I recently saw a young couple for a breastfeeding consult. They were here with their first baby who was about 4 months old. They had just recently been to see a doctor. During the 15 minute appointment the doctor looked at the baby’s weight gain from the last time the baby had been weighed and noticed that the baby had gone from the 50% at birth to the 15% now 4 months later. She then told them to start supplementing with formula and sent them on their way. So what is wrong with this picture?? A lot! Here are 8 crucial things to do when you are told to supplement.
1. ASK THE HEALTH CARE PROFESSIONAL FOR A DETAILED DESCRIPTION AS TO WHY THEY ARE TELLING YOU TO SUPPLEMENT. “Because baby is low on the growth chart” is not in of itself a reason to supplement. Some babies will be smaller than others!
I frequently hear of cases where a doctor will tell someone to supplement just because of where the baby is on the growth chart. But it is not as simple as this. A baby who is on the 10% can be just as healthy as a baby who is on the 75%. We accept that adults are different sizes yet question babies who are “low” on the chart. My first baby was a little string bean. He stayed at the 10% on the chart for basically forever but on all other accounts was doing exactly what we expected to see. Meeting his milestones, happy etc…I am forever thankful for my doctor at the time who recognized this and never pressured me to supplement just because he was “little”.
So when is there cause for concern? When a baby continues to DROP percentiles over time. A baby who is born at the 95% who over time continues to drop down the percentiles on the chart is reason for concern. NOT a baby who starts at the 10% and continues to stay at the 10%. Remember my story from above? What the doctor failed to do was actually look at the weight gain of that baby since he was born. There was an initial drop in percentiles after baby was born (from the 50% to the 15%) however the baby had continued to stay at the 15% for the past 3 months. The baby was continuing to gain weight and stay at that percentile.
Make sure you and your doctor (or health care provider) are charting your baby on The World Health Organization’s charts for breastfed babies as babies who are breastfed grow and gain weight differently than formula fed babies.
2.LOOK AT THE WHOLE PICTURE…NOT JUST THE CHART. I cannot stress this enough. We are not raising babies on charts here, they are whole human beings with many different aspects of their health that we need to look at.
Back to the story I started with. This couple’s doctor did not once ask for their baby’s entire history of weight gain. She did not ask them if their baby was meeting his developmental milestones or showing any signs of developmental issues. In every way their baby was (and is) 100% normal. He is meeting his developmental milestones, he is continuing to gain weight steadily and staying at the 15% on the chart and during the entire visit was alert, smiling at me and interacting with all of us. He was also peeing and pooping as expected for his age. These are all of the important factors that go into a proper assessment. It is NOT JUST ABOUT THE CHART. I observed the baby breastfeed and have formed a plan with this couple for the future. Following up is so important and crucial for long term success of women reaching their breastfeeding goals and making sure the baby continues to gain weight and stay at the percentile they have been on.
3.TALK ABOUT THE POSSIBILITY OF YOUR LABOR AND BIRTH AFFECTING BABY’S BIRTH WEIGHT. Something not often mentioned is the affect of IV’s and medications on a baby’s birth weight. “There is evidence that intravenous therapy in labour contributes to newborns who may be ‘water logged’. Excessive infant weight loss in the early neonatal period is often a reason for aggressive supplementation of breastfeeding newborns.”  What was your labour and birth like? This can affect the initial weight that was taken of your baby. In the case I’ve mentioned above, the woman had received bags of IV fluids throughout her labour. This is an important piece of information when assessing their situation.
4.GET CONTINUED SUPPORT FROM SOMEONE TO GET TO THE BOTTOM OF WHY YOUR BABY IS NOT GAINING WEIGHT AS EXPECTED if you have a baby who is continuing to drop percentiles on the chart, losing weight or showing signs of failure to thrive. There is no clear definition of this but the generally accepted criteria for diagnosis of a baby who is “failure to thrive” includes a baby who is showing signs of being undernourished and losing weight or gaining very slowly. Just telling a woman, ”your baby is failure to thrive” or “you need to supplement” without actually getting to the bottom of WHY this is happening is not only unhelpful but actually can be detrimental to a mother who would like to continue to breastfeed her baby exclusively. “In order to evaluate the situation, both mother and infant must be assessed for their contribution to the breastfeeding relationship.”  Unfortunately often times this important step is completely overlooked as a couple leaves the office with their baby and formula sample.
