Thursday, 10 December 2015

My breastfed baby has low weight gain. Is it a problem?

Sometimes in breastfeeding support you go through a period of weeks seeing dyads with similar issues.  The last few weeks it has been low weight gain in babies, so It gave me a prod to blog.

First things first - what is normal weight gain in a baby and are the charts relevant?  When someone posts on a forum about their low gaining breastfed baby, there is often a conversation about whether the charts are actually based on breastfed infants, and whether charts are relevant anyway.  Don't babies grow at their own individual rate? So let's deal with those 2 issues.

The charts are based on solely breastfed infants!  Not formula fed, nor mixed fed.  They are based on a 15 year growth study of approximately 8500 exclusively breastfed infants (they had to be exclusively breastfed for 4 months to qualify) from Brazil, Ghana, India, Norway, Oman and the USA.  These countries were chosen since they differed culturally, ethnically and economically.  The study found that babies who are breastfed optimally grow in a very similar way no matter what their background.  The charts therefore show normal growth of an exclusively breastfed baby regardless of where they are born in the world, including Northern Ireland.

When a baby is born, they are expected to lose some weight in the following 3-4 days due to loss of water, and then weight should begin to increase.  A breastfed baby has usually regained birthweight by 2 weeks, and should then continue to gain weight rapidly in the first 3 months.  So what about individual variation?  Don't some babies grow more slowly?

Let's go back to think about pregnancy.  Remember the approx 12 week dating scan?  It is done at that age because a foetus grows at a pretty defined rate in the first trimester and within a small margin of error we are able to tell the age of the foetus.  After this time growth becomes slightly more variable and individual, however we still expect the women's uterus to grow and for measurements of her fundal height to increase.  We expect the baby to continue to grow.  If growth became static, much slower than normal, or dropped through centiles we would think there was an issue.  The same stands for newborn growth.

Growth in the 4th trimester
Just as weight is predictable and similar for most babies during early pregnancy, the first 3 months of infant life (the 4th trimester) is also similar across breastfed babies (providing breastfeeding is going well).  Weight gain may be more variable after 3 months (and that is when the comments about watching the baby, not the scales are absolutely appropriate) but in the early weeks weight gain should be quite predictable.  On average a full term, healthy breastfed baby who is optimally fed gains 8oz a week, with boys gaining slightly more than girls.  On average girls gain just under 1.2oz a day and boys gain just over 1.4oz a day. (Elson et al 1989).  Obviously this is an average, and babies will gain more and less than this and that is normal.  No one expects your baby to be exactly average.  None of us are.  All babies are expected to gain at least 4-5 Oz a week at a minimum however, and lower than 5oz will probably trigger closer monitoring from your Health Visitor or midwife.  This may seem harsh or worrying, but there are very good reasons for monitoring.  Weight gain is one of the ways that some uncommon medical conditions are discovered!  
On web forums you may be told there is no cause for concern unless the weight gain falls through 2 centiles.  That is true for a baby over 3 months, but it is not the case for a baby under this age.  A newborn who has static growth or falls through 1 centile should have feeding evaluated.

Causes of Low Weight Gain.
Possible uncommon causes of low weight gain may be a congenital illness in the baby, infections, metabolic conditions etc, but in the vast majority of cases low weight gain is caused by low milk intake.    Low milk intake can be caused by a variety of things.  Perhaps it is a poor latch meaning that the baby isn't transferring milk well.  Perhaps the mum has been poorly advised about foremilk and hindmilk and  hasn't been switching sides frequently enough to stimulate good supply.  Perhaps the baby has a tongue restriction meaning that even when the latch looks good, the milk transfer is poor.  Perhaps the mum hasn't been taught how to identify good feeding at the breast, so that even though the baby seems to be feeding frequently, he isn't actually drinking.  Perhaps the baby also sucks on a dummy and therefore is spending less time at the breast.  Perhaps the baby has allergies which are impacting weight gain.  Maybe the mum's supply needs extra help due to hormonal issues, like diabetes, thyroid problems, PCOS, birth control or an issue with birth such as retained placenta or haemorrhage.  Maybe a birth issue has affected the baby's ability to suck effectively, perhaps an instrumental birth for example.   It could be any number of things, but what's important to remember is that baby's milk intake and mum's supply are linked.  If a baby isn't drinking well, or not frequently enough and therefore isn't removing enough milk from the breast, then mum's supply is not stimulated and it drops.  If mum's milk supply is low it is more difficult for a baby to transfer milk from the breast.

