Appropriate weight gain for a breastfed baby

[*Infinity*]

Thank you all so much for your responses.

MantaRay, as always you were spot on with everything you've said in your post. Especially in relation to the temporary lactose issues and the article from the ABA. I think its exactly where we're at right now and certainly not going to be permament for DD.

To respond to a few of your points....

Do the doctors you are seeing see many breastfed babies? Bf poos are usually wet and runny. That is very normal for bf babies and another sign that she is getting enough milk. Frothy can be a sign of either too much lactose (ie lots of the early, watery milk) or a temporary issue with processing it. It doesn't necessarily mean any problem at all though. I wonder with all the meds you are taking for supply whether you might be getting very full, which will definitely increase the amount of lactose miss H is getting. This could also reduce her gains a bit as she would be getting less of the high fat milk in this case.

The paeds do see their fair share of bf babies. They keep saying that yellow, mustard, pasty poos are more 'normal' but surely there is a whole spectrum of normal DDs bowel motions are certainly wet & runny and occasionally a bit frothy too and I do think she has some temporary lactose overload going on....firstly as a result of her gut surgery but also because they were asking me to limit the time of bfs i.e. 10 mins each side then offer a top-up (with the aim not to tire her at the breast). But of course it doesn't allow her to finish a feed in her own time and probably only gets foremilk and less of the fatty hind milk. So what I'm doing now is just offering her longer on one each feed with the hope that she gets more hindmilk.

With regard to my supply I know that it dropped off initially when DD came home for a number of reasons:
a) using nipple sheilds
b) changing the feeding program every 2-3 days based on what the paeds wanted us to do hence my boobs getting very confused
c) a couple of days where i was less vigilant about expressing when I should have - but gee whiz, I had to get a bit of rest here and there (tutt tutt I know)

I've managed to build it back up a bit so I'm hopeful it will be ok.

Firstly, 95g in a week is not a bad gain. Usually doctors like babies to put on at least 150g a week, but 100 or so gms a week usually doesn't raise too many concerns. Also gains do vary a lot from week to week which is why in most cases weighing only every 3 - 4 weeks is a better idea. Obviously with premmies more emphasis is put on weekly weights, but it makes it hard to know if 95gms is a typical gain, or a whether it's a small gain week. I can understand them reacting immediately if she's lost in a week, but in this case I would have thought seeing how she goes over another week or two wouldn't hurt.

They've said they actually like to see 150-200g gains over a week holy moly that is a tough expectation. But equally, the outreach nurses do acknowledge that every baby is different and will follow their own trend. I'm confident enough now to go in and advocate for DD because her gains are still really good and everything else is well for her. The outreach team are coming to weigh at home on Monday so I'll be asking them to go to weekly weighs after that. Half the problem has been created by weighing DD every two or three days....no wonder I feel like the pressure is on.

Have you compared it with your son's weigh gains at the same corrected age?

Great point Kate. DS isn't really a good comparison as I switched to artificial milk after bf went horribly wrong when he was around 6 weeks old. BUT, despite that....he is still a tiny little guy - a real lightweight - and he always will be, because that's just him. So really, DD wasn't genetically destined to be a big chubba either though....so they need to take that into consideration as well.

I don't like the express and bottle feed idea - she'll get less that way, I would think, than straight from the breast. But I do understand the rationale for it.

I didn't either Marcellus, but I felt it was worthwhile simply to prove to them that breastmilk if fine for her to tolerate. And after bottling EBM for 3 days she had a really solid gain (over 100g) so the proof was there for the taking. Just part of playing the game really. And really just emphasised that its more of a volume issue than anything. When they're in hospital they set input targets on a mls per kilo calculation....so we needed to aim for about 600ml over 24 hours and it worked. But it kind of flies in the face of babies regulating their own intake. And that is just a compromise I need to make to keep them satistifed now that we're home. But it was a major PITA trying to bottle her, express to keep supply going etc on top of everything else right now. Its not the way I'm planning on doing things long term.

