Expert: Sally Wendkos Olds - 11/29/2008

Question
QUESTION: My daughter is 5 months old and just last week I noticed that she was looking a little thin and her ribs were a little more noticeable. I took her to the health unit and weighed her and found that she had lost 13 oz in 3 weeks. At her 4 month shots she weighed 12lbs 10oz, 3 weeks later she weighed 11lbs 13oz. When I weighed her the second time, it was on the same scale as at her shots.  I took her to A doctor (not her doctor, too long of a wait) and she wasn't concerned, she just told me to up the feedings or add formula. I don't want to introduce formula as I'm afraid it will mess with my supply.  She is not lethargic or fussy, she is very happy and active. The only thing that made me wonder about her weight was that her ribs were more noticeable.
Is there any reason for this? I am breastfeeding her exclusively. We were supplementing for the first while, but since she was 3 months we have BF exclusively. Is there something wrong with my milk? Is it time for solids?

ANSWER: Dear Jennifer,

First, congratulations for giving your daughter the best start in life by breastfeeding her!

I agree with you that your baby's weight loss is of concern. It's quite unusual for a baby of this age to lose weight. I suggest that you go to her own doctor and tell him or her that you need to see him/her soon. This doctor knows your baby and is in a better position to evaluate her than is a doctor who has not seen her before.

Meanwhile, I suggest that you nurse her more frequently to build up your milk production. You can also pump your breasts to remove more milk. You can then save this milk to use as a supplement.

And you can also start solids. Many pediatricians start solids at 4 to 6 months, and your daughter is well within that range.

After your baby's doctor has seen her and weighed her, she/he may recommend that you supplement her nursing with formula. But the doctor may want to wait until you try these other measures first.

The most important thing is taking your daughter to her doctor very soon. An examination may show some reason for her weight loss.

Good luck! And I would like to hear how your daughter is doing.

Regards,

Sally
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Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with pediatrician Laura M. Marks, M.D.




---------- FOLLOW-UP ----------

QUESTION: I did see a doctor and she has continued to lose another 3 ounces since the last time I wrote. The doctor recommended that I supplement with formula because she is quite underweight. I understand and am supplementing. But I'm not sure how much or how often to supplement. The first night I fed her as much as I 'thought' I could give her of my breastmilk...she just stopped eating. Then i put 4 1/2 ounces of formula into a bottle to see how much she'd take. She ate 3 ounces. The next morning, I did the same thing and she ate about 2 oz.
This Friday, Dec 5, I go to see HER doctor finally...he's hard to get into. I'm hoping that she will have gained. So far I am giving her 6 ounces of formula broken up through out the day, after I breastfeed her. I don't know if that is a good amount and I'm scared my milk supply will dwindle to nothing.
When I look back over this past month, she did have her 4 month growth spurt, but it only lasted a day as opposed to her regular 3-5 day binges like before. That's the only thing that I can think as to why i'm not able to feed her completely. I don't know if I didn't make myself available enough, or if something else happened, but I remember it being a very easy growth spurt...and then she started losing weight.
What do you recommend for a good feeding schedule with "combination feeding"? I did try to increase my milk supply, but it didn't work I guess.
Thanks so much for helping.

Answer
Dear Jennifer,

I'm glad to hear that you will be taking your baby to her own doctor very soon. That's a little worrisome that he's so hard to get an appointment with, even in a situation like this.

Many lactation consultants and doctors,including Dr. Laura Marks (see below) now recommend that when a baby needs supplementation with formula that you give the bottle first -- and then offer your breast. That way she may get a feeling of satisfaction from the breast and not grow to prefer the bottle, but meanwhile she will be getting more nourishment.

I am attaching some information about techniques for bottle-feeding that have been suggested by Dee Kassing, a lactation consultant. I hope this helps.

Also, if you have not been pumping your breasts in between feedings, you might do this on a regular basis to increase your milk supply.

Good luck! Let me know what the doctor says after you see him on Friday.

Regards, Sally
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Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with pediatrician Laura M. Marks, M.D.
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  Breastfeeding Support Services, Inc.
  302 Chesapeake Lane
  Collinsville, Illinois 62234-4344
  618-346-1919


BOTTLE-FEEDING THE BREASTFED BABY
Dee Kassing, BS, MLS, IBCLC, RLC

1.   Use straight bottle, not bent.

2.   Use bottle with small-mouthed opening, not a disposable or wide-mouthed bottle.

3.   Nipple should have an old-fashioned long, round shape.  The base of the nipple should be about 1 inch (25 mm.) across, and the base should preferably be tapered, not bulbous.  The nipple should not be orthodontic, stubby, or shaped like a miniature human breast.

4.   Nipple should be a slow-flow nipple, unless otherwise directed by the lactation consultant.

5.   Support baby in an upright position.  Babies younger than two months will usually need support for the lower back.  This can be accomplished by the caregiver crossing her/his legs and setting the baby on the lower leg with back against higher leg.  Or caregiver can place one foot on a footstool.  If sitting in a chair with high arms, a pillow could be tucked against baby’s back.  Caregiver can support baby’s head and neck by placing the thumb behind one of the baby’s ears and fingers behind the other ear.  Hold head firmly enough to keep baby’s chin up off chest.

6.   Gently brush nipple DOWN over center of baby’s lips.  Pull nipple away from face and center nipple in front of baby’s mouth.  Pause.  Wait for baby to open WIDE, like a yawn.  If baby does not open WIDE after pausing, caregiver may repeat downward stroke of nipple.  If baby still does not open WIDE, try gently tapping nipple 2-3 times on baby’s lower lip.  Pull nipple away from face and center nipple in front of baby’s mouth.  When baby opens WIDE, insert nipple all the way into mouth, so baby’s lips touch the collar that holds the nipple onto the bottle.

7.   Tip up bottom of bottle just enough so milk covers the hole in the nipple.  (Healthy full-term babies will pause and breathe on their own.  If you are working with a young premie or a neurologically impaired baby, you may have to periodically tip the bottle so no milk remains in the nipple, to allow the baby to pause and breathe.)

8.   When there is very little food left in the bottle, lean baby’s body back about 45 degrees.  This will keep his head and neck in line, yet allow the bottle to tip for remainder of feeding.

Bottle-feeding baby in this manner should take approximately 15-20 minutes.  If feedings consistently take 30 minutes or longer, please contact your lactation consultant.

For more information about this style of bottle-feeding, see:  Kassing, D.  “Bottle-Feeding as a Tool to Reinforce Breastfeeding.” J Hum Lact 18 (1), 2002.