If your young breastfed baby is gaining less than 4-5 Oz a week then weight gain does need to be looked at.  It may be that at this time, top-ups are suggested to you by a midwife or HV.  I think it's important to make this point very clear - what they are really suggesting at this point is trying to get more calories into your baby.  Increasing calorie intake will make clear whether the issue is simply one of not enough milk, or whether there is one of those uncommon reasons for your baby's low weight gain, such as illness.  Increasing milk intake usually does not have to mean top-ups of formula.  In most cases early intervention means that steps should be taken to increase breastmilk intake.  Each mum and baby dyad are individual and the right steps for them may vary and should be worked out between them and their HCP or lactation consultant (IBCLC) but here are some general steps to approach increasing gain in babies who have a need of intervention in the early weeks.

Make sure you understand what happens at the breast, and what you should be seeing.  
Your baby should begin a feed with fast fluttery type sucks.  Your baby is not transferring much milk at this stage but is stimulating the nerves in and around the nipple area which then sends a signal to "letdown" your milk.  During a letdown muscles around the milk producing areas literally squeeze your milk down the ducts to your baby.  You may feel this happen, but whether you feel it or not you can tell it's happening by watching your baby's sucking pattern.  The sucks will change to long slow sucks and swallows.  The rhythm becomes suck-swallow-suck-swallow.   This is when your baby starts to get good flow and volume of milk.  This should happen at every feed.  In the further info section at the bottom I have attached links to videos which will help you to identify good swallowing.  A letdown should happen at every feed.  If your baby is spending a long time at the breast and not drinking, he is not transferring milk well.  

A letdown lasts on average 1.5 mins (Ramsay 2004a).  Sucking will then change back to the fluttery sucking pattern for several minutes (maybe 5 mins) and then generally another letdown will be triggered.  It will be a longer time between subsequent letdowns (if any).  These are average amounts and figures from studies.  If your milk supply is already low however, you may find it takes longer to stimulate a letdown, the letdown may be shorter and there may be more time between letdowns.  If your baby is having slow weight gain, it generally doesn't help to have him on one breast for 45mins or longer in the hope of getting hind milk.  What may be happening is that your baby is getting minimal quantities of any milk whatsoever.  Swapping sides will increase milk intake.

Increase number of feeds
Young babies need to feed at least 8-12 times in 24 hours.  That means that a baby really needs to be feeding every 2 hrs during the day at a minimum.  If you are not feeding every 2 hrs, then offer 2 hrly, even every 90mins.  The neonatologist Nils Bergman says that the biologically normal frequency of feeds for a newborn is every 90 mins.  Many mothers still have a figure of 3-4 hrly feeds in mind, but it's important to remember that feeding every 2-3 hrs is normal until the baby is taking a significant amount of solids.  Consider how often you have eaten or drunk something today.  You may have had breakfast, perhaps mid morning cup of tea, maybe another class of water before lunch.  Perhaps you had another couple of cups of tea or water or a snack before dinner.  Adults actually "feed" at least as frequently as every 2-3 hrs as well in general, so it should be expected that a baby will do the same.

Increase milk intake in each feed
As above, make sure your baby is getting a good letdown at each feed.  Don't get caught up in the idea of foremilk and hindmilk to increase weight gain.  It is the volume of milk which is associated with weight gain, not the fat content.  Rather than sticking to one side for long periods, switching more often can help.  Where you need to increase weight gain quickly, particularly in a slightly older baby, what's often termed "switch nursing" can often help.  In switch nursing you begin on 1 breast to trigger the letdown.  Once the letdown is over, switch to the 2nd side to trigger a quick second letdown.  After it has slowed, return to the 1st side and let the baby remain on that side for as long as they are comfortable.  If your baby has been spending very long times at the breast with very little drinking this can substantially increase the amount of milk they take in at a feed.  It will also increase your supply.  A very small baby may not need to switch feed in this way, it may just be a matter of improving the latch and making sure that he feeds well from the breast at each feed.  Your lactation consultant will be able to work out the best strategy.

