I received a phone call from Lisa when Sophie was 19 days old. Lisa had just been to see the maternal child health nurse 3 days before and found out that Sophie was not gaining weight quite as planned.
Lisa was feeling understandably upset, worried and a bit deflated at the thought that Sophie was not taking enough from the breast...
Almost 70% of babies gain back weight to be at or above their birth weight by two weeks of age and 97% of babies will have regained to their birth weight by three weeks of age. Sophie had lost a further 40g from her birth weight at 16 days of age.
Here are Sophie’s weights:
- Weight at birth 3120g
- First weight check after birth 2848g – a loss of 272g (9.5% weight loss)
- Gained weight for first Maternal Child Health Nurse (MCHN) check on day 9 – 2980g an increase of 132g, now only 140g from birthweight. This could easily be easily regained by day 14 if Sophie is gaining average expected weight of 25-30g per day. So, there were no concerns from myself or MCHN at this stage.
- Weight at 16-day check 2940g – decreased 40g
- Weight at 19-day check 3000g – increased 60g
There are a few issues that health professionals would want to look at at this stage, because all babies should be back at their birth weight or getting close ideally by 14 days of age and back to birth weight at the very latest by day 21.
As Sophie has started to lose weight, the MCHN wanted to make sure that the weight loss / poor weight gaining is due to a feeding issue and not a medical issue.
When you are having your baby weighed, the maternal child health nurse or paediatrician will be checking for lots of others things as well but will use the weight as a guide to general health and growth.
Any babies who are not quite meeting the expected goals as discussed above will be checked further by your GP or paediatrician to rule out any other issues, like a urine infection for example.
Sophie’s MCHN had referred Lisa to her GP or paediatrician and Lisa had been to see both of them by the time I spoke to Lisa.
Lisa explained that, since I’d last met with her, on day 9, Sophie’s feeding pattern had changed and there were a few other things going on which she was concerned about. Lisa told me that Sophie was now:
- Constantly feeding and not satisfied for long
- There was lots of crying
- Lisa thought that she had a fast flow of milk
- Sophie was vomiting a lot after feeds
- Sophie was now having yellow very watery stools which were sometimes frothy
- When I asked about Sophie’s wet nappies we worked out that they were not as heavily soaked as they should be. Now the nappies were feeling much lighter than before.
So, What’s the Diagnosis?
From all of these symptoms, I made a diagnosis that Sophie was probably trying to deal with a very fast let down from Lisa. Some mums have a really quick initial fast flow of milk which can be a bit overwhelming for some babies.
Often baby will get full very quickly with the lighter, less fat rich milk at the beginning. Baby will have completed the feed in a few minutes and then becomes quite uncomfortable after feeds and may likely vomit as well.
The watery stools and occasional frothiness can also indicate this as well. Because Sophie was getting full up on lots of low fat, high sugar milk, this could explain why she was awake much more frequently and wanting to feed more. This would also lead to the poor weight gain.
Vomiting is usually normal for nearly all babies. But vomiting with weight loss or no weight gain, vomiting which is projectile or vomiting which is a non-milk colour is not normal. If your baby is having any of these symptoms then it is important to have your bub checked by your GP or paediatrician.
As Sophie had been checked I was confident that it was most likely the high amount of fast flowing first milk that was causing the problem.
Lisa described to me how the doctors had felt Sophie was healthy but perhaps she was suffering with a lactose intolerance. The doctors had suggested that Lisa express off some of the first fast-flowing milk just before breastfeeds. They also suggested giving Sophie Zantac, which is an antacid medicine and that Lisa should give up all dairy.
Progress in the Last 3 Days Since Seeing the Paediatrician
Lisa told me that, since she saw the doctors 3 days ago, she had been expressing off some milk before breastfeeds and given up all dairy. Lisa had found that Sophie was more settled after feeds but still frequently feeding and really unsettled prior to pooing.
Sophie had increased in weight by 60g but was still below birth weight. And poor Lisa was suffering not having any dairy in her diet! Who doesn’t love cheese? Lisa said that she had not wanted to put Sophie on the Zantac medicine at this stage and try and do things naturally.
For me, as a lactation consultant, it was almost definitely pointing towards my first thoughts of too much milk at the beginning of the feed. I did not feel that it was a lactose intolerance at this stage as Sophie was having normal coloured stools with no blood in them. She was also starting to settle down after feeds and had gained weight. These are all great signs of improvement.
