Listen to the full episode below:

Sign up for Peds RAP to earn free CME credits for listening!

Liza Green Golan Mackintosh, MD, Michael Cosimini, MD, and Jonathan Goldfinger, MD, MPH

 Children’s Hospital Los Angeles chiefs discuss breastfeeding and weight concerns of infants, as well as demystifying issues with a lactation specialist Dr.Goldfinger.
Pearls:
  • It is not uncommon for a fully breastfed infant to lose more than 10% of their birth weight in the first few days of life.

  • Babies who are born with increased weight for length can reset to a new weight baseline when exclusively breastfeeding. These babies may not be gaining the full 30g per day average you would expect in a typical baby and this is OK as long as they are feeding well.

  • A common parental concern is uncertainty about how much the baby is feeding. A before and after feed weight with a scale that is adequately sensitive can document the volume of a feed.

  • The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for about six months with the continuation of breastfeeding for one year or longer as mutually desired by the mother and infant.

    • Benefits of breastfeeding for the infant include lower incidence of asthma, atopy, otitis media, upper and lower respiratory infection, gastrointestinal infection, obesity, Type-1 and 2 diabetes, cancers including acute lymphoblastic leukemia, necrotizing enterocolitis and sudden infant death syndrome.

    • Benefits to mothers include lower risks of post-postpartum depression, diabetes, rheumatoid arthritis, cardiovascular disease, and certain cancers.  Mothers who breastfeed are also less likely to abuse or neglect their babies.

  • Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012 Mar;129(3):e827-41  PMID: 22371471

  • Traditionally, 10% weight loss has been taught as the abnormal level of weight loss for a newborn. This teaching is challenged by two new studies  giving nomograms for weight loss in newborns; one for fully breastfed newborns born either vaginally or by cesarean section, the other for fully formula fed newborns also divided by mode of delivery.  These studies show that it is common for the breastfed newborn to lose more than 10% of its birthweight before starting to gain weight.

    • For the fully breastfed infants the 95th percentile for the vaginally delivered group has not yet reached its nadir when the curve ends at 72 hours, with just over 11% weight loss. For the C-section group the 95th percentile dips below 12% at 78 hours.

    • Much less weight loss is seen in the formula fed study with an average weight loss of 2.9 to 3.7% range depending on delivery type with only the rare infant losing more than 7 or 8% of birth weight.

  • This large discrepancy between the groups is unsurprising since during  the first few days of breastfeeding the mother produces  low volumes of colostrum, a yellow substance that is very high in protein and immunoglobulins, fat, and very calorie-rich.

  • It takes about three to five days for the breast milk to come in. It is no surprise that the breastfed kids, while they’re waiting on the high-volume milk supply to come in, those first 3 days lose a little more weight than their formula-fed counterparts.

  • Flaherman VJ et al. Early weight loss nomograms for exclusively breastfed newborns. Pediatrics. 2015 Jan;135(1):e16-23 PMID 25554815

  • Miller JR et al. Early weight loss nomograms for formula fed newborns. Hosp Pediatr. 2015 May;5(5):263-8. PMID 25934810

  • If we’re not using 10%, how much weight loss is really too much? There is no hard number that works for every baby. Any infant losing more than 10% of the birth weight that shows signs of dehydration, lethargy or is not well appearing  needs an intensive evaluation to make sure that the weight loss is not caused by and organic medical problem or a feeding problem that we can intervene on.

  • How do you introduce the idea of breast feeding to a family that had not previously considered it? Public health and the media have done a really good job of educating on the topic.  In the United States, at least about 95% of mothers want to breastfeed their baby. They often try right after the birth, but many of them will struggle, so it’s really important to ask all mothers what their own goals are for feeding their child. If the family does express interest in using formula the physician can ask “Have you thought about breastfeeding your child?” The physician can bring up breastfeeding and potentially clarify any misconceptions the parent may have. Hopefully this will bring up opportunities for the physician to help with any problems or perceived problems the family may have with breastfeeding. Mothers breastfeeding for the first time with their second child may have more difficulty and support should be offered early.

  • What are common misconceptions families have about breastfeeding? The prevailing theory in the community for a long time was that formula is equivalent to breastfeeding based on marketing by formula companies.  We have to correct them on this and let them know all the benefits of breastfeeding for their child.

  • How do you approach families that are giving a mixture of breastmilk and formula in the first few days? Ask about their goals for breastfeeding their infants. The mother will often say, “I’d like to breastfeed for 6 months,” and then you can jump in and say, “We know babies that are formula-fed or even bottle-fed breast milk this early are very, very unlikely to reach 6 months of breastfeeding. This is because the mothers need the physiologic feedback from the baby telling them that they actually need to create milk.” After addressing the goals address the challenges. Common ones in this situation may include: trouble with the baby latching, trouble with the mother’s milk supply (whether that’s real or perceived) and the perception that the baby is not satisfied by the breast milk alone. For this last concern teaching hunger cues and identifying other sources of crying other than hunger are important.

