Evaluation & Treatment of the Slow Growing

Breastfed InfantLaurie B. Jones MD, FAAP, FABM, IBCLC

Agave PediatricsU of A Clinical Assistant Professor Pediatrics

Disclosures

As a speaker/consultant for Willow Pump Company, I do not intend to discuss specific, trademarked agents/products of this commercial interest.

Learning objectives

1. Recognize normal/abnormal human milk fed growth trajectories

2. Discuss longitudinal milk supply principlesAnatomy: storage capacity Physiology: apoptosis, FIL factor

3. Build differential diagnosis skills for the feeding dyadHypolactation DMX (Dysfunctional Milk Extraction)

4. Create collaborative treatment plans for slow growth Respect family feeding goals Ensure a well growing infant

5. Prevention of the slow growing breast milk fed infantAnticipatory guidance at well checks

There is no way that I can cover these objectives in 40 minutes

However, I can hit HIGHLIGHTS

And give you resources for more self-directed learning

Adult learners

● Time to displace old knowledge

● Practical application

● References for later

Ambitious objectives

Busy day in the office….

6 month well check

Healthy, happy infant breastfed only; ready to start solidsWeight % has dropped from 45th%-53rd% at last two visits to 17th% todayNBS #1/#2 normal Length/HC tracking on curveDevelopment is on track, No changes in social determinants of health

…… now the visit is rapid fire questions about feeding type, frequency, volumes, intervals, maternal history, freezer info, feeding goals, and plan

Challenging scenario

To make a plan we have to understand:How breasts make milkHow babies take milk out of breastsNormals for milk volume over time

DYAD: two person differential diagnosis

Fix the problem without creating new ones

Learn how to predict/prevent slow growing infants

- Finding genetic curve?

- Sign of problem ?

- Controversy over exact criteria

- Below 3rd%- “Plummeting”

Slow growth definitions

Slow drift FTT/Pediatric undernutrition

Growth charts – using the right one?

? EMRWHO Birth – 5 yrs

7 countriesAll human milk for 2 yearsVery consistent patterns

Does your inpatient EMR use CDC 2010/WHO?

Outpatient?

CDC 2010

Birth – 24 mo: WHO data2y-24y: 2000 data

All infants measured against human milk

standards

- No one wants to be average

- Not understanding Gaussian distribution of humans

- Unhealthy focus on infant length to predict adult height

- Obsessed over “two lines” crossed

- Not looking at bigger picture or genetics

- Bringing back too soon to recheck

Over-reading growth charts

Parent worry Physician worry

From AAP Breastfeeding Curriculum for residents (FREE and effective)

● You need 1 breast to feed 1 baby● Capable of making enough for two infants● Ductal glandular wedges don’t connect to

each other; apoptosis not inter-dependent

● Storage capacity: amount breast can hold without downregulating volume made

○ EXCEED storage capacity -> milk supply goes down

How breasts make milk

Milk

synthesis

Dopamine

(-)

Prolactin

Milk

secretion

Oxytocin

Anterior

pituitary

Posterior

pituitary

Paraventricular

nucleus

(+)

Milk ejection

reflex

Placenta

Progesterone (-)

Hypothalamus

(+)Cortisol

T3, T4

Insulin

Growth hormone

How breasts make milk: HORMONAL control

A. Stuebe with permission

How breasts make milk

Autocrine control

MAGIC NUMBER PRINCIPLES (Nancy Mohrbacher!!)

Frequent emptying: 8-12 times in 24 hours

Leave milk in the breast: supply goes down

Apoptosis: cell death, remodeling- back pressure on lactocyte- cuboidal shape vs. columnar- FIL mystery: Feedback Inhibitor

of Lactation

Remove milk = make more milk

Day & Night

- Expectations- Night parenting

duties

No PAUSE button

- Breasts make milk 24/7 at relatively constant rate

UNICORN BREASTS

- Breasts that can hold milk for 10-12 hours without emptying

- Just like your teen thinks he/she will be a millionaire YouTube Star

“Hits” to supply

- Some lactating parents can exceed storage capacity frequently and have minimal effect on supply

- Others are extremely sensitive to degree of emptying

How breasts make milk

• All lactating parents with female breasts make similar volumes

(exception: Hypoplasia, IGT, surgeries )

• 24-30 ounces in 24 hours750-900 mL

• 1 – 1.25 oz/hour combined breast output

How breasts make milk

Birth to 1 month : climbs to steady-state(then enters Lactogenesis Stage III)

1 month – 6 months: 24 – 30 oz per 24 hourSame as 1 – 1.25 oz per hour

Slow slide to 12 mo : average is 18 oz/24 hours by one year of age

Growth/calories of human-milk-fed humans

• C, Daymont, Hoffman N, Schaefer Ew, and Fiks Ag. “Clinician Diagnoses of Failure to Thrive Before and After Switch to World Health Organization Growth Curves.” Academic pediatrics, April 2020. https://doi.org/10.1016/j.acap.2019.05.126.

