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Lactation Case Study: Poor weight gain at 5 months

January 17, 2024
Lactation Case Study: Poor weight gain at 5 months
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This is the case of a dyad that I saw where the baby was exhibiting poor weight gain at 5 months after appropriate weight gain previously. I’ll share the background details, my thoughts about the case, and my recommendations and the evidence supporting them.

I’ll deliver this information in the format of an SBAR. SBAR stands for Situation, Background, Assessment, and Recommendations. This charting format is often used in nursing. I teach it to my Pathway 2 students. I think it is a good method for telling a story with the case documentation that enables better hand off and continuity of care when working with other lactation consultants and health care providers.

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Situation

Poor weight gain in exclusively breastfed infant at 5 months of age.

Background

  • Mom is a G3P3. She breastfed her other two children for 12 and 18 months without any problems.
  • Mom has no history of infertility, thyroid, hormone problems, or breast surgeries.
  • Mom collected colostrum antenatally.
  • Baby Boy was born via NSV at 39 weeks weighing 4309 g (9 lbs, 8oz). Lactogenesis II occurred on postpartum day 3.
  • Mom does not work and is home with baby and rarely separated.
  • At 4 weeks, I saw mom due to oversupply. She was using the Haakaa frequently and pumping due to fullness. Baby was fussy, gassy, and having green stools. Baby was choking with letdown. I gave her a care plan to reduce the supply with eliminating pumping and extra milk removal. Within a week the oversupply was resolved and baby continued to nurse well. Baby weighed 6000g at this visit and transferred 95ml easily at the feeding.
  • At 12 weeks baby had been cluster feeding frequently throughout the night and mother decided to sleep train baby. Since then, baby has been sleeping from 6pm to 5am without feeding. Mother has also been sleeping all night without expressing any milk.
  • At 5 months baby went for a routine pediatrician check up. The pediatrician was concerned about baby’s weight and suggested that mom begin offering two 8 oz bottles of formula each day in addition to breastfeeding. Pediatrician did not advise waking baby to feed at night. Mother was very upset about this recommendation and expressed to me that she did not want to give formula. She wants to continue breastfeeding baby for as long as he desires.
  • At this visit with me, baby weighed 7475g and transferred 30ml total after nursing for 3-5 minutes from each breast. Mom reports that she has been taking Milky Mama Pump Hero supplement for the last week. Mother reports that baby nurses every 2 hours during the day for about 5 minutes per side. Mother recently increased to offering both breasts at every feeding. Mother reports baby is generally pretty fussy during the day and doesn’t want to be put down. Baby does not take a pacifier. I confirmed that a dip was not related to mother’s period nor being pregnant.

Assessment

Due to the sudden change in breastfeeding frequency, mother’s supply is very low and baby is not getting adequate milk in the 13 hours per day that he has access to the breast.

Recommendations

  • Babies need to take 750-1050ml (25-35oz)/ 24-hours 1. If I use the feeding that I observed to assess how much baby takes at each feeding, baby takes about 30ml (1oz) 6-7 times/ day for a total of 6-7oz/ 24-hours. It is likely that baby does take a larger volume at some feedings, potentially the early morning feeds, making the 24-hour total larger. However, it is unlikely that he’s taking 4-5oz or more per feeding, getting him close to the 25-35oz that he needs in 24-hours. Since mother is not interested in waking baby for night feeds, baby will need to take more during the daytime to reach his total daily intake needs.
  • Baby already feeds fairly frequently, but mother needs increased stimulation to increase the milk supply.2  Baby refuses to feed longer due to low supply, so I recommended that mom increase stimulation by adding pumping after every feeding for 10 minutes. I encouraged mom to pump as soon as possible after the feeding. I reminded mom that she won’t see much in the pump for the first few days, but if she’s consistent, within 3-4 days she will either start noticing more milk in the pump or baby will start nursing longer, taking more milk.
  • Regarding the herbal supplement (galactagogue), we have little evidence supporting the efficacy of herbal supplements to increase milk supply 3. In this case, I believe it is a self-limiting problem of baby having limited access to the breast and refusing to nurse longer when the supply is low, limiting stimulation and preventing the supply from increasing naturally. I recommended that mom just focus on the increased stimulation to increase supply.
  • I also recommended that mom add one pumping session before she goes to bed, around 9pm.
  • Mother is not interested in supplementing baby with formula. However, I did recommend that she collect any milk from pumping sessions (add frozen milk if needed) to supplement baby at least once per day for the next few days. Mom suggested that she will give a bottle after baby’s last breastfeeding, just before he goes to bed for the night. Mother reported that baby has taken a bottle up to 6oz so she will try to get him to take that.
  • Mother will stick to plan for the next 4 days and we will follow up via phone to evaluate progress. Following the phone update, we will adjust plan if needed and plan for another visit to do a weighted feed and evaluate milk transfer.

Share your thoughts!

Have you worked with a similar case? Do you have any questions that weren't answered here? I'd love to hear from you. Comment below and share your thoughts!

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References

Rios-Leyvraz, Magali, and Qisi Yao. “The volume of breast milk intake in infants and young children: A systematic review and meta-analysis.” Breastfeeding Medicine, vol. 18, no. 3, 2023, pp. 188–197, https://doi.org/10.1089/bfm.2022.0281.

“Milk Volume.” Nutrition during Lactation, National Academy Press, Washington, DC, 1996. https://www.ncbi.nlm.nih.gov/books/NBK235589/

Mortel, Mylove, and Supriya D. Mehta. “Systematic review of the efficacy of herbal galactogogues.” Journal of Human Lactation, vol. 29, no. 2, 2013, pp. 154–162, https://doi.org/10.1177/0890334413477243.