daily weight gain? • Regain birth weight by 2-3 weeks

7. Is there really a problem? • Differences in growth charts • Breastfed infants grow more rapidly first 2 months of life • Less rapidly from 3-12 months • Weight gain only one parameter • Length and HC also important • Familial considerations

8. Etiology of the Problem

9. Evaluation of the Infant • Underlying physical problems • Metabolic conditions • Congestive Heart Failure • Cystic fibrosis • Mechanical Abnormalities of the Mouth • Ankyloglossia • Short tongue • Bubble palate • Tight jaw

10. Evaluation of Infant (cont.) • Neurologic • ability to root, suck and coordinate swallows • Acute infections • Septic, GI issues • Chronic fetal infections • CMV, HIV, Toxoplasmosis, etc. • High energy requirements • Some CNS disorders, fetal exposure to stimulants, stimulants transferred in breast milk,

11. Conditions associated with or causing disorders of sucking and swallowing Absent or diminished suck • Maternal anesthesia or analgesia • Anoxia or hypoxia • High bilirubin • Prematurity • Trisomy 21 • Hypothyroidism • Neuromuscular abnormality • Werdnig-Hoffmann • Muscular dystrophy • Central nervous system infections • Toxoplamosis • CMV • Meningitis Mechanical factors interfering with sucking • Macroglossia • Cleft lip • Fusion of gums • Tumors of mouth or gums • Ankylossia (tongue or labial) Disorders of swallowing • Choanal atresia • Cleft palate • Micrognathia • Post-intubation dysphagia • Pharyngeal tumors • Familial dysautonomia Adapted from Lawrence & Lawrence (2005)

12. Muscle Tone – a continuumWhen does it become “abnormal”? Slightly hypotonic infants may demonstrate: • Weak Suck • Poor lip closure • Frequent slipping off the breast Hypotonia Normal Tone Hypertonia Slightly hypertonic infants may demonstrate: • Extended posture • Excessive irritability • Strong bite reflex Note that some infants show “soft signs” or very mild indications of either hypo or hyper tone. These infants are often missed because they appear more “normal” than “abnormal”. Tone should always be assessed with any feeding difficulty.

13. Physiology of Milk Production

14. Prolactin • Causes milk production • Circadian rhythm • Can be increased by emotional and physical stress • Inhibited by dopamine, nicotine and alcohol • Pharmacologic stimulation • Prolactin levels

15. Oxytocin • Released from the posterior pituitary • Immediate reaction to nipple stimulation • Causes contraction of smooth muscle epithelial cells surrounding the mammary alveoli • Largely influenced by psychological factors • Pharmacologic stimulation?

16. Lactogenic effects of Prolactin • Modulated by the complex interplay of many hormones • System which requires significant exploration when faced with a an unknown cause of poor milk production

17. Endocrine vs. Autocrine Control • Initial milk production governed by prolactin production, activation of prolactin receptors and oxytocin release • Eventually prolactin levels decline and milk production is governed by milk removal • Early stimulation and milk removal are essential in the establishment and continuation of a robust milk supply

18. Evaluation of the Mother Potential maternal causes of FTT

19. Maternal Health History • Endocrine History • Difficulty conceiving • Thyroid problems • Pituitary problems • PCOS • Previous Breast Surgery • Prenatal History • Breast changes during pregnancy • Leaking colostrum

20. Maternal Health History (cont.) • Delivery • Length of labor • Drugs during labor • Epidural • Delivery of Placenta • Placental fragments • Excessive bleeding/hemorrhage • Sheehan’s syndrome

21. Maternal Health History (cont.) • Postpartum • Stress and exhaustion • Maternal illness • Maternal medications

22. Lesser known causes of Maternal Low Milk Supply

23. Maternal Physical Exam • Breast inspection • Assessment of nipple and areola • Scars

24. Nipple and Areola • Firm, fibrous breast tissue • nipple and areolar compressibility • Nipple protractility • Flat • Dimpled • Inverted

