Pediatric Primary Care Case Studies, 1st Ed.

Chapter 8. The Breastfed Infant Who Is Not Gaining

Pamela J. Hellings

Breastfeeding is a learned skill. Not infrequently, mothers encounter feeding difficulties that may result in slow weight gain for the baby. The challenge is to separate the common problems from the more complex issues. Slow weight gain cannot be dismissed as simply poor feeding technique in the early post-partum days. The provider must consider and eliminate other possibilities through a knowledgeable and thoughtful history and physical examination process.

Educational Objectives

1.  Recognize issues associated with slow weight gain in a newborn infant.

2.  Manage the feeding issues to maintain breastfeeding whenever possible.

3.  Provide appropriate follow-up to assure adequate nutrition and weight gain in the infant and to support the family.

  Case Presentation and Discussion

You pick up a message that Mrs. Jackson called one hour ago. She gave birth 8 days ago to her first child, a male infant, Peter. She did not keep her 3-day follow-up appointment at the clinic because she was “too exhausted” after delivery. She is breastfeeding but is worried that he is not getting enough to eat.

What further information would be helpful at this point? image

In order to make the decision regarding the need for follow-up, a description of the feeding frequency and duration as well as a wet diaper and stool count would be helpful.

You call her back and she reveals that Peter is eating five to six times per day for 20 to 30 minutes total and is sleeping most of the rest of the time. He has had four wet diapers in the last 24 hours and no stool in 72 hours. You ask her to bring Peter in for a status check.

Table 8–1 After Breastmilk Comes In: How to Tell If Infant Is Getting Enough

Infant should:

 

Nurse at least 8 times in 24 hours, although 10–12 times is more common

 

Seem satisfied after feeding

 

Have at least six wet diapers with light yellow or colorless urine

 

Have four or more bowel movements per day

 

Have yellow and curdy, cottage cheese–like stool

 

Swallow loudly

 

Breasts should:

 

Feel full before a feeding and softer after a feeding


 

Your criteria for adequate breastfeeding are as follows: At 8 days old, a baby should be feeding 8 to 12 times in 24 hours for a minimum of 10 to 15 minutes per side. In addition, he should be stooling three to four times daily and voiding light yellow urine at least six to eight times (see Table 8-1).

You are concerned so you fit them into the day’s schedule. She arrives one hour later with Peter and her husband. You do not have any information on this patient because this will be their first visit to your practice.

Breastfeeding Support

In addition to the indicators that Peter is not feeding adequately, there are also other reasons for bringing in the Jackson family at this point. The transition to successful lactation often requires providing support and information for families. Even in the absence of significant problems, a review of technique and expectations for breastfeeding and evaluation for maternal breast comfort are warranted. Among the most common reasons given for stopping breastfeeding are perception of inadequate milk production and sore nipples (Schwartz et al., 2002). The 3-day visit provides an important opportunity to address these issues. However, the Jackson family missed that appointment, so now is the time to assess the situation and provide needed support and/or intervention.

Professional healthcare organizations recommend exclusive breastfeeding for 6 months (American Academy of Pediatrics, 2005; National Association of Pediatric Nurse Practitioners, 2007); the Healthy People 2010 goal (Healthy People, 2000) is for 50% of babies to continue to be breastfed at 6 months of age.

First Visit

What information do you want to collect now? image

The history-taking process for breastfeeding problems needs to include gathering key information about the baby, the mother, and breastfeeding activities in areas where problems may interfere with adequate weight gain.

The measurements were taken and the baby weighs 6 pounds 6 ounces today. You now enter the room and find a sleeping baby in the arms of a worried looking mother. Mr. Jackson also appears somewhat somber. Mrs. Jackson provides you with the following information.

Infant, Mother, and Breastfeeding History

Birth History. The baby was born at 37 weeks and was a 6-pound 13-ounce male infant. There were no complications for mother or baby after a vaginal birth and an uneventful first pregnancy for this 27-year-old woman. Mother and baby were discharged together at 48 hours. The baby was sleepy during hospitalization, but nurses observed two feedings and did not report any problems. The discharge weight was 6 pounds 6 ounces (7% weight loss). The family was given a follow-up clinic appointment for 3 days after discharge but they did not attend.