We're back to breastfeeds with EBM top-ups now YAY! I'm still struggling A LOT with very bad pain and attachment issues, I truly hope it starts to improve. The nipple shields are going to be required for some time yet, the pain is just exquisite. I did see a GP (very b/f friendly too BTW) who gave me some nifedipine for the vasospasm issues but I had a really nasty allergic reaction to the drug so it won't be easily solved unfortunately). The other thing is trying to encourage more vigorous feeding at the breast....DD still tires quite easily and rather than feeding she's comfort sucking a lot. Which is lovely, but more milk in would be great LOL! And the key to her gains is going to be efficient feeding....so any suggestions are welcome there.

Phew, that was a big response LOL!

[Early Kids]

You are doing such a great job

My boys paediatricians all recommended monthly weigh-ins as it's a bit more accurate than weekly (because they can fluctuate so much). Brendan follows his own curve, has never been 'by the book' and Tristan's chart looks like steps. One month he might only gain 40grams or so but the next he would gain 500gm. It varied so much. Tristan's paed and CHN always looked at the bigger picture, his weight was only a small proportion of their concern.... they looked at development, over-all growth and how happy he was. At 17 months he is *just* on the 3rd %ile.

They were happy with an average of 100 gram weight gain over a week.

I hope that helps x

[black_rose]

Hope it goes well on Monday. It sounds like your they need to back off a bit, changing a feeding pattern is really hard at the best of times let alone every few days. Her weight gain is pretty good for a premmie.

She probably would be having such good gains if the lactose was a big issue. Dd1 was a 34 weeker and we struggled to get her weight to 80 a week, it only improved once she was on solids. It was only at 8 months that I worked out she was lactose intolerant. She would throw up a thick sticky vomit.

Ds was full term but his weight gains for his first three months were barely 60 grams. He was screaming a lot too, through a process of trial and error we have confirmed he is lactose intolerant too. He is putting in about 170 a week know.

My point is your dd sounds like she is doing so well, she has probably got a sensitive gut after all she has been through and just needs a chance to settle into a proper feeding routine.

[onthefly]

Sounds like you're doing brilliantly under dificult circumstances
They realy do need to back off a bit - all the choping adn changing can't be helpful and her gains are pretty good, I reckon.
Glad the bottle thing worked out ok - you've proved yourself
Now, what to do about those sore nipples?
This may not work for Heidi, but sometimes when babies are dozing off and not quite having enough, it's recommended that once they swtich to comfort sucking/dozing to burp, change etc (to wake) and switch sides, then repeat the process back on the first side again if they're still interested. That way they get 2-3 sides rather than just one.

[MantaRay]

Infinity, you really are doing a fantastic job hun. It's extra hard work having to keep doctors calm as well as nourishing your little on I'm really that glad you are feeling better about things.

As you have pointed out, changing sides before she is finished can lead to too much lactose-rich early milk and limit weight gains. My guess is that by giving her EBM in a bottle you have seen better gains not just because of the amount she is getting but also because the milk is fattier. I think 20 minutes on one side if she will take it would be more productive than 10 mins on each. Better still would be letting her have as much as she wants from the breasts - as long as she is drinking - and then topping up if necessary, but perhaps there is a reason why they have suggested stopping her.

Infinity hun, I don't think there is any problem with using shields if they are helping. There is no real evidence that the modern shields reduce supply. In fact one study has shown that premmie babies get more milk when shields are used. I think doing whatever works for you is just fine. It's not good that you still have pain though. Has your DD been checked for tongue-tie or high palate at all? Those things can affect babies from being able to attach properly. Another idea might be to try Baby Led Attachment - see this article - Australian Breastfeeding Association - Baby-led attachment. If that doesn't help then maybe seeing a Lactation Consultant might be worthwhile for you. Feeding without pain should be possible and it must be very hard for you to be having so much pain.