Work on your supply
If your baby has been slow to gain it is likely that you also have a low supply because the demand and supply arrangement isn't working optimally.  Switching sides frequently will help with your supply, but it may be that you will also need to express.  You can work out the best arrangement with your IBCLC or HCP but I often suggest power pumping.  The phrase power pumping as been used on the Internet for a few different strategies, but I prefer the strategy from IBCLC Cathy Watson Genna as I think it works well for mums who are feeding frequently and don't have a lot of time to sit and pump.  The details are in the further reading section.  The milk you express can be used as a "top up" while you are working at improving the milk intake at the breast.
Low weight gain in the early weeks has a knock on effect.  Sometimes the early weeks go by with weight gain which is low and just below normal range, but by the time he has reached 2-3 months and interventions are suggested mum's supply has been affected more definitely.  Milk supply is primarily set up in the first 5 weeks, and by the end of that time (assuming everything has gone to plan), a mother will be at full milk production.  A breastfed baby drinks roughly the same daily volume between 6 weeks and 6 months.  If you haven't reached full production by 5 weeks, it can be harder to reach full milk supply later.  It may require some extra support from galactagogues (foods, herbs or drugs which increase milk production) and support around expressing strategies.  For some, some short term supplementation of breastfeeding may even be needed until the baby moves on to solids.  This is why is it so important to identify and resolve any breastfeeding issues early.  It can be very difficult to confront the fact that your supply may be low, but with the right support and interventions at the right time, this can be turned around.

A word on silent reflux
In many cases babies with low weight gain also have a diagnosis of silent reflux.  The diagnosis is often made on symptoms such as arching at the breast and a crying unsettled baby much of the day.  It is important to note that arching at the breast and being unsettled are also signs of low milk intake.  Reflux may be a complex picture in many babies, but it does have a cause, and milk intake may be part of the solution.  Even with babies who have a picture of allergies (including blood in the stools), symptoms may be related to low milk intake.  Jack Newman, the Canadian paediatrician and IBCLC, has described cases in his practice where increasing milk supply and milk intake resolved the issue with blood in stool.

Getting Help
The steps to identify the problem, resolve it, increase milk intake and supply are logical, but this is where you can really benefit from good breastfeeding support.  A latch check is usually not sufficient as it is generally just looking at the shape of the baby's mouth at the breast.  A thorough breastfeeding assessment from a skilled professional, such as an IBCLC (International Board Certified Lactation Consultant) will look at the entire feeding picture and can start to tease out if milk transfer has been an issue.  The lactation consultant can work on a feeding strategy with you to increase gain and increase supply to improve feeding while still under the care of your HV and HCP team.
It is normal for babies to want to spend a lot of time at the breast in the early days and weeks, and it is ok for them to comfort at the breast.  No where is more comforting to a baby that the breast.  It is also important that they drink well however and that they drink well at least 8-12 times a day.  If your baby is not drinking/ getting letdowns during feeding talk to someone about the feeding pattern.  If your baby hasn't regained birthweight in the first 2-3 weeks, breastfeeding should be assessed.  If you have a low gaining baby diagnosed with silent reflux consider meeting with an IBCLC to look more closely at how breastfeeding is going.  
The first weeks are important for weight gain, but it's not just about the baby.  Weight gain/milk transfer is important for the mother too, and both must be considered together.  It's not just about the growth of your baby, it's also about your supply.  It impacts both of you.  Resolving issues early in the early days means that problems are usually quite quick to turn around and can ensure an easier, worry free breastfeeding experience for as long as you choose to feed.  

Further Reading

Video of feeding showing how to recognise swallowing -
Video of baby at breast, but not feeding well -

Increasing milk intake at a feed -

Switch Nursing / Increasing Milk supply through Nursing -

Power Pumping -

When supplements are needed -

Nils Bergman interview on normal frequency of newborn feeding -

Jack Newman comment on blood in stools and milk supply -

Info on Growth Charts

Find a lactation consultant
Book a consult with Mammae -
Ireland -

Friday, 4 December 2015

Breastfeeding, Reflux, Stomach Acid & Gut Bugs

A few weeks ago I wrote an article on reflux and breastfeeding, and the need to look for a cause for reflux in your breastfed baby.  This is a companion article to that one, looking at the role of stomach acid in our bodies.  It seems that reflux is so frequently diagnosed (and often misdiagnosed) and acid suppressing drugs are now so prevalent that acid itself is being seen as an issue by some mums.    I wanted to write a little about what stomach acid is, what is does and the relationship between breastfeeding, acid and our gut health.  If you haven't already read the previous blog, please do so as it looks at the NICE guidance regarding acid suppression treatment and root causes of reflux.