Key information in this history: Peter’s history to date has been uncomplicated by any notable problems. However, his birth at 37 weeks (near preterm) and his 7% weight loss, although within normal limits, are important to note. (See Table 8-2.)

Feeding history. Mr. Jackson has been trying to help keep Peter awake during feeding attempts. They have to wake the baby for feedings and stimulate him to keep him awake. They are successful every 4+ hours. Peter generally feeds for 20–30 minutes but a lot of that time is spent in waking him up. Mrs. Jackson reaffirms that he has had four to five wet diapers (disposable) in the last 24 hours and no stool for 3 days. The last stool was green, pasty, and smooth in texture. She has seen him urinate during a diaper change and describes a strong stream. Mrs. Jackson thinks maybe she feels her let-down but does not hear any loud swallows from Peter during feeding. She has leaked breastmilk occasionally but not as much in the last 48 hours. On the second day home, she experienced some engorgement but Peter continued to nurse and her breasts became less hard. Her nipples are a little sore but she has not experienced any cracking or bleeding.

Table 8–2 Infant Problems That May Affect Weight Gain

Infections

 

Endocrine/metabolic problems

 

Abnormalities of mouth or throat

 

Congenital heart disease

 

CNS problems

 

Near preterm status

 

Table 8–3 Technique Problems That May Affect Weight Gain

Infrequent feeds

 

Inadequate postejection suckling time

 

Ineffective suckling (poor latch or flutter sucking)

 

The parents have been grateful that Peter has been such a great sleeper for the past few days because they now are getting more sleep than they expected. However, in the last 2 days they have begun to worry that he may not be getting enough to eat. Peter’s maternal grandmother says he looks “skinny” and has recommended that they supplement with formula. They want to breastfeed and have resisted supplementation so far. Peter’s last feeding was 2.5 hours ago.

Key information in this history: The infrequent and less than vigorous feedings are important to note. The lack of audible sounds of swallowing are also concerning. Finally, the absence of stool for 72 hours provides an indication that Peter is not getting enough breastmilk to gain weight. (See Table 8-3.)

Mother’s related history. Mrs. Jackson has some allergies to pollens and dust but takes no prescription or over-the-counter medication on a regular basis. She denies any other chronic illnesses or conditions. She has not had any surgery other than an appendectomy at age 13 years. The pregnancy was uneventful and uncomplicated with routine prenatal care beginning in the first trimester. Her vaginal bleeding has stopped. She plans to use progestin-type birth control pills beginning at 6 weeks postpartum. She has been drinking lots of fluids and eating well in order to provide milk.

Key information in this history: Mrs. Jackson is healthy by history. The lack of any chronic illnesses or surgery to the breasts or thorax is encouraging. In addition, she is not using any medications routinely and there is no evidence of hormonal influences from retained placenta or contraceptives. (See Tables 8-4 and 8-5.)

Other than the feeding concerns, Mr. and Mrs. Jackson have no other questions about Peter at this time.

What will you look for on the physical examination given the history to this point? image

Table 8–4 Drugs That May Decrease Milk Supply

L-dopa derivatives

 

Ergot compounds such as bromocriptine

 

Large doses (> 600 mg/day) vitamin B6 (pyridoxine)

 

Estrogen

 

Nicotine

 

Table 8–5 Maternal Problems That May Affect Infant Weight Gain

Chronic illnesses

 

Certain medications (see Table 8-4)

 

Drug or alcohol abuse

 

Smoking

 

Endocrine problems, especially involving the thyroid

 

Breast surgery

 

Anatomical problems including inadequate mammary gland development

 

Fatigue or stress

 

Inability to “let down”

 

Inadequate diet

 

Retained placenta

 