All the best with it hun. I am so pleased to hear that things have improved, and I hope they get easier for you soon

black_rose - did you read the lactose intolerant article I posted earlier in the thread? Lactose intolerance doesn't happen in babies unless it's secondary to something else. It is quite likely there are other food intolerances/allergies in play with your kids. Have you had any allergy testing?

[*Beema*]

Infinity ~ you are doing a fabulous job hun

I can give you our experience, DD1 wasn't as prem but we did have a lot of feeding issues, slow then no weight gains to losses. Nipple shields, top ups expressing.....

Originally DD1's Paed wanted 150 grams a week as an average, then at 6 months he said he would have been happy with 100grams

The 95 grams in 5 days is fabulous!

I agree with Manta the Prems get more milk with the shields, when I stopped using them DD1 started losing weight, she was tiring much quicker on the breast. I had to work a lot harder to get her to feed efficiently, she was a crappy feeder, bad attachment, and a comfort sucker looooooong feeds.

What I can recommend is yes to lether finish her feeds on the breast then top up, but make every suck count, tickle her under the chin, strip her down, keep her awake and alert, even pull you brest back away from her face, as if you are "taking it away" so she has to suck harder to keep it. Watch the skin next to her ear, is it moving when she sucks, if not carefully detach her, wake her up and go again. It can be hard, it take a lot of attention which is hard woth a toddler as well, and late at night.

I can't comment on any of the intolerances, but the only thing I have noticed is the little one's who have gone through NEC, have been much slower in their gains, a friends little boy has just gone through a heap of testing, he is also a very early prem, suffered NEC, but is older then Heidi, but everything cae back clear. He is also on elemental formula.

I think you are doing an amazing job

I can't add more now, little one is demanding attention but will keep an eye on your thread xxoo

[*Infinity*]

MR & Beema, thank for your reassurance about the shields. Its good to know that its appropriate for us to be using them...right now they're the only thing making the pain bearable. I had hoped we could have ditched them by now but not the case so I'll just keep up with them.

The pain is due to a number of factors....DD has a small mouth (shaped a lot like a little cupid's bow LOL!) and also has a high palate. DS had the same. So I know that is making it harder to attach her comfortably. I just keep telling myself she will grow and it will getter better (as I grit my teeth through each feed). As far as I know she doesn't have a tongue-tie but I will get the nurses to check on Monday - is it something I could look for myself? Would it be obvious? And while my nipples are not completely flat, they're certainly not 'out there' if you like, so getting enough breast into her mouth for her to take it back to the soft palate is tough. I also have vasospasm which adds another layer of discomfort and so far no progress on treating that. I do hope that one day I will experience a pain-free breastfeed. Its making it very wearing right now.

Beema, DD sounds alot like Miss N.....

I had to work a lot harder to get her to feed efficiently, she was a crappy feeder, bad attachment, and a comfort sucker looooooong feeds.

She gets on well initially but soon enough she reverts back to comfort sucking and fluttering away, has a snooze & a little smile etc. etc. By the time I wake her, change her, re-attach (painfully) and then *think* she's had enough AND try & poke a top-up down her neck, two hours (or more) has passed and poor DS is just hanging around wondering why mummy is so busy, yet still stuck to the lounge. I'll be interested to see what her gain is on Monday as there have been feeds where I just can't get a top-up in so have had to leave it and hope that she's sucked effeciently at the boob. Arrrrrrgh. They can all go away & leave us alone now. I want DD to grow, don't get me wrong, but my mummy instincts tell me she is fine. I'll keep you all posted.

[*Beema*]

I do hope that one day I will experience a pain-free breastfeed. Its making it very wearing right now.

I know what that feeling is like It took 5 1/2 months with N And TBH I don't know how I got through it and we didn't have half the contributing factors that you have

I think your mummy instincts are very important and to be able to believe in yourself and your body's abilities to feed and nourish ~ which it can do.