Stomach acid & digestion

I wanted to start with a brief overview of what happens in the stomach and the role of acid.  Our stomach fluid is comprised primarily of hydrochloric acid, produced by cells in the stomach lining.   If you remember your chemistry from school, neutral pH is  7, acid is lower than 7 and alkaline is higher. Our gastric fluid is very acidic, with a pH of 1.5-3.5.  Smelling, tasting and chewing food stimulates our stomach to secrete this acid in preparation for digestion.  Obviously babies don't get a chance to chew food and wait for acid to be secreted, but perhaps this is another design reason why a baby sucks for a short time before milk lets down?  Perhaps it facilitates this process?  

Acid is vital for protein digestion.  Once food reaches the stomach, the acid environment causes the proteins in the food to unfold.  The acid then activates an enzyme called Pepsin which breaks down the protein bonds (literally breaks the protein apart).  If stomach acid is suppressed the proteins can't be broken down and digested.  Any vitamins or minerals which are attached to proteins (e.g. B12) can't be extracted and therefore can't be absorbed.
The gloopy mix of food and stomach acid is called chyme.  Once the gloopy chyme reaches the correct acid pH level it triggers the valve at the bottom of the stomach (the pyloric sphincter valve) to open and empty the stomach contents into the intestine.  If stomach acid is suppressed chyme has to stay in the stomach for a longer time in order to reach the correct pH to open the sphincter valve.

Humans are a complex ecological environment, containing around 10 times as many bacterial cells as we have human cells, and having a balance of healthy bacteria is key to our health.  Eating/drinking is a route for infection causing bacteria to enter the body, but a robust acidic stomach environment kills off a lot of pathogenic bacteria and prevents it from getting into our intestines.  It's a first line of defence.  If acid is suppressed however, the stomach has limited capacity to kill any problem bacteria.  This fact that chyme sits in the stomach for longer means that not only is the bacteria not destroyed, it has a chance to grow in the stomach and ferment the chyme.  This fermentation process creates gas and pressure in the stomach, which needs to be released.  The pyloric sphincter (bottom of the stomach) is a one way valve, and it isn't going to open until the chyme is at the right pH, so the 2 way upper sphincter valve (the lower eosophageal sphincter or LES) opens and reflux occurs!  
In addition to this gas effect, the suppression of stomach acid can actually allow pathogenic bacteria to grow around the upper sphincter muscle.  This growth partially paralyses the sphincter, and without correct function - reflux occurs.  Yes you read that correctly - acid suppression causes reflux.  The listed common side effects of Omeprazole, for example ( a commonly prescribed drug for infant reflux) are:
  • Vomiting
  • Flatulence
  • Stomach pain
  • Constipation 
  • Diarrhea

Gut bacteria & the immune system

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The surface of the digestive system is covered by a vast number of bacteria.  I recently heard the digestive system being described as an area outside of the body, which is an interesting way to think of it.  Essentially we have a tube from our mouth to our anus which carries food and other substances from one end to the other.  Our "body" is on the other side of this tube wall, and therefore the tube or gut could be thought of as an outside area where we absorb nutrition into the body.  It's an interesting approach which helps us to picture bacteria covering the gut wall on the "outside" surface in the same way that our skin is covered in bacteria on that outside surface.  
Our gut wall is crammed (hopefully) with beneficial bacteria, and these bacteria help to synthesise immune system cells called lymphocytes which protect the body from invaders.  They also play a role in other immune responses in fighting viral infections.  It is estimated that 80-85% of the immune system is located in the gut wall.  If the gut bacteria biome is damaged the whole immune system is affected.  

Acid suppression means that pathogenic bacteria, which would normally be killed in the acid stomach, survive and pass into the intestines where they upset the bacterial balance.  This affects the immune system.  Studies have shown significantly increased risks of gastro-intestinal infection and of respiratory infection, including pneumonia in infants treated with acid suppressing drugs.

Another link between digestion and immune function is in allergies.  There is a well established link between asthma and reflux.  1 in 13 people in the UK now have asthma, and as early as the 1930s a study found that 80% of children with asthma had low stomach acid (Bray, GW 1931).  A recent  study ( Untersmayr & Jensen-Jerolim, 2008) looking at protein digestion and allergies found the following:

"The data reviewed here suggest that the immunologic or clinical outcome after the consumption of a digestion-sensitive dietary protein depends to a certain degree on the gastric digestive capacity. If the food protein is exposed to gastric enzymes during transit, protein cleavage takes place, inducing either oral tolerance or immune ignorance toward the ingested food protein. However, if proteins persist during the gastric transit because of impaired digestion, such as during acid-suppression treatment, IgE-mediated food allergy can be induced. Gastric digestion might also influence the extent of reactivity in already sensitized patients. Physiologic gastric proteolysis substantially decreases the allergenic capacity of ingested food proteins, whereas severe allergic reactions at much lower amounts of ingested food proteins could occur if digestion is impaired"

