May 2011
Weight loss and slow weight gain issues seem to be very common for breastfed babies. It is quite hard to get the bottom of where exactly the problems lies and there can be hard decisions to make about what action to take and in particular if you should supplement. You will get lots of conflicting advice - different midwives, health visitors and doctors may well tell you completely different things. There are health professionals who will want you to switch formula at the slighest dip in the growth curve and breastfeeding evangelists who are in denial that weight issues are ever a legitimate issue of concern. You will feel guilty if you stop exclusively breastfeeding and feel guilty wondering if your baby is going hungry. Welcome to the world of having to be assertive in your questioning and having to form your own judgements based on multiple different opinions!
Big disclaimer: none of the following is medical advice - these are just views based on my personal experience, which is obviously very individual. I encourage you to see a doctor if you have any worries at all.
If it is a very young baby, then you will still be under the care of the midwives who will hospitalise you if it is serious. If this happens then the hospital will probably conduct some tests and do a 'test feed' where you feed the baby on a schedule, three hourly in our case, and they top-up the feeds with formula, probably via tube. They will weigh the baby before and after the test feed to see if the baby gains weight with these top-ups. This may last a day or two and they are basically trying to figure out if it is a medical issue or a 'feeding issue' i.e. whether the baby is just not getting enough calories from breastfeeding or whether the weight loss is caused by some underlying issue. This will inevitably be a rather stressful experience, but according to the nurses I spoke to, the vast majority of babies referred to hospital in this way have feeding issues rather than medical issues apparently, with the most common problem being that the baby is not latching on correctly.
As well as weight, midwives will be on the lookout for whether the baby is dehydrated. The classic test for dehydration is to pinch some of the baby's skin and see if it springs back quickly. Sunken fontanelles and a lack of wet nappies are also signs of dehydration. Other things that midwives will be looking at generally to get an indication if the baby is thriving are number and type of dirty nappies and whether the baby is alert, active and settled between feeds.
If it is less serious weight issue, or the baby is older, it can often be a bit harder to tell if slow weight gain is a genuine issue or not, even though you may want to start taking action before you are sure. The amounts of weight concerned are very small and having just had a feed or done a dirty nappy can make a big difference to a baby's weight. Scales can also be different calibrated - if you can, try to get your baby weighed on the same set of scales each time and perhaps make a note of the ID of the scales for each weighing. Since May 2009, the charts in the red book have been based on breastfed babies although lots of people still assume that they are based on formula fed babies. Breastfed babies usually gain more than formula fed babies for the first three months and then less after that. Weight also often goes up in steps so after the first few months. It is common to have a period of slow weight gain just before a growth spurt (at e.g. 12 weeks, 19 weeks, 26 weeks) followed by a large gain afterwards. Also, remember 39% of babies do cross at least two percentiles between birth and six months.
However, even if you decide that there is nothing to panic about yet, you probably want to be making sure you are eliminating any possible reasons for slow weight gain. As well as the things to try below, this is a useful article: 'Slow weight gain following earlier good weight gain'.
1) Improve transfer of milk
You should definitely get your latch and positioning checked for a young baby. Even for an older baby, it's worth making sure you haven't become complacent. As well as meaning that your baby gets more milk, because milk production works on a supply and demand basis, the better the latch, the more your milk supply will be stimulated.
I'd recommend going to a NCT breastfeeding counsellor if you have one locally. Although some are excellent, many midwives, health visitors and nurses have had very little training on breastfeeding and so support can be a bit mixed. Definitely get more than one person to check that your latch and positioning as one person may spot an improvement that somebody else has missed. Even if you are not in pain and the latch is 'ok', there may be room for improvement. Try different positions. I found biological nurturing, where you basically lie back in bed and put the baby on top of you, using gravity to improve the latch, useful. I also found it was worth being patient and often relatching at the start of a feed, until the latch was really good - sometimes I would do this up to a dozen times if necessary. If it is a young baby, you want to make sure that the baby is as awake as possible for feeds so that it feeds well. There are lots of tricks for waking up babies for feeds. Undressing them, blowing on them, running your finger down their back, doing a nappy change are the common ones. There are also some useful videos on the Jack Newman site to show what good feeding looks like.
The other issue is that of foremilk and hindmilk with the number of calories in milk increasing as the breast gets emptier. It is important to make sure that the baby has 'finished' one breast before moving onto the next to get this more caloric milk. I have heard that tucking in a baby's bottom well helps get more hind milk - don't know if this is true or not!
2) Make sure you are feeding often enough
The advice I was given from almost all NHS sources was to feed every 2-3 hours during the day and every 3 hours during the night, waking up the baby if necessary, as well as 'on demand' (nobody ever quite tells you what this means, but for a young baby, it pretty much means 'whenever the baby cries'). Times between feeds are measured from the start of one feed to the start of the next. Many of the sources of breastfeeding support will tell you to feed as much as possible and e.g. recommend a 'babymoon' (spending the day in bed with your baby) as a way to do this. I'm not totally convinced by this because a baby taking fuller feeds will empty the breasts more and sleep also helps babies' growth (see below for more on both of these) and it didn't seem to help for us. Sucking also burns calories and a baby comfort sucking can easily burn more calories than gained from the milk obtained.
However if you are only feeding every four hours or not from both breasts at each feed then you almost definitely need to be feeding more often. More frequent feedings are supposed to lead to higher fat milk. You certainly want to be feeding more often than just when the baby is hungry. I suspect it's a case of finding the right sweet spot that works between feeding too often and not often enough. This is an interesting article on feeding spacing: The Infant Feeding Schedule
3) Improve your milk supply
It is very difficult to know if you have a low milk supply or not, but if you have weight issues, then you should probably assume that it is a problem.
