By Sr Teresa Hayward (RM, RN, Lactation consultant, Infant & Paediatric Nutritionist, Baby Sleep consultant)
Sometimes a breastfed baby may struggle to gain weight, either not gaining weight at all or not gaining enough weight to stay on their growth curve. This article looks at the possible reasons for not gaining weight and what to do to get breastfeeding back on track and baby well fed.
It is important to stay in close contact with your Lactation consultant if your baby is not gaining weight as expected, and your baby’s weight should be checked weekly
What are the reasons for a breastfed baby not gaining weight?
#1 Not enough milk – in most cases the reason for not gaining enough weight is because baby is not getting enough milk. Instead of just supplementing milk, it is important to assess why this is happening. There can be a few reasons, but poor latch can be one of them. A Lactation consultant will be able to help you find the reason.
#2 Health issues for baby – Sometimes underlying health issues may be identified as causes. Your Lactation consultant will refer you to your Paediatrician is she suspects this.
#3 One thing leads to another
Once a baby is underweight they can become very sleepy and not very interested in feeding. Or they may seem hungry, but quickly fall asleep at the breast instead of actively feeding. This type of infrequent feeding causes a mother’s milk supply to drop which adds to the problem of low weight gain in a vicious cycle.
Is my baby gaining enough weight?
If your baby is gaining some weight, you may wonder if you really do need to be worried or whether it is within normal limits
Normal gain – a normal weight gain for a breastfed baby is 150g to 200g per week in the first 3months and then an average of 120g per week from 3 to 6mo
Hungry or satisfied?
In addition to monitoring weight gain, it is useful to be aware of some typical characteristics of both an underweight baby and one who is getting enough milk:
The hungry/underweight baby. A baby who has not had enough milk may be tense, with his arms bent at the elbow and held close to his body. He may fall asleep with his hands in tight fists and look worried with a frown on his face. A hungry baby may seem fussy and want to stay at the breast for long periods which may be mistaken for breastfeeding “continuously” but actually he is not actively sucking or swallowing milk. Fussy behaviour or difficulty sleeping might also be attributed to colic, reflux, silent reflux or intolerance to mother’s diet instead of hunger. Alternatively a hungry baby may sleep a lot and be mistaken for a “good baby”. A very underweight baby can have loose skin and facial features that look like a little old man and he may have infrequent wet or dirty nappies. Signs of dehydration include dry lips and mouth, drowsiness, and dark, concentrated urine.
The baby who is full. When your baby has had enough milk or is full to satiety he will usually fall asleep and let go of the breast on his own after a period of active sucking and swallowing. He will have relaxed hands and probably a ‘milk drunk’ satisfied expression. He will have plenty of wet and dirty nappies each day and good weight gain
Next steps
In an ideal situation, your lactation consultant will pick up on genuine poor weight gain, during your visits to the Breastfeeding clinic, starting at around 5 days old. The problem is that most moms do not attend any well baby checks between their Paediatrician visits. The paediatrician will rarely refer to a lactation consultant but will just supplement with formula and give incorrect Breastfeeding advice.
At the breastfeeding clinic, a close eye will be kept on the baby’s weight gain by weighing regularly (e.g. weekly or more often). The Lactation consultant will usually take a full medical history, study the baby’s weight chart, watch a breastfeed from start to finish and put a plan in place to increase baby’s intake of milk to get them back on track.
Step one: feed the baby
If a baby is considerably underweight it may take time to build up mom’s milk supply and formula may be needed at first. Mothers who are reluctant to use formula may need gentle counselling to understand that the priority is to rebuild their baby’s bodyweight and energy levels; they need more food. It can help the mother to think of formula as a necessary medicine to supplement direct breastfeeding.
If a mother can pump enough breast milk then that can and should be used as the supplement instead. But we have to assume that for whatever reason, the baby is not able to get enough milk from the breast themselves and the first rule is to get the baby fed… to satiety (i.e. until they are full).
Step two: build mother’s milk supply
With baby’s calorific needs met in the short-term, work can begin on maximising a mother’s milk supply. After breastfeeding from breast for a total of around 20-30 minutes or until baby fusses, use a breastpump to pump and this will stimulate the breasts more effectively than continuing to breastfeed for hours at a time with a baby who isn’t really drinking (and isn’t gaining weight). Your Lactation consultant will go through other ways with you to increase milk
Catch up growth
If your baby has been short on calories for some time, there will usually be good catch up growth once they are getting more milk. Your baby may become very interested in feeding and may take more and more supplement when their appetite returns and they start to catch up.
Unless the infant has an underlying medical problem, failure to begin catch-up weight gain means insufficient supplement is being given.
Watch out for poor advice
Hopefully your health professional will be very knowledgable about breastfeeding. Unfortunately they may not be or you may come across poor advice from elsewhere. You may be told to feed for 10min and then give formula which is incorrect and will decrease your milk further. Advice to feed more often or for a certain number of minutes isn’t helpful if that baby isn’t very good at feeding, why spend more time doing something that already doesn’t work? Alternatively the advice you hear may be to supplement with formula —without addressing the underlying breastfeeding problems. Suggesting formula instead of breastfeeding without actively trying to increase a mom’s milk can undermine breastfeeding and cause early weaning.
Avoid Dr Google and Nurse Facebook!!!!!
When a mother desperately wants to breastfeed, and is worried about her baby, she may look to search engines on the internet and social media platforms. She may find breastfeeding forums where mothers reassure her that their babies didn’t gain much weight either but they were fine, and that she is doing great, and that breastfeeding is the best thing for her baby. They may tell her “carry on hun” or another favourite "it sounds like a tongue tie". However these cheer leaders often don’t ask any important questions; they can’t see the baby’s weight chart; they are not trained breastfeeding specialists. Following this kind of advice may lull the mother into a false sense of security while her baby continues to fail to thrive and her milk supply gets less and less.
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