• C, Garza, and Butte Nf. “Energy Intakes of Human Milk-Fed Infants during the First Year.” The Journal of pediatrics, August 1990. https://doi.org/10.1016/s0022-3476(05)80009-5.

• Ct, Wood, Skinner Ac, Yin Hs, Rothman Rl, Sanders Lm, Delamater Am, and Perrin Em. “Bottle Size and Weight Gain in Formula-Fed Infants.” Pediatrics, July 2016. https://doi.org/10.1542/peds.2015-4538.

• Je, Stuff, and Nichols Bl. “Nutrient Intake and Growth Performance of Older Infants Fed Human Milk.” The Journal of pediatrics, December 1989. https://doi.org/10.1016/s0022-3476(89)80750-4.

• Ka, Bell, Wagner Cl, Feldman Ha, Shypailo Rj, and Belfort Mb. “Associations of Infant Feeding with Trajectories of Body Composition and Growth.” The American journal of clinical nutrition, August 2017. https://doi.org/10.3945/ajcn.116.151126.

● Kg, Dewey. “Growth Characteristics of Breast-Fed Compared to Formula-Fed Infants.” Biology of the neonate, 1998. https://doi.org/10.1159/000014016.

● Nc, de Bruin, Degenhart Hj, Gàl S, Westerterp Kr, Stijnen T, and Visser Hk. “Energy Utilization and Growth in Breast-Fed and Formula-Fed Infants Measured Prospectively during the First Year of Life.” The American journal of clinical nutrition, May 1998. https://doi.org/10.1093/ajcn/67.5.885.

● Nf, Butte, Wong Ww, Hopkinson Jm, Heinz Cj, Mehta Nr, and Smith Eo. “Energy Requirements Derived from Total Energy Expenditure and Energy Deposition during the First 2 y of Life.” The American journal of clinical nutrition, December 2000. https://doi.org/10.1093/ajcn/72.6.1558.

● Ps, Davies. “Energy Requirements for Growth and Development in Infancy.” The American journal of clinical nutrition, October 1998. https://doi.org/10.1093/ajcn/68.4.939S.

● Sw, Jones, Lee M, and Brown A. “Spoonfeeding Is Associated with Increased Infant Weight but Only amongst Formula-Fed Infants.” Maternal & child nutrition, July 2020. https://doi.org/10.1111/mcn.12941.

● Z, Karatas, Durmus Aydogdu S, Dinleyici Ec, Colak O, and Dogruel N. “Breastmilk Ghrelin, Leptin, and Fat Levels Changing Foremilk to Hindmilk: Is That Important for Self-Control of Feeding?” European journal of pediatrics, October 2011. https://doi.org/10.1007/s00431-011-1438-1.

Volume is 24 – 30 ounces per 24 hours

1. Jc, Kent, Hepworth Ar, Sherriff Jl, Cox Db, Mitoulas Lr, and Hartmann Pe. “Longitudinal Changes in Breastfeeding Patterns from 1 to 6 Months of Lactation.” Breastfeeding medicine, August 2013. https://doi.org/10.1089/bfm.2012.0141.

2. Jc, Kent, Mitoulas L, Cox Db, Owens Ra, and Hartmann Pe. “Breast Volume and Milk Production during Extended Lactation in Women.” Experimental physiology, March 1999. https://pubmed.ncbi.nlm.nih.gov/10226183/.

3. Jc, Kent, Mitoulas Lr, Cregan Md, Ramsay Dt, Doherty Da, and Hartmann Pe. “Volume and Frequency of Breastfeedings and Fat Content of Breast Milk throughout the Day.” Pediatrics, March 2006. https://doi.org/10.1542/peds.2005-1417.

How baby removes milk from the breast

• Vacuum with jaw drop• Strength of head/neck• Tongue peristalsis• Shape of palate/facial

bones

© Laurie B. Jones

DMX: cause for low supply➢ Infant does not remove milk effectively from the breast

Drinking through BENT STRAW

➢ Lactating parent’s supply dwindles down from incomplete emptying, nipple injury/pain, callous/blisters, plugged ducts, mastitis, abscess

➢ Multi-factorial function diagnosis (VERB)Not a visual diagnosis (NOUN)

➢ Requires intervention with combination of: PT, feeding therapy, ENT, frenectomy, OMM

➢ Triple feeding: direct breastfeeding, pumping after feeding, supplementing (PACED BOTTLE FEEDING. SNS/LactAid)

Growth:Human milk fed infants

Grow slower3-12 months

Caloric needDecreases over time

Grow faster0-2 months

Same volume grows a baby at 6 weeks as 6 months of age!