Physical Examination

You move on to the physical examination of Peter. Your examination reveals a baby with decreased fat distribution over his face, abdomen, and extremities but no evidence of dehydration. He is quietly alert at this time. He appears somewhat pale without any signs of jaundice. He weighs in at 6 pounds 6 ounces. His temperature taken in the axilla is 98°F. He has good tone and responds to light and sounds. His heart rate is regular, and no heart murmur is heard. Femoral pulses are palpable and equal. His lungs are clear. His mucous membranes are moist, his suck is strong, and his palate intact. His umbilical cord stump has fallen off, and the area is clean and dry. In addition, his circumcision is healing well. He has voided in his disposable diaper and the urine is a light golden color. There is no “brick dust,” an indicator that a baby is not getting enough milk. (“Brick dust” on the diaper results from uric acid crystals forming in concentrated urine). Otherwise his physical examination is unremarkable.

Mr. and Mrs. Jackson become very upset at his weight as they realize he has not gained any weight since discharge. They wonder if they should go and get some formula immediately.

What do you say at this point? image

Peter’s exam is within normal limits with the exception of weight. In addition, there are indicators supporting inadequate weight gain but not the more serious failure to thrive. You share this information with the Jacksons in a supportive manner and urge them to stay calm while you proceed with the breastfeeding evaluation.

What will you look for on your breastfeeding evaluation? image

Breastfeeding Observation

Prior to observing a feeding, you examine Mrs. Jackson’s breasts. Her breasts are slightly firm with nipples that appear somewhat flat but evert with tactile stimulation. There are no cracks or bleeding visible. You are able to hand express drops of milk from both breasts.

Observation of a breastfeeding session reveals that Peter latches on successfully but starts to get drowsy fairly quickly. Positioning is adequate in the “cradle” position but Mrs. Jackson is reminded to keep him “tummy to tummy” as Peter falls away from the breast as he goes to sleep. Mr. Jackson attempts to help by talking to Peter and stroking his back. Meanwhile, Mrs. Jackson makes a few attempts to wake him but then gives up and shrugs her shoulders as if to say that this is typical. When removed from the breast and stimulated with a cold wet washcloth on his trunk, Peter wakes up again. Regular stimulation with gentle but persistent scratching to the soles of his feet and top of his head helps him stay with feeding. Periodically Peter is taken off, given additional stimulation, and switched to the other side if he does not respond to wakening techniques at the breast. He ends up at the breast for more than 30 minutes—most of which is alert feeding. He has gone back and forth twice to each breast. Some loud swallows are heard briefly at the beginning on each side. After feeding, he weighs 6 pounds 8.5 ounces on the same scale he was weighed on prior to your seeing him, a gain of 1.5 oz. Mom and dad are somewhat relieved by this news.

Making the Diagnosis

Given the histories of the mother and baby as well as the feeding history, the physical examination, and breastfeeding assessment/observation, the problem appears to be slow weight gain.

In assessing slow weight gain, a helpful way to approach the evaluation is to identify risk factors that are mother-related, infant-related, and/or technique-related (Lawrence & Lawrence, 2005). In this case, the mother has no chronic illness, takes no medications routinely, and her vaginal bleeding has stopped. Her breast exam reveals no significant issues as her nipples evert with stimulation, there are no cracks or bleeding, she is not engorged, and breastmilk is expressible from both breasts. There are no red flags for maternal health issues other than that she is a first-time mother and seems unclear about expected feeding frequency and output. She is producing milk for her baby.

The baby is afebrile and not visibly jaundiced. Key information obtained includes the following:

•  Special attention should be paid to evaluation of the heart to rule out congenital heart disease that may not have been apparent before hospital discharge. There is no murmur and his pulses are normal.

•  The suck is strong, and the palate is intact. Submucosal clefts can result in poor weight gain and need to be ruled out.

•  This baby has no evidence of positive physical findings related to infection, hyperbilirubinemia, or dehydration.

•  However, this baby was born at 37 weeks and should be considered a “late preterm infant.” Sleepiness and slow feeding are common in the slightly preterm infant, despite a healthy birth weight and absence of other problems associated with prematurity (Meier, Furman, & Degenhardt, 2007).