In other words, an acidic stomach environment promotes protein digestion and substantially decreases the potential of an allergic reaction.  Or putting it another way (since an acid environment is the normal physiology ), acid suppression inhibits protein digestion and substantially increases the potential of allergic reaction.  Look at how many children are diagnosed with both reflux and cows milk protein allergy/intolerance.  Which came first?  Is the CMPI causing the reflux, or is the reflux medication causing the CMPI?

A 2012 article from the Journal of the Amercian Medical Association discussing PPI drugs and asthma in children stated,

 "Given their potential adverse effects, these medications should thus be used with great restraint for treatment of GER/ GERD during childhood. The substantial increase in use of PPIs in children during the last decade is worrisome and unwarranted." (Martinez, 2012)

Breastfeeding & Stomach acid

Part of the way that Breastmilk has an effect on the development of the immune system is through its effect on the type of bacteria which colonise a baby's gut.  If I can just quote a couple of studies which highlight this: 

In The impact of Breastmilk on infant and child health, Oddy (2002) states:

"The commensal (normal, healthy) microbial flora of the gastrointestinal tract as well as respiratory microbial agents, stimulate the functional maturation of the immune system (Holt, Sly &Björkson 1997).... 
The microbiology of Breastmilk has a large impact on bowel development and gut microflora"

Likewise Wold & Adlerberth (2002) say :

"Breast-feeding is associated with protection from the following infections or infection-related conditions: gastroenteritis, upper and lower respiratory tract infection, acute otitis media, urinary tract infection, neonatal septicaemia and necrotizing enterocolitis. Some of the protective effects may derive from an altered mucosal colonization pattern in the breast-fed infant. "

There is a direct link between the pH of a baby's GI tract and how they are fed.  Although the intestine is much closer to neutral than the stomach, breastfed babies have a more acidic digestive environment than a formula fed baby due to the gut bacteria that colonises the gut.  In the first 6 weeks of life breastfed babies have a lower gut pH of approx 5.1-5.4 compared to a formula fed baby's lower gut pH of 5.9-7.3.  The 3rd most abundant component in Breast milk is HMOs (human milk oligosaccarides).  Oligosaccarides are specific carbohydrates which canot be digested by the baby.  They are purely there to feed bacteria - specific helpful bacteria!  They encourage the growth or lactobacillus and bifida bacteria.  Lactobacillus species produce lactic acid, and what does lactic acid do?  It lowers the pH of the intestinal environment, making digestion easier and also creating a healthy environment for those  bacterial strains to continue growing.  Acid suppression makes it harder for these bacteria to colonise the gut by changing the balance of bacteria and allowing pathogenic bacteria strains to reach and establish in the gut.

Acid is not the enemy.  We are designed to have an acidic environment in our stomach, and human and our healthy, helpful commensal bacteria evolved around an acid digestive environment.  

That brings me full circle back to the previous blog on looking at the root causes of reflux.  Mothers and babies deserve someone to look in a holistic way at reflux rather than prescribing drugs with far reaching effects without full discussion.  If you are struggling with reflux in your breastfed baby and would prefer to look at how altering breastfeeding might help, have a look at my previous blog and contact a board certified lactation consultant or a qualified breastfeeding counsellor to look at root causes.  

We should  think carefully before undoing some of protective effects that breastfeeding promotes in our babies.

Further Reading

Articles on Low Stomach Acid and reflux:

Bray GW. The hypochlorhydria of asthma in childhood. Q J Med 1931;24:181-97.

Untersmayr & Jensen-Jerolim.  The Role of protein digestibility and antacids on food allergy outcomes.  J Allergy Clin Immunol. 2008.Jun: 121(6): 1301-1310!po=38.7500

Martinez.  Children, Asthma, and Proton Pump Inhibitors Costs and Perils of Therapeutic Creep  JAMA January 25, 2012 - Vol 307, No. 4 p.406-407

Oddy, 2002 The impact of Breastmilk on infant and child health.

  • Wold & 
  • Adlerberth, 2002  
  • Breast Feeding and the Intestinal Microflora of the Infant — Implications for Protection Against Infectious Diseases 

    Acid Suppression and increased Risk of Pneumonia and GI infections -