I did buy some baby scales to use for DD1, just so they I could do some things myself, on occassion I would bare weigh before and after a feed, while it is not hugely accurate, it did give me an indication of about how much she was getting and it gave me more confidence that she was getting a good amount from the breast. If you did consider having your own scales I would recommend that you limit the time you use them, because it can become obsessive. But what I felt it did was enable me to see how DD1 was going without someone looking over my shoulder, making comment etc.

Sending good gain vibes your way for Monday

[MantaRay]

They can all go away & leave us alone now. I want DD to grow, don't get me wrong, but my mummy instincts tell me she is fine.

I think that's the key hun. Keep trusting those instincts and I hope the doctors will trust your instincts also and leave you alone

The high palate and vasospasm are going to make things a bit more difficult hun - you are so amazing to be going through all that and still keep going. It's obvious where Miss H got her fight from! Don't worry too much about those nipples - once she is bigger and able to draw them out they will be just fine. With the vasospasm, keeping the nipples warm helps a lot - you can even buy nipple warmers believe it or not!! Also many mums find taking supplements helpful - I can't remember which mineral it is but there should be some posts on here somewhere about it - and there is also medication that apparently helps.

Keep up the great work hun

[Kmn]

Just wondering - if you're going to be expressing and topping up anyway, then it might be better to do it in a different order (depending on how predictable Miss H is). Express the first 50ml from each side and then give her the boob - that way the let downs are already going and the big lactose content is out of the way. And then top her up from what you've just expressed - no need to reheat or anything else, just pop it in the bottle.

I don't know if it helps to think of all the checks as an early warning system rather than some kind of nasty big brother doubting your ability to nourish Miss H.

Hang in there!

[Cassius2]

It's not good that you still have pain though. Has your DD been checked for tongue-tie or high palate at all? Those things can affect babies from being able to attach properly. Another idea might be to try Baby Led Attachment - see this article - Australian Breastfeeding Association - Baby-led attachment. If that doesn't help then maybe seeing a Lactation Consultant might be worthwhile for you. Feeding without pain should be possible and it must be very hard for you to be having so much pain.

I was about to ask the same thing about the tongue tie. we had painful attachment and lots of issues with getting her to do a full feed. it would seem that she would get tired after only a few minutes and kind of pop on, pop off. so we went to the RWH to see the LC and the LC asked me several questions about DDs feeding and it included the "frothy poo". apparently bubs with tongue-tie also tend to have frothy poos! DDs tongue tie is nowhere near obvious. it a posterior tongue tie meaning that the 'tie' is UNDER the soft tissue (where the tongue meets the base of the mouth ITMS). and it means that her feeding is tiring, sore nipples etc and frothy, runny poo (all of which she has)....just something that might be worth getting checked. we had a review and sure enough Marta has a posterior tongue tie...

[*Infinity*]

Cassius that is so interesting about the tongue tie....I will definitely get it checked out. Thanks gorgeous. Did you end up having anything done about it with DD1?

Beema, we do have a set of baby scales here at home (the hospital grade one, some friends lent them to me). I use them sparingly, but they're here all the same if I feel like I want to keep an eye on them. I'm also very clear with the Neonatal docs & nurses that we're comparing apples with apples i.e. same scales (I've got a chart LOL what a nerd!) to ensure they don't use dodgy weighs to make decisions. As for how we'll get through all of this, right now I'm just going one feed at a time. Had a shocker afternoon & evening but this morning is a new day and who knows what it will bring. I'm not ready to give up yet.

MR I will definitely look into the supplements - I did start another thread on treatments for vasospasm & there were some suggestions there. Nifedipine is actually successfully used to treat it for some women but I had a really nasty allergic reaction to it when I tried it a couple of weeks ago which rules any further use out.