Peter Davies 1998, Dewey amazing work too

Kcalper Kg

Goes down over time

WEIGHT BASED

VOLUME

CALCULATIONS

*ARE NOT* for

human milk fed

babies

Treatment Plan

More emptyingReferrals for DMX

Labs for parentFeed more milk

4

1

2

3

Fix the fixables

Lactating parentInfant

While homeWhile separatedPin down details

Detailed history

Newborn screen results, sweating with feeds, bloody

stools, renal disease,vomiting, dysmorphic features, recurrent infections

ROSShows true concerning

pattern

Growth chart

DDx: Detailed feeding history

Type of milk

From the tapFrozen parent milkDonated peer milk

Formula

Longest stretch of sleep

Infant did on own?Parent sleep trained ?

# of feeds

Direct BF pump only

Pump after direct BF

Freezer

Is parent freezing milk daily?How much frozen milk exists

in house?

# of pumpHow many oz pumped

when pump only

Sides

Both at each feedingOne makes >>> than other

Denial/bargaining

Can’t argue with growth chart that has accurate measurements on it

“Happy to starve”/content babies are the scariest

“He/she seems full. I can’t get baby to take more even when I offer.

All my kids are small.”

DDx: Signs of DMX

Nipple shape

? Lipstick shape? Crease down the middleImmediately after feeding

Plugged ducts

From callous – FRICTION-keratin BLEB

Milk stasis leads to plugs

Painful feedings-Should not have chomping, chewing, tongue thrust-Should not need nipple shield or salves daily

One side not painful

Neck tight from in utero positioning

Clicking

Fast flow all babies clickContinuous METRONOME

clicking is abnormal Snap back of tongue

MastitisSkin infection (a sign of DMX/poor

latch) or milk stasis Recurrent mastitis is DMX until proven otherwise

● Making enough for a future baby and current baby is oversupply

● Oversupply leads to milk stasis if pumping isn’t maintained

● Oversupply masks DMX problems until parent slows down pumping

● Direct feeding in massive oversupply can have slow growing infant (% fat start of feed is very low)

● Normal milk supply and freezing daily WILL LEAD to a slow growing infant

● Feed the baby not the freezer

● Always always always ask where the pumped milk is going. We assume into baby but often it’s going into freezer

● How much is being frozen per day?

Oversupply Freezer Theft

Over 6 months

❖ How much do we all HATE the phrase solids under 1 are just for fun ?

❖ DANGEROUS for growth and iron stores and zinc deficiency

❖ Baby led solids vs. purees vs. combination

❖ Fear of gagging, choking. Fear of allergies. Trying to make all organic or perfectionism in the baby foods

❖ Slow solids are a major contributor to slow weight gain over six months

DDx: Maternal questions

Chest or pituitarysurgery

Chest tubeRadiation

Central line

New medicationsHerbs, vitamins

TobaccoPseudophed

Estrogen

Breast surgery

ReductionImplant (above/below)

Hypoplasia?Peri-areolar biopsies/incisions

Contraception

Implanted devicePills (? E ?P)

Lack of …. And there’s a new placenta!!

Medical history

PCOS, hypothyroidism, infertility, insulin resistance, gestDM,

retained placenta, Post partum hemorrhage

Dietary restrictionsVegan (B12)

Rapid weight loss

Family feeding goals

PMAD

Perinatal Mood and Anxiety DisorderCheck EPDS score

Shared decision making – avoid paternalistic approach

Reassess goals

How important is breastmilk only for feeding?Exclusive pumping- nightmare or relief?

INCLUSIVE BREASTFEEDING

You aren’t defined by how many ounces you make

Pressured feeding can lead to oral aversion

Feeding trauma

What happened with previous children?

Transmitting concern without trauma is challenging

Social Determinants of Health

Return to work/school

- Infant becomes a “project”- Less direct breastfeeding

Breast pump

- WIC pump- Private insurance

DME companies

Family support

- Caregivers are bottle feeding

- No help at night

Specialist appts

- Cost and travel to appointments

- Out of pocket for some services

- Copays

Treatment Plan

More emptyingReferrals for DMX

Labs for parentFeed more milk

4

1

2

3

Fix the fixables

Lactating parentInfant

While homeWhile separatedPin down details

Detailed history

Newborn screen results, sweating with feeds, bloody

stools, renal disease,vomiting, dysmorphic features, recurrent infections

ROSShows true concerning

pattern

Growth chart

Best galactogogue

GOOD EMPTYINGFREQUENT EMPTYING

- cookies: time sink, eat any calories, pump more- Pills: no quick fix plenty of side effects (Reglan, Domperidone)- Herbs: expensive, know what you are treating- Nasal oxytocin: tachyphylaxis, challenging to find

Effectiveness depends on how far into apoptosis the lactocytes/alveoli/quadrants/breast have gone