The technique issues are primarily related to feeding frequency and duration, although inefficient suckling with inadequate milk transfer must also be considered. Mrs. Jackson is using proper positioning and gets latch-on with little difficulty. Peter gained 1.5 ounces after an alert and persistent feeding. That is very good news, and seems to confirm that his lack of weight gain is likely not related to health problems for him or his mother.

Successful breastmilk production is based on supply and demand. Regular, frequent stimulation with a successful latch, routine emptying of the breast, and the release of maternal hormones aid in the establishment of an adequate milk supply to sustain infant growth (Hellings, 2009). Peter has not been feeding the expected 10–12 times in 24 hours, and quality feedings have been of short duration.

After consideration of the possibilities, the most likely expanded diagnosis is slow weight gain due to inadequate feeding frequency and duration.

Management

The Jacksons are sent home with instructions to feed Peter every 2–3 hours for the next 24 hours and to use the awakening techniques demonstrated. They are reminded to set an alarm if necessary to wake themselves and to count the interval between feedings as the time from the start of one feeding to the start of the next. They are asked to keep a diary of feedings—time feeding started, duration, and a statement about quality of the feed—and number of voids and stools. Finally, they are asked to return tomorrow to check on progress. Mr. and Mrs. Jackson indicate that they think this is something they can do for 24 hours and they both state they really want the baby to be breastfed.

Important Considerations in Making the Management Plan

It is good that the parents came in so soon and that the mother’s supply does not appear to have markedly decreased at this time. The weight gain associated with the feeding in the clinic also provides support for sending the family home with clear instructions regarding feeding. Supplementation is not necessary at this time; however, early follow-up to make sure that Peter continues to gain weight is very important.

Follow-Up Visit #1

The Jacksons return the next afternoon. They look tired and state they did not get much sleep last night. However, they think Peter has been doing better with feedings. In reviewing their diary, you note the feeding frequency and duration, wet diaper counts, and stool output. They still have to stimulate him a bit, but he has fed nine times in the last 24 hours. He had one large, loose, curdy, slightly greenish stool at 5 a.m. You commend them for their efforts. Mrs. Jackson does state that her nipples are sorer than yesterday. They are anxiously awaiting his weight check to see if their feeding efforts have been successful.

Important considerations in the follow-up examination: Peter’s general appearance is important to note. In addition, he should be weighed on the same scale as yesterday. A full physical examination was completed yesterday and need not be repeated today.

Physical Examinations of Infant and Mother

Peter is alert and responsive. His cheeks look fuller. He weighs 6 pounds 9 ounces, an overall gain of 2 ounces in 24 hours. Mrs. Jackson says that her breasts feel fuller between feedings.

As Mrs. Jackson prepares to feed Peter, you examine her breasts again. You note some redness and a chapped appearance on the nipples. There is no cracking or bleeding. You review positioning and latch-on techniques with her as she puts Peter to breast. She states that she can feel the difference between a good latch and a poor one as you take him on and off several times to secure a good latch. You advise her to reposition him if the latch is painful rather than trying to ignore the pain. She finishes feeding Peter before they return home with another scheduled weight-check appointment in 2 days and instructions to call with any questions.

Peter has gained 2 ounces in 24 hours and has stooled once. The frequent feedings with poor technique at times has resulted in some increased nipple tenderness and irritation for Mrs. Jackson. With better technique and continued attention to feeding frequency and duration, the parents can go home and continue with the plan.

Follow-Up Visit #2

Mrs. Jackson is smiling and feeling confident that he has gained more weight. She states that her husband had to return to work so she came alone this time with Peter. He is 11 days old and is waking up now on his own to feed and fed 10 times in the last 24 hours. He stooled three times in the last 24 hours and the most recent one was runny, yellow-orange in color, and very curdy. She states that her nipples are less sore and admits that she did not set the alarm last night. Peter awakened on his own every 2 to 2.5 hours, with one stretch of 3 hours during the night.

