Elaine Webber DNP, PPCNP-BC, IBCLC

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

Weight loss after 10 days

Birth weight not regained by three weeks Rate of weight gain below 10th% beyond

one month of age

Weight gain slow but consistent

Weight, length and HC proportional

Developmental milestones normal

Infant who is slow to gain weight

AlertGood muscle toneAt least six wet diapers/dayPale, dilute urineStools frequent, seedy (or if infrequent, large and soft)Eight or more nursings/day of active feedsWeight gain consistent by slow

Infant with failure to thrive

Apathetic or cryingPoor tonePoor turgorFew wet diapers“Strong” urine odorStools infrequent, scantyFewer than eight feedings, often briefNo evidence of milk-ejection reflex (no swallowing noted)Weight erratic, may be losing weight

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

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

Underlying physical problems◦ Metabolic conditions◦ Congestive Heart Failure◦ Cystic fibrosis

Mechanical Abnormalities of the Mouth ◦ Ankyloglossia◦ Short tongue◦ Bubble palate◦ Tight jaw

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,

Absent or diminished suck

Maternal anesthesia or analgesiaAnoxia or hypoxiaHigh bilirubinPrematurityTrisomy 21HypothyroidismNeuromuscular 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)

Slightly hypotonic infants may demonstrate:

Weak SuckPoor lip closureFrequent slipping off the breast

Hypotonia Normal Tone Hypertonia

Slightly hypertonic infants may demonstrate:

Extended postureExcessive irritabilityStrong 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.

Causes milk production

Circadian rhythm

Can be increased by emotional and physical stress

Inhibited by dopamine, nicotine and alcohol

Pharmacologic stimulation

Prolactin levels

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?

Modulated by the complex interplay of many hormones

System which requires significant exploration when faced with a an unknown cause of poor milk production

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

Potential maternal causes of FTT

Endocrine History◦Difficulty conceiving◦Thyroid problems◦Pituitary problems◦PCOS

Previous Breast Surgery

Prenatal History◦Breast changes during pregnancy◦Leaking colostrum

Delivery

◦ Length of labor

◦ Drugs during labor

◦ Epidural

◦ Delivery of Placenta

Placental fragments

◦ Excessive bleeding/hemorrhage

Sheehan’s syndrome

Postpartum◦ Stress and exhaustion◦ Maternal illness◦ Maternal medications

Breast inspection

Assessment of nipple and areola

Scars

Firm, fibrous breast tissue◦ nipple and areolar compressibility

Nipple protractility◦ Flat

◦ Dimpled

◦ Inverted

Breast Turgor

Large Nipples

Flat/Fibrous Nipples

Inverted/dimpled Nipples

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

Inadequate Milk Production◦ Breastfeeding Mismanagement

Positioning

Frequency/duration of feeds

Engorgement

Use of nipple shields

Complimentary/supplemental feeds

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.

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)

Secondary Factors (Physiologic/psycho-emotional)◦ Maternal Illness/fatigue/diet

◦ Mental illness (PP depression)

◦ Emotional disturbances

◦ Impaired maternal-infant attachment

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

Inappropriate Suckling Response◦ Identify problem

Tongue tie◦ Identify provider who will clip

NP, ENT, Dentist, etc.

Uncoordinated suck swallow

Active feeding

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!

Support/improve mom’s milk supply

Increase intake for the baby

When to follow up?

When to refer?

Accurate Electronic Scale

Supplemental Nursing System or other tube

feeding devises

Cup/syringe feeds

Nipple Shields

Piston Action Electric Breastpump

Galactagogues:

◦Metaclopromide

◦Domperidone

◦Goat’s rue

◦Fenugreek

◦Brewers Yeast

◦Homeopathics

Improve Milk Removal

◦ Correct latch

◦ Correct suck

◦ frequency and/or length of time nursing

◦ Discontinue pacifiers

Leads to milk removal, then supply Stategies

◦ Improve latch

◦ Finger feed (suck training)

◦ SNS

◦ Referrals

Improve Milk Removal

◦ Correct suck

◦ length of time nursing

◦ Correct latch

Deep latch Shallow latch

Labs◦ Thyroid ◦ Prolactin

Term pregnancy 200-500ng/ml

During lactation:

1st 10 days up to 500

10-90 days ranges from 60-110

Metaclopromide (rx required)◦ 10mg TID 7-10 days

Fenugreek Brewers Yeast Homeopathics

◦ Lactuca Virosa◦ Alfalfa Tablets

Accurate Electronic Scale

Supplemental Nursing System

Nipple Shields

Piston Action Electric Breastpump

Ask what kind of breastpump

After every nursing session

8-10 x daily if not nursing

Night-time pumping very important

Psychological approach Artificial oxytocin

Get rid of the pacifier!!!

Switch nursing

◦ Takes advantage of MER

Bring baby into bed throughout the day

Frequent feeds One sided feeds

◦ fat content of milk

Lengthy active feeds Pump first to elicit MER Maternal diet

Scale rental for home use

Expectation for weight gain

Weight checks (don’t wait too long)

◦ daily, q other day, weekly

Phone contact and encouragement

Making More Milk : Diane West & Lisa Marasco

Breastfeeding: A Guide for the Medical Profession : Ruth Lawrence

Breastfeeding management for the Clinician: Marcia Walker

Medications and Mother’s Milk : Thomas Hale