Treatment Booby Traps

❑ Pump volume for 24 hours does NOT equal what infant is taking in. Breasts can hold more than infant removes and not all parents can let down as well for pump as infant

❑ Adding unsterile formula powder to breast milk does not solve a volume problem and adulterates the milk

Give formula mixed with water properly if there is low milk production and there is none of parent’s own milk to use

❑ When there is extra milk – don’t use formula – feed it directly and can Lactoengineer excess frozen milk: thaw in fridge, fat separates out, scoop with spoon and add to bottles the next day

o Extra milk beyond normal volume,

fresh or thawed frozen milk

o Set aside 3+ ounces of milk in

wide opening container (closed lid)

for 24 hours in fridge

o Scoop out fat spoon or spatula

add to one bottle of EBM per day

o Label the remaining milk for other

purposes (eczema, etc.)

● Works with oversupply and those who pump

● Divide a typical pump session time (in minutes) into thirds

● First 2/3rd of time collect & freeze for later

● Remaining 1/3rd of time collect and feed to infant

Lactoengineering

ACTIVE (skimming) PASSIVE (hindmilk)

Lactoengineering, hindmilk, crematocrit references

1. Meier, P., Engstrom, J., Murtaugh, M. et al. Mothers' Milk Feedings in the Neonatal Intensive Care Unit: Accuracy of the Creamatocrit Technique. J Perinatol 22, 646–649 (2002). https://doi.org/10.1038/sj.jp.7210825

2. S. Zibadi, R.R. Watson and V.R. Preedy (eds.) Handbook of dietary and nutritional aspects of human breast milk Human Health Handbooks no. 5 – DOI 10.3920/978-90-8686-764-6_11, © Wageningen Academic Publishers 2013 (Pages 193-213)

3. Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities, 3rd Ed. Pediatric Nutrition Practice Group; Caroline Steele, MS, RD, CSP, IBCLC, FAND and Emily Collins, MHA, RD, CNSC, 2019. Chapter Six: “Lactoengineering” pages 113 –128.

Treatment Booby Traps

❑ No such thing as low calorie milk

❑ Maternal diet (short of extreme starvation) does not impact milk quality or calories

❑ Cannot increase fat content of lactating parent’s milk by diet

❑ Fat sticking to bottle: PROBLEM

❑ Fat sticking to feeding tube: HUGE PROBLEM50% of the calories from human milk come from fat Warm the tubing, lechithin, bolus vs. drip

Treatment Booby Traps

❑ Misuse of milk transfer (weighted feeds) measured in office in a single time point

❑ Ounces that breasts “hold” at maximum are not equal to what baby is extracting/drinking

❑ Bottle demand volumes do not correlate with volume removed from breasts with on-demand feeding

❑ Wet diapers have no value after first days of life; stool counts drift lower as the casein: whey changes in the milk

Counsel carefully to avoid trauma

✓ #NQOYWD Never Quit On Your Worst Day

✓ Baby’s growth chart is not a report card on your parenting ability

✓ We will slowly correct this together

✓ Give parents TOOLS in tool belt: they decide which ones work

✓ Reassess with enough time to show change

✓ May have new tracking on lower curve as success

Anticipatory Guidanceto prevent slow growing infant

➢ 1 month WCC: milk volume is almost in steady state, on demand intuitive feeding key to robust supply

➢ 2 mo WCC: milk volume does not go up over time, paced bottle feeding by caregivers; rigid schedules not good

➢ Most WCC: sleep expectations, need 1-3 overnight feeds through first year of life depending on MAGIC # (storage capacity). Don’t give advice for unicorn breasts.

➢ Sleep training to go long stretches overnight will lower milk supply unless parent wakes to pump or dream feed.

Self-directed learning

www.lacted.org ** Non-profit ** “IABLE” Institute for the Advancement of Breastfeeding Lactation Education

1 hour, 3 hour, 8 hour, 2 day, 4 day courses GIVEN BY PHYSICIANS for physicians; “Little Green Book of Breastfeeding” for physicians

LactFact app, Podcasts, case series webinar Sunday nights, FREE & low cost to residents and medical students

www.bfmed.org Academy of Breastfeeding Medicine physician organization PROTOCOLS! Don’t reinvent the wheel. Annual meeting: great place for resident/student poster presentations!

International membership.

www.infantrisk.org

Never ever say pump and dump without looking (app) or calling.

Online communities

Dr. MILK on Facebook- helping physician (MD/DO/MBSS) parents reach breastfeeding goals- 31,000+ members from around the world- cis-gendered men not allowed in the group

Doctors Practicing Breastfeeding Medicine - on Facebook - how to incorporate BF into your practice- pursuing IBCLC or FABM- practice management- complicated cases you’ve seen - all genders/nonbinary welcome in this group

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