5.HAVE YOU AND YOUR BABY THOROUGHLY ASSESSED TO RULE OUT DIFFERENT POSSIBILITIES AS TO WHY YOUR BABY IS NOT GAINING AS EXPECTED. Most often it is simply caused by a baby who is not latching on effectively, as statistically speaking more women are physically able to produce enough milk if their babies are effectively and efficiently able to drain the breast. However there are many different possible reasons as to why a mother’s milk supply is low…
Possible contributing factors to low weight gain  as caused by the mother:
- Breast surgery
- Chronic illness of any type
- Connective tissue disease
- Eating discorder
- Inverted nipples
- Polycystic ovary syndrome
- Postpartum hemorrhage
(*AMONG MANY OTHERS!)
And the infant:
- Tongue/lip tie
- Biliary atresia
- Cleft lip or palate
- CNS abnormality
- Congenital heart disease
- Cystic fibrosis
- Gastrointestinal infections
- Gastrointestinal malformations
- Gastroesophageal reflux
- Inborn errors of metabolism
- Increased caloric needs from chronic disease, infeaction, malabsorption
- Neurological disorders
(*AMONG MANY OTHERS!)
Do not freak out and diagnose you or your baby with these things just because you read them here! These are some examples of different situations that would affect a baby’s weight gain. Get testing done for one or both of you if you suspect there is an underlying reason for weight gain issues with your baby unrelated to just breastfeeding management issues like latch problems that can usually be easily fixed with some good support.
6.HAVE A BREASTFEEDING SPECIALIST (INTERNATIONAL BOARD CERTIFIED LACTATION CONSULTANT, IBCLC) OR TRAINED VOLUNTEER BREASTFEEDING COUNSELOR HAVE A GOOD LOOK AT YOUR BABY WHILE BREASTFEEDING. This is crucial. Not for the “let’s have a look at the latch” reason (click here for why the look of the latch really does not matter so much) but because someone needs to assess if your baby is actually sucking and swallowing as expected during the breastfeed. It is really important to see whether or not your baby is actively sucking and getting milk when breastfeeding. This is the first important step to forming a long term plan for you as we need to know if your baby is getting a good amount of milk when they are breastfeeding. Then of course looking at the other factors involved with knowing your baby is getting “enough” which including counting their nappy (diaper) output every 24 hours and observing your baby’s general contentedness. As in, are they content most of the time? Or are they very unsettled or very sleepy and on the breast ALL.THE.TIME. which can be an indication they are not getting much while breastfeeding.
7.GET SOMEONE TO FORM A SHORT-TERM AND LONG-TERM PLAN WITH YOU. If it has been established that yes, you do need to supplement and your baby is not getting enough it’s then so important to have a long term plan set up for you. Supplementing does not always have to happen with a bottle and formula. If your baby is willing and able to breastfeed frequently and on demand then using a supplemental nursing system (SNS) is an awesome way to get your supply up as quickly and efficiently as possible while also supplementing at the same time. Head here for Brogey’s story of why she used an SNS with donor breastmilk for the entire 2 years of breastfeeding her daughter Junipah.
8.STAY POSITIVE AND KEEP IN CONTACT WITH THE BREASTFEEDING SPECIALIST (IBCLC OR BREASTFEEDING COUNSELOR). This will help ensure that you get to the bottom of WHY you have low supply (due to you or your baby or possibly a combination of both) and WHAT your plan is for the near and distant future. Including how to know if your supply is increasing and how to then go about weaning off of the supplements.
*If your baby is truly needing to be supplemented the first rule is FEED THE BABY! Whether that is with your expressed breastmilk, donor milk or formula. The World Health Organization recommends the following (*side note this is not just a recommendation for those who are in developing countries but for women worldwide)
“For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative- expressed breast milk from an infant’s own mother, breastmilk from a healthy wet-nurse or human-milk bank, or a breast-milk substitute fed with a cup…”
1. Kroegar, M. Impact of birthing practices on breastfeeding. Jones and Bartlett: Boston; 2004
2. Riordjan J, Wambach K. Breastfeeding and human lactation. 3rd ed. Jones and Bartlett: Boston: 2010.