Admittedly, Sophie’s weight gain was slower than needed but it was a good start.
I told Lisa what an amazing job she was doing and that it sounds like they are on the right track now. We still had an issue to sort, which was that Sophie was not yet up to her birth weight and she was 19 days old.
I advised Lisa that I felt that Sophie would settle down even more once we gave her more milk. I felt that Sophie was unsettled purely because she was hungry.
More often than not in the first few weeks babies are unsettled because they are hungry. Once most babies are full, they are usually sleeping! So that was going to form my breastfeeding plan for the next few days.
Lisa and I discussed whether she still needed to keep the lactose free diet and we decided that she would try focusing on the main breastfeeding issues first; weight loss and probably that Sophie was not drinking enough which was causing her unsettled behaviour.
So, together we decided that Lisa could go back to enjoying her usual dairy in her diet and we would come back to that point if we needed to in the future.
The Feeding Plan
Here’s what we decided to focus on when it comes to Lisa’s feeding plan for Sophie.
Lisa would breastfeed Sophie 3 hourly (8 times every 24 hours).
She would still express a little milk off before a feed – until the flow slows down a bit. This should help calm the milk flow before Sophie breastfeeds.
Lisa would top up with extra feeds of about 40mls of expressed breastmilk in a Calma bottle. This will help Sophie have better weight gain and should settle her to sleep as well. I advised the Calma bottle to make sure Sophie still uses a vacuum to draw the milk out of the bottle, like she will do at the breast. This way Sophie will go back to the breast easily with no future problems
After each feed, Lisa expresses milk for the next feed. She uses the double pump attachment as this has been shown in the studies to help a mum express up to 18% more milk when pumping both breasts together, as well as taking half the time of a single pumping session.
Ideally Lisa will complete Sophie's feed before she expresses. Then she should be settled and sleeping allowing her some time to express without feeling as stressed out.
Rest, Rest, Rest in between! Lisa should limit all visitors and get as much support as possible. This plan is really hard work so she will have no time for anything else.
This is only temporary until we get Sophie back on track, it is not a permanent solution just one to boost Sophie’s milk intake and help her settle and sleep.
I agreed to check in with Lisa every day or two to see how she and Sophie are going and to make sure they are both coping well. This is a massive task right now and I wouldn’t want Lisa to feel overly stressed out or too exhausted where she cannot cope.
There has to always be a happy balance. I was hoping that with some good regular support Lisa would be OK with the plan and would feel much better soon as Sophie started to sleep more.
Lisa’s Response: Breast, Settle, Blink, and Repeat…
“It has been a loooong three weeks and we are at the point of not knowing what to try next - Sophie just won’t settle!
Every trick we had used with our eldest just wasn’t cutting the mustard with this new addition. Apart from the exhaustion, I’m really starting to worry about Sophie’s wellbeing. There is no way she is getting enough sleep for a newborn (not to mention getting enough weight gain.)
Trying to explain what is happening with an unsettled baby can be very difficult. Trying to distinguish between what is normal and what isn’t.
I felt that I knew something wasn’t right and definitely not within the realms of “normal” baby behaviour. The MCHN confirmed my concerns upon weighing Sophie and realising not only had Sophie not gained weight she had in fact gone backwards.
This was my first meltdown since her birth; I jumped in the car called my husband and just cried. As any new mother would know, all you want is for your bubba to be thriving and comfortable. My baby girl was neither.
At this point, I booked into to see the paediatrician after I had already seen the GP. I needed some guidance as what to do next. The paediatrician suggested that I try eliminating lactose from my diet (dairy) and expressing off before feeds. I was a little worried that expressing off would mean less for Sophie.
I have faith in our health professionals, but still felt that I needed the expert knowledge of someone who could guide and help me with the feeding in hope of Sophie putting on some weight. Katie with her expertise in the lactation area was my go to. She was seriously amazing!
Not only did Katie talk me through a plan to help me with Sophie, but, she also reassured me in what I was trying to do and gave me confidence to continue with the breastfeeding journey.
The plan she gave me, while a little daunting, was also worth doing to help Sophie gain weight. The plan was clear and I was set to get things improving.” - Lisa
Have you ever experienced a challenge with getting your baby to gain weight? What did you do? Please join the conversation here or on the Medela Australia Facebook page! We’re here to support each other.