Physical Examinations of Infant and Mother

Mrs. Jackson’s nipples no longer have a chapped appearance but are still a little red. The skin remains intact. Her breasts are full, and she begins to actively leak milk during her exam. She puts Peter to breast with no difficulty, and he begins to feed vigorously with audible swallows.

Peter is awake and alert during the feeding. He requires no stimulation to keep feeding. He weighs 6 pounds 14 ounces, 1 ounce above birth weight and 5 ounces more than 2 days ago.

Because he is feeding well, you go ahead and get the second metabolic screening test done. Mrs. Jackson is really happy and gets out her cell phone to call her husband and share the news.

Peter gained 5 ounces in 2 days, more than the ½ to 1 ounce per day gain usually expected. He has been gaining at a “catch-up” rate. He is likely to continue at this rate for only a few more days and will then slow down to the normal expected daily weight gain. He has reached birth weight, an important milestone. Peter should return in 1 week to make sure he continues to gain weight. The parents should be encouraged to call with questions and are provided with information about how to assess if he is getting enough breastmilk.

What problems were avoided by this quick intervention and what could have been done preventively to avoid this breastfeeding problem? image

This case study details a common clinical scenario in pediatric primary care. This time, there is a happy ending with a baby gaining weight on exclusive breastfeeding and with more confident parents. The story might have played out differently if the parents had delayed seeking assistance or if the mother’s milk supply had been more compromised.

The problems might have been avoided if early assessment at the 3-day postdischarge visit had taken place and the slow feeding identified and managed. It is imperative to emphasize to parents the importance of that early follow-up visit, especially for the breastfeeding family. In addition, providing verbal and written information regarding expectations for breastfeeding and urine/stool output at the time of discharge from the hospital can be very helpful to parents, especially first-time parents, as they begin to care for their newborns (see Table 8-6).

In the assessment process for each individual patient, other problems might be found that suggest more complex health concerns for mother or baby. The need to carefully consider potential risk factors for insufficient infant weight gain is an important part of an initial breastfeeding visit.

Key Points from the Case

1. Early follow-up of breastfeeding families and assessment/identification of problems are important for supporting successful breastfeeding.

2. Common breastfeeding problems do not always require the services of a lactation consultant. However, primary care providers need to have a knowledgeable approach to the assessment and management process.

3. The assessment process includes recognition and identification of problems in the baby, mother, and breastfeeding technique.

4. Management strategies for slow weight gain must take into account issues for the baby, the mother, and breastfeeding technique.

Table 8–6 Guidelines for Breastfeeding in the First Few Days

image

REFERENCES

American Academy of Pediatrics. (2005). Breastfeeding and the use of human milk. Pediatrics, 115, 496–506.

Healthy People 2010. (2000). National health promotion and disease prevention objectives. DHHS Pub. No. 91-50213. Washington, DC: Government Printing Office.

Hellings, P. (2009). Breastfeeding. In C. Burns, A. Dunn, M. Brady, N. Starr, & C. Blosser (Eds.), Pediatric primary care (4th ed., pp. 235–252). St. Louis, MO: Saunders Elsevier.

Lawrence, R. A., & Lawrence, R. M. (2005). Normal growth, failure to thrive, and obesity in the breastfed infant. In R. A. Lawrence, R. M. Lawrence (Eds.) Breastfeeding: A guide for the medical profession (pp. 436–447). Philadelphia: Elsevier Mosby.

Meier, P., Furman, L., & Degenhardt, M. (2007). Increased lactation risk for late preterm infants and mothers: Evidence and management strategies to protect breastfeeding. Journal of Midwifery and Women’s Health, 52, 579–587.

National Association of Pediatric Nurse Practitioners. (2007). NAPNAP position statement on breastfeeding. Journal of Pediatric Health Care, 21(2), A39–A40.

Schwartz, D., Arcy, H., Gillespie, B., Bobo, J., Longeway, M., & Foxman, B. (2002). Factors associated with weaning in the first 3 months postpartum. Journal of Family Practice, 51(5), 439–444.

Thilo, E. H. & Townsend, S. F. (1996). Early newborn discharge: Have we gone too far? Contemporary Pediatrics, 13, 29–46.