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Elaine Webber DNP, PPCNP-BC, IBCLC

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Presentation on theme: "Elaine Webber DNP, PPCNP-BC, IBCLC"— Presentation transcript:

1 Elaine Webber DNP, PPCNP-BC, IBCLC
Managing Slow Weight Gain in the Breastfed Infant Assessment & Management Strategies Elaine Webber DNP, PPCNP-BC, IBCLC

2 Weight Gain Concerns 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

3 Failure to Thrive (as defined by Ruth Lawrence)
Weight loss after 10 days Birth weight not regained by three weeks Rate of weight gain below 10th% beyond one month of age

4 Slow Weight Gain Weight gain slow but consistent
Weight, length and HC proportional Developmental milestones normal

5 Differentiating Slow Weight Gain and Failure to thrive
Infant who is slow to gain weight Alert Good muscle tone At least six wet diapers/day Pale, dilute urine Stools frequent, seedy (or if infrequent, large and soft) Eight or more nursings/day of active feeds Weight gain consistent by slow Infant with failure to thrive Apathetic or crying Poor tone Poor turgor Few wet diapers “Strong” urine odor Stools infrequent, scanty Fewer than eight feedings, often brief No evidence of milk-ejection reflex (no swallowing noted) Weight erratic, may be losing weight

6 Normal Growth Initial weight loss Expected weight gain
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

7 Is there really a problem?
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

8 Etiology of the Problem

9 Evaluation of the Infant
Underlying physical problems Metabolic conditions Congestive Heart Failure Cystic fibrosis Mechanical Abnormalities of the Mouth Ankyloglossia Short tongue Bubble palate Tight jaw

10 Evaluation of Infant (cont.)
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,

11 Mechanical factors interfering with sucking Disorders of swallowing
Conditions associated with or causing disorders of sucking and swallowing Absent or diminished suck Maternal anesthesia or analgesia Anoxia or hypoxia High bilirubin Prematurity Trisomy 21 Hypothyroidism Neuromuscular 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)

12 Muscle Tone – a continuum When does it become “abnormal”?
Hypotonia Normal Tone Hypertonia Slightly hypotonic infants may demonstrate: Weak Suck Poor lip closure Frequent slipping off the breast Slightly hypertonic infants may demonstrate: Extended posture Excessive irritability Strong 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.

13 Physiology of Milk Production

14 Prolactin Causes milk production Circadian rhythm
Can be increased by emotional and physical stress Inhibited by dopamine, nicotine and alcohol Pharmacologic stimulation Prolactin levels

15 Oxytocin 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?

16 Lactogenic effects of Prolactin
Modulated by the complex interplay of many hormones System which requires significant exploration when faced with a an unknown cause of poor milk production

17 Endocrine vs. Autocrine Control
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

18 Evaluation of the Mother
Maternal Causes Poor production Pharmacologic Hormonal Anatomic Stress Fatigue Illness Poor Milk-ejection Pain Psychological Potential maternal causes of FTT

19 Maternal Health History
Endocrine History Difficulty conceiving Thyroid problems Pituitary problems PCOS Previous Breast Surgery Prenatal History Breast changes during pregnancy Leaking colostrum

20 Maternal Health History (cont.)
Delivery Length of labor Drugs during labor Epidural Delivery of Placenta Placental fragments Excessive bleeding/hemorrhage Sheehan’s syndrome

21 Maternal Health History (cont.)
Postpartum Stress and exhaustion Maternal illness Maternal medications

22 Lesser known causes of Maternal Low Milk Supply
(Pre)-Diabetes PCOS Mammary Hypoplasia

23 Maternal Physical Exam
Breast inspection Assessment of nipple and areola Scars

24 Nipple and Areola Firm, fibrous breast tissue Nipple protractility
nipple and areolar compressibility Nipple protractility Flat Dimpled Inverted

25 Breast and Nipple Anatomy
Breast Turgor Large Nipples Flat/Fibrous Nipples Inverted/dimpled Nipples

26 Putting It All Together
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

27 Maternal Factors Inadequate Milk Production Positioning
Breastfeeding Mismanagement Positioning Frequency/duration of feeds Engorgement Use of nipple shields Complimentary/supplemental feeds

28 Identify and treat (if possible) hormonal causes
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.

29 Identify and treat (if possible) hormonal causes
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)

30 Inadequate Milk Production
Secondary Factors (Physiologic/psycho-emotional) Maternal Illness/fatigue/diet Mental illness (PP depression) Emotional disturbances Impaired maternal-infant attachment

31 Maternal Factors Impaired Milk Ejection reflex Milk Composition
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

32 Infant Factors Inappropriate Suckling Response Tongue tie
Identify problem Tongue tie Identify provider who will clip NP, ENT, Dentist, etc.

33 Identify milk transfer issues
Uncoordinated suck swallow Active feeding

34 Basic Management Strategies
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!

35 After determining possible causes:
Support/improve mom’s milk supply Increase intake for the baby When to follow up? When to refer?

36 Important Tools Accurate Electronic Scale
Supplemental Nursing System or other tube feeding devises Cup/syringe feeds Nipple Shields Piston Action Electric Breastpump

37 To improve milk production:
Galactagogues: Metaclopromide Domperidone Goat’s rue Fenugreek Brewers Yeast Homeopathics

38 To improve milk production:
Improve Milk Removal Correct latch Correct suck  frequency and/or length of time nursing Discontinue pacifiers

39 Disorganized Suck Leads to  milk removal, then  supply Stategies
Improve latch Finger feed (suck training) SNS Referrals

40 Finger Feed with Syringe

41 Poor Milk Supply Improve Milk Removal Correct suck
 length of time nursing Correct latch

42 Assessing Latch Deep latch Shallow latch

43 Poor Milk Supply Labs Thyroid Prolactin Term pregnancy 200-500ng/ml
During lactation: 1st 10 days up to 500 10-90 days ranges from

44 Galactagogues Metaclopromide (rx required) Fenugreek Brewers Yeast
10mg TID 7-10 days Fenugreek Brewers Yeast Homeopathics Lactuca Virosa Alfalfa Tablets

45 Important Tools - Review
Accurate Electronic Scale Supplemental Nursing System Nipple Shields Piston Action Electric Breastpump

46 Babyweigh Scale

47 Nipple Shields/Breast Shells

48 Expressing Milk

49 Pumping Ask what kind of breastpump After every nursing session
8-10 x daily if not nursing Night-time pumping very important

50

51 Impaired MER Psychological approach Artificial oxytocin

52 Increasing Overall Intake
Get rid of the pacifier!!! Switch nursing Takes advantage of MER Bring baby into bed throughout the day

53 Increasing Caloric Intake at Breast
Frequent feeds One sided feeds  fat content of milk Lengthy active feeds Pump first to elicit MER Maternal diet

54 Monitoring Progress 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

55 Good Office Resources 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


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