Milk works on a supply and demand basis - so as a rough rule, the more you feed, the more milk will be produced. However, it is a bit more subtle than that as more milk is produced if the breast is fully emptied. See this article How does milk production work? I found that expressing after a feed seemed to have a better effect on my milk supply than just letting the baby feed more than every 2-3 hours during the day, perhaps because a baby feeding too often is never quite hungry enough to completely empty your breast. I'd recommend hiring a hospital grade double breast pump for this - one of those certainly worked much better for me than my Avent electric pump. Pumping is exhausting so you need to be careful about what you can sensibly manage - one approach that I have heard of since is to stop feeding when baby starts just comfort feeding and then pump to make the total time 45 minutes. Some people manange to pump from one breast while feeding from the other, but not sure that I could do this even now that I can feed on autopilot! If a baby latches and feeds well they are more efficient than a pump, but if part of your problem is that your baby does not latch or feed well then you may be better off pumping.
Night feeds are also supposed to be good for milk production because prolactin levels are highest then but I'm a bit sceptical about how strong this effect is - if it makes much difference, I should have the best milk supply ever! There do exist prescription drugs that can help with milk supply but you would need to talk to your doctor about those. Fenugreek (tastes horrible if not in capsule form, very expensive but supposedly very good for your milk supply) and fennel tea (tastes nice, but not as effective apparently) are both reputedly good for your milk supply but there's no scientific evidence to support this from what I can make out, but doesn't do any harm to try them as well as everything else. I'm convinced that my milk supply improved enormously when I started actually getting a vaguely sensible amount of sleep at night. You can also try breast compressions.
If you think milk supply is an issue, then I recommend the book Making More Milk. There is also this website about low milk supply. If I did things again I would also pay privately for a lactation consulatant as early as possible to try and get to the bottom of whether low milk supply was the issue.
4) Encourage production of growth hormones
I never saw this advice explicitly anywhere, but I have become convinced that many babies with weight issues have problems not with calorific intake but with production of growth hormones. In particular I have heard of cases of people switching to formula and seeing no improvement in weight gain.
Sleep, skin-to-skin (e.g. when breastfeeding) and human touch (e.g. baby massage) seem to be good for growth hormones as far as I can make out, while stress is bad for growth hormones. Obviously you can't always make your baby sleep as much as you would like, but you can do as much skin-to-skin as possible. I am convinced this helped with us. You'll sometimes see the advice to try feeding your baby in the bath - this can be fun to do, but I'm not convinced that it helps much more than skin-to-skin outside the bath, although being in water does calm babies down, so if you have a fussy feeder, they may feed better in the bath. It's not practical to do for every feed though, whereas you can do skin-to-skin for the majority of feeds in a day.
My view is currently that crying if there is not physical discomfort is a form of stress release and that if you have a stressed baby and are confident that it is not crying because it is e.g. hungry (a dummy can be useful to ascertain this when you are paranoid about whether it is hungry!) then it is best just to let the baby cry in your arms to release that stress. I think you want to avoid getting your baby stressed in the first place, but that once it is stressed then there is actually no harm done by the baby crying. Ways to minimise stress include making sure that your baby is not overstimulated e.g. don't move them around too much or have lots of different people hold them, and to make things as predictable as possible for your baby e.g. always use the same words and routine when changing them.
5) Rule out medical problems
There are medical reasons why babies may not be gaining weight well. It is also certainly not uncommon for babies with e.g. silent reflux or lactose intolerance to have weight issues. This is obviously something that you need to speak a doctor about, but if you are worried at all, I would encourage you to see your GP, rather than just talk to health visitors who I have found can be a bit reluctant to suggest that you do so and can't do much anyway. Also, don't be afraid to ask your GP for a referral to a pediatrician if you are really worried.
6) Supplement
The NHS is very quick to suggest supplementing with expressed breast milk and failing that formula. It is often necessary, but if you feel that the person giving you advice is suggesting it as a knee-jerk reaction (which does happen) then one route you can go down apparently is to ask for a referral to the 'Infant Feeding Coordinator' for your area.
Supplementing with expressed milk can be exhausting especially if you cannot pump very much - you are having to pump, breastfeed and then bottlefeed (or e.g. cupfeed). If you have serious weight issues you will almost certainly end up supplementing with formula although you will not necessarily need to do this long-term. It can be difficult to make decisions about when to start supplementing and how. Again this is one time I think we should have tried to see a lactation consultant. You basically have two options - to top up each feed or to replace an entire feed. The late evening feed is the standard first feed to replace - your milk supply is lowest then, you get a rest and you can be confident that your baby is not hungry if it wakes up in the night shortly after that feed. Replacing night feeds is not recommended as the higher prolactin levels then mean that feeding then is good for your milk supply. I have heard tha replacing a feed is less likely to impact your milk supply than doing top-ups but haven't seen any evidence to that effect, although it is what we decided to do and it hasn't caused any problems. Replacing one feed however may not be enough to help with your baby's weight gain.
7) Monitor the situation
Get your baby weighed regularly, but not so often that you can't see what the trend is - how often you want to get your baby will depend on their age and how serious the problem is, so it's probably best to follow the advice of health visitors on this. If you have serious weight issues, you may want to get height and head circumference plotted as well as weight and keep an eye on whether your baby is meeting developmental milestones.
This will happen evenutally! Babies with early weight issues often go on to have sleep issues as they get older. I think there are three reasons for this
I plan to write something separate about sleep, but being conscious that you will probably have sleep issues that may not resolve themselves until the baby is much older may help you do something about them sooner rather than later.