Kmn, thanks for your suggestions. Right now, I'm so time poor with a toddler at home too that I'm not actually expressing on top of feeds. DDs top-ups are from my freezer stash of EBM that built up over 4 months while she was in hospital which I'm very lucky to still have. And I wholeheartedly agree - the checks are there for a reason and DDs needs are quite unique, we are mindful that there is a whole spectrum of possibilities for her but right now to me, everything is within the range of 'normal' if you like so I'm willing to let my mummy instincts kick in a bit now and ask them to back off. I know my daughter and I know the things to look out for that may indicate if something is not quite right and thankfully the paeds know our family well and trust that we will raise any concerns.

I will pop in later today and let you know how the weigh in went and where to from here.

Thanks for all your support xo

[thepixie]

Good luck Infinity
You know her best - and from the pics I've seen she looks chubby and healthy and definitely like a little girl who is thriving on mummy's milk. So good luck with the Paeds - I'm sure you will be fine.

[Cassius2]

Cassius that is so interesting about the tongue tie....I will definitely get it checked out. Thanks gorgeous. Did you end up having anything done about it with DD1?

yeah i have been reading loads! the first thing the hossy wanted to do was to send her to a paed surgeon to have it cut. i asked to wait and some reading first. from what i have read we will go the route of cranio-osteopathy and tongue exercises first. alot of the medical literature spoke of these two things working well. so marta is seeing the osteo today for the first time!! will let you know how it floats...
i chose not to snip yet, as although the feeding is fussy and attachment after the first few minutes goes out the window (we also get "fluttering"). she is gaining well and feeds are short. the LC did say however that it is not uncommon for the condition to be signified by looong frustrating feeds and low weight gain. and if H has a high palate it is worth checking for TT and importantly, posterior as it is sometimes tricky to diagnose...

HTH, and really, just food for thought!

[MantaRay]

That's true Cas, tt and high palate often go together as the tongue doesn't shape the palate correctly in the womb. However high palate on it's own could cause the attachment issues.

Infinity, my DS1 also had a t-t and we opted to have it snipped as soon as possible (DS was 3 weeks). In our case DS was totally unable to attach with the tie and from our reading we also found out that it causes other problems down the track - like speech issues and dental decay from not being able to clear food from the mouth effectively. We never looked back after the snip - it took literally seconds and DS was totally unfussed by the whole thing. All the issues he had with the t-t disappeared - he even attached himself perfectly immediately after the snip.

Good luck for today. I hope I'll be reading great news from you soon

[Kmn]

"DDs top-ups are from my freezer stash of EBM that built up over 4 months while she was in hospital which I'm very lucky to still have." - I'm actually wondering if that may be part of the issue - more specifically, in full term babies the milk from the first few weeks has a more laxative effect than that from later on. It would be a complete pain, but it might actually be worth a day of expressing and giving "current" milk to see if that is any better??

[*Infinity*]

Wellll, DD weighed in at 3510g which is 110g up from her weigh exactly one week ago. So, while its not off the charts, its still a reasonable gain in my book and it fits HER trend too. So its been very reassuring. The outreach nurse today (who knows us well and knows where I'm coming from) was happy with it, she did say that the paed we've been liaising with will want more (i.e. 150-200g) but she'll chat to him and work it through. So that plan is to continue as is, with breastfeeds and EBM top-ups of however much she feels like and we'll weigh again in one week. I *know* that we can push her a little bit more with the top-ups. Its only been today that I've realised that trying to top her up straight after a b/f just wasn't working. She was too booby-drunk and groggy to really get onto the bottle so I've started to put her down straight after a b/f and let her rouse again herself (which she normally does anyway about 20-30 minutes later) then change her nappy and offer the top-up. Works a treat because she's taking a lot more which is great. And over time she'll get more efficient at the breast too which will help.

Must go DD needs my attention but all in all good progress. Thanks again everyone x

[HotI]

That's a great weight gain! Keep doing what you have been doing.

FYI- My little one has put on average of