25. Breast and Nipple Anatomy • Breast Turgor • Large Nipples • Flat/Fibrous Nipples • Inverted/dimpled Nipples

26. Putting It All Together • Management of FTT or slow Weight Gain • Complex cause-and-effect relationship • Direct attention to both mother and baby • There is NO substitute for direct observation of the breastfeeding couplet

27. Maternal Factors • Inadequate Milk Production • Breastfeeding Mismanagement • Positioning • Frequency/duration of feeds • Engorgement • Use of nipple shields • Complimentary/supplemental feeds

28. Identify and treat (if possible) hormonal causes • Measuring Prolactin • Varies based on stage of lactation • Draw baseline (prior to a feed), then 45 minutes after nursing or pumping to measure the surge • In early months; should at least double • If cost an issue – baseline is more important Adapted from Lawrence & Lawrence 2005.

29. Identify and treat (if possible) hormonal causes • PCOS • Metformin – • Informal feedback- variable impact on milk production • Dosages vary (500mg-2500mg daily) • Goat’s Rue • Hypothyroid • Be alert for “low normal” TSH and T3 • Has been correlated with low milk production • Low thyroid during pregnancy should always be rechecked after delivery (2 weeks, 4-5 weeks)

30. Inadequate Milk Production • Secondary Factors (Physiologic/psycho-emotional) • Maternal Illness/fatigue/diet • Mental illness (PP depression) • Emotional disturbances • Impaired maternal-infant attachment

31. Maternal Factors • Impaired Milk Ejection reflex • Primary factors (pituitary disease, surgery) • Secondary factors (pain, smoking, alcohol, meds) • Milk Composition • Vegan diet • Extreme maternal malnourishment (can also lead to decreased milk production) • Low fat content of milk

32. Infant Factors • Inappropriate Suckling Response • Identify problem • Tongue tie • Identify provider who will clip • NP, ENT, Dentist, etc.

33. Identify milk transfer issues • Uncoordinated suck swallow • Active feeding

34. Basic Management Strategies • Diagnose the problem (methodical) • Remember interplay of various conditions • Various problems can lead to same effect • Don’t make assumptions • Evaluate Mom and baby and OBSERVE THE FEEDING!

35. After determining possible causes: • Support/improve mom’s milk supply • Increase intake for the baby • When to follow up? • When to refer?

36. Important Tools • Accurate Electronic Scale • Supplemental Nursing System or other tube feeding devises • Cup/syringe feeds • Nipple Shields • Piston Action Electric Breastpump

37. To improve milk production: • Galactagogues: • Metaclopromide • Domperidone • Goat’s rue • Fenugreek • Brewers Yeast • Homeopathics

38. To improve milk production: • Improve Milk Removal • Correct latch • Correct suck •  frequency and/or length of time nursing • Discontinue pacifiers

39. Disorganized Suck • Leads to  milk removal, then  supply • Stategies • Improve latch • Finger feed (suck training) • SNS • Referrals

40. Finger Feed with Syringe

41. Poor Milk Supply • Improve Milk Removal • Correct suck •  length of time nursing • Correct latch

42. Assessing Latch • Deep latch • Shallow latch

43. Poor Milk Supply • Labs • Thyroid • Prolactin • Term pregnancy 200-500ng/ml • During lactation: • 1st 10 days up to 500 • 10-90 days ranges from 60-110

44. Galactagogues • Metaclopromide (rx required) • 10mg TID 7-10 days • Fenugreek • Brewers Yeast • Homeopathics • Lactuca Virosa • Alfalfa Tablets

45. Important Tools - Review • Accurate Electronic Scale • Supplemental Nursing System • Nipple Shields • Piston Action Electric Breastpump

46. Babyweigh Scale

47. Nipple Shields/Breast Shells

48. Expressing Milk

49. Pumping • Ask what kind of breastpump • After every nursing session • 8-10 x daily if not nursing • Night-time pumping very important