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 StrategiesElaine Webber DNP, PPCNP-BC, IBCLC
2 Weight Gain Concerns Approached in orderly diagnostic process Complete history and PEDetails of feedingObservation of feedingAppropriate labsData organizationWill help identify factors that appear under maternal and infant cases separately
3 Failure to Thrive (as defined by Ruth Lawrence) Weight loss after 10 daysBirth weight not regained by three weeksRate of weight gain below 10th% beyond one month of age
4 Slow Weight Gain Weight gain slow but consistent Weight, length and HC proportionalDevelopmental milestones normal
5 Differentiating Slow Weight Gain and Failure to thrive Infant who is slow to gain weightAlertGood 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 slowInfant with failure to thriveApathetic 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
6 Normal Growth Initial weight loss Expected weight gain Normal 7-10% of birth weightWhat 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 chartsBreastfed infants grow more rapidly first 2 months of lifeLess rapidly from 3-12 monthsWeight gain only one parameterLength and HC also importantFamilial considerations
9 Evaluation of the Infant Underlying physical problemsMetabolic conditionsCongestive Heart FailureCystic fibrosisMechanical Abnormalities of the MouthAnkyloglossiaShort tongueBubble palateTight jaw
10 Evaluation of Infant (cont.) Neurologicability to root, suck and coordinate swallowsAcute infectionsSeptic, GI issuesChronic fetal infectionsCMV, HIV, Toxoplasmosis, etc.High energy requirementsSome 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 swallowingAbsent ordiminished suckMaternal anesthesia or analgesiaAnoxia or hypoxiaHigh bilirubinPrematurityTrisomy 21HypothyroidismNeuromuscular abnormalityWerdnig-HoffmannMuscular dystrophyCentral nervous system infectionsToxoplamosisCMVMeningitisMechanical factors interfering with suckingMacroglossiaCleft lipFusion of gumsTumors of mouth or gumsAnkylossia (tongue or labial)Disorders of swallowingChoanal atresiaCleft palateMicrognathiaPost-intubation dysphagiaPharyngeal tumorsFamilial dysautonomiaAdapted from Lawrence & Lawrence (2005)
12 Muscle Tone – a continuum When does it become “abnormal”? Hypotonia Normal Tone HypertoniaSlightly hypotonic infants may demonstrate:Weak SuckPoor lip closureFrequent slipping off the breastSlightly hypertonic infants may demonstrate:Extended postureExcessive irritabilityStrong bite reflexNote 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.
14 Prolactin Causes milk production Circadian rhythm Can be increased by emotional and physical stressInhibited by dopamine, nicotine and alcoholPharmacologic stimulationProlactin levels
15 Oxytocin Released from the posterior pituitary Immediate reaction to nipple stimulationCauses contraction of smooth muscle epithelial cells surrounding the mammary alveoliLargely influenced by psychologicalfactorsPharmacologic stimulation?
16 Lactogenic effects of Prolactin Modulated by the complex interplay of many hormonesSystem 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 releaseEventually prolactin levels decline and milk production is governed by milk removalEarly stimulation and milk removal are essential in the establishment and continuation of a robust milk supply
18 Evaluation of the Mother Maternal CausesPoor productionPharmacologicHormonalAnatomicStressFatigueIllnessPoorMilk-ejectionPainPsychologicalPotential maternal causes of FTT
19 Maternal Health History Endocrine HistoryDifficulty conceivingThyroid problemsPituitary problemsPCOSPrevious Breast SurgeryPrenatal HistoryBreast changes during pregnancyLeaking colostrum
20 Maternal Health History (cont.) DeliveryLength of laborDrugs during laborEpiduralDelivery of PlacentaPlacental fragmentsExcessive bleeding/hemorrhageSheehan’s syndrome
21 Maternal Health History (cont.) PostpartumStress and exhaustionMaternal illnessMaternal medications
22 Lesser known causes of Maternal Low Milk Supply (Pre)-DiabetesPCOSMammary Hypoplasia
23 Maternal Physical Exam Breast inspectionAssessment of nipple and areolaScars
24 Nipple and Areola Firm, fibrous breast tissue Nipple protractility nipple and areolar compressibilityNipple protractilityFlatDimpledInverted
25 Breast and Nipple Anatomy Breast TurgorLarge NipplesFlat/Fibrous NipplesInverted/dimpled Nipples
26 Putting It All Together Management of FTT or slow Weight GainComplex cause-and-effect relationshipDirect attention to both mother and babyThere is NO substitute for direct observation of the breastfeeding couplet
27 Maternal Factors Inadequate Milk Production Positioning Breastfeeding MismanagementPositioningFrequency/duration of feedsEngorgementUse of nipple shieldsComplimentary/supplemental feeds
28 Identify and treat (if possible) hormonal causes Measuring ProlactinVaries based on stage of lactationDraw baseline (prior to a feed), then 45 minutes after nursing or pumping to measure the surgeIn early months; should at least doubleIf cost an issue – baseline is more importantAdapted from Lawrence & Lawrence 2005.
29 Identify and treat (if possible) hormonal causes PCOSMetformin –Informal feedback- variable impact on milk productionDosages vary (500mg-2500mg daily)Goat’s RueHypothyroidBe alert for “low normal” TSH and T3Has been correlated with low milk productionLow thyroid during pregnancy should always be rechecked after delivery (2 weeks, 4-5 weeks)
31 Maternal Factors Impaired Milk Ejection reflex Milk Composition Primary factors (pituitary disease, surgery)Secondary factors (pain, smoking, alcohol, meds)Milk CompositionVegan dietExtreme maternal malnourishment (can also lead to decreased milk production)Low fat content of milk
32 Infant Factors Inappropriate Suckling Response Tongue tie Identify problemTongue tieIdentify provider who will clipNP, ENT, Dentist, etc.
33 Identify milk transfer issues Uncoordinated suck swallowActive feeding
34 Basic Management Strategies Diagnose the problem (methodical)Remember interplay of various conditionsVarious problems can lead to same effectDon’t make assumptionsEvaluate Mom and baby andOBSERVE THE FEEDING!
35 After determining possible causes: Support/improve mom’s milk supplyIncrease intake for the babyWhen to follow up?When to refer?
36 Important Tools Accurate Electronic Scale Supplemental Nursing System or other tube feeding devisesCup/syringe feedsNipple ShieldsPiston Action Electric Breastpump
37 To improve milk production: Galactagogues:MetaclopromideDomperidoneGoat’s rueFenugreekBrewers YeastHomeopathics
38 To improve milk production: Improve Milk RemovalCorrect latchCorrect suck frequency and/or length of time nursingDiscontinue pacifiers
39 Disorganized Suck Leads to milk removal, then supply Stategies Improve latchFinger feed (suck training)SNSReferrals
52 Increasing Overall Intake Get rid of the pacifier!!!Switch nursingTakes advantage of MERBring baby into bed throughout the day
53 Increasing Caloric Intake at Breast Frequent feedsOne sided feeds fat content of milkLengthy active feedsPump first to elicit MERMaternal diet
54 Monitoring Progress Scale rental for home use Expectation for weight gainWeight checks (don’t wait too long)daily, q other day, weeklyPhone contact and encouragement
55 Good Office ResourcesMaking 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