  • One problem with perception is that many mothers cannot feel their let-down and may not know that the baby is transferring enough. With a sensitive enough scale we can demonstrate how much the baby took by doing a before and after feed weight. As long as the baby is doing well in terms of  weight gain and urine output, reassurance can be beneficial.

*Editors note: To estimate a feed volume by weight  the baby should be weighed before and after the feed with a scale that is sensitive down to a gram. The baby should keep the same clothing and diaper through the pre-weight, feed and post-weight.  The weight gained in grams is equal to the volume taken in milliliters.

  • What should we know about pumps as pediatricians? Which pump should we be recommending to our families? It’s very rare to have complete insufficient milk supply, and  delayed or inadequate lactogenesis are uncommon.  Sometimes mothers are told to pump after every single feed in order to increase supply. This can get so exhausting and stressful that it may actually be contributing to the mother’s declining milk supply. Unless advised by a professional lactation expert, mothers in the first few weeks should not be pumping. Once a professional acknowledges that a mother has delayed lactogenesis, then it is appropriate to prescribe a electric pump.

  • Where should families be getting these pumps? In the U.S., The Affordable Care Act mandates that insurance companies now have to pay for personal machine pumps. The doctor should be writing a prescription and sending it to a durable medical equipment provider. Many mothers can also get pumps from WIC (Women, Infants, & Children, a U.S.  federal assistance program) and may be able to get one on loan while waiting for the prescription pump.

  • What galactagogues do you recommend or prescribe? On-demand feeding of the baby, appropriate pumping under the guidance of a professional, and even herbal supplements are actually better means of improving milk supply than medications.

    • If a medication is needed Goldfinger uses Reglan (metoclopramide). Domperidone is not FDA approved for this indication.

    • For herbal supplements, fenugreek can be used.

      • The standard capsule contains between 600-650 mg. Dosing ranges from one capsule daily to three capsules three times a day (9 capsules a day).  Mothers are instructed to start with one capsule a day and increase as up to the maximum dose as needed.

      • Fenugreek can cause the mother’s sweat  and urine to smell like maple syrup.

*Editors note: Data on herbal galactogogues (efficacy, dosing and side effects) are somewhat limited. A summary is available here: Zapantis A et al. Use of herbals as galactagogues. J Pharm Pract. 2012 Apr;25(2):222-31. PMID 22392841

  • What should pediatricians be looking for when evaluating a latch?

    • Look for appropriate positioning, making sure the baby is parallel to the mom’s chest and is not turning its neck.

    • Make sure that the mother understands how to hold the breast and hold the her newborn. The cross-cradle technique tends to work better than others, so mothers have good control of the baby’s head and their breast.

    • Make sure that the baby has a wide open mouth when the breast and the nipple goes in. The nipple should be buried deep in the throat where the hard and soft palate connect.

*Editors note: Goldfinger mentions the importance of proper holding of the breast. The typically recommend hold is the “C-hold.” This to do this the mother should hold the breast well behind the areola with four fingers below the breast and thumb above. Images of these positions and further guidance in assessing latch can be seen in this powerpoint titled “Basic Breastfeeding Assessment” from the AAP here.

 

  • Finally, do not forget to check for tongue ties. This should be looked for routinely but signs that may raise suspicion include “clicking or clacking” noises with feeds, difficulty maintaining a latch or if the baby is frequently gassy. Goldfinger will clip a lingual frenulum that is less than one centimeter from  base of the mouth to the tongue and a centimeter or less from the tip of the tongue to where the frenulum inserts. This should be done by a skilled professional though not necessarily an otolaryngologist.

 

*Editors note: As Goldfinger mentions in the segment this procedure remains controversial. There are studies supporting the practice with outcomes like perceived improvement of latch but the quality of evidence is very low.  There is a new systematic review in Pediatrics, June 2015 addressing this very issue:  Francis DO et al.Treatment of Ankyloglossia and Breastfeeding Outcomes: A Systematic Review . Pediatrics. 2015 Jun;135(6):e1458-e1466. PMID 25941303)

  • Any final pearls or take home points? Many babies are born with increased weight for length  because of gestational diabetes or maternal thyroid issues. These babies will reset to a new weight baseline when exclusively breastfeeding. These babies may not be gaining the full 30g per day average you would expect in a typical baby and this is OK as long as they are drinking appropriately, latching appropriately, transferring appropriately, and having normal urine output and bowel movements.

Early referral to lactation professionals is very important. Many pediatricians have not gained the skills they need to help mother latch babies. If a mother is having trouble that referral should be placed in the first week of life. Goldfinger created a phone application to help mothers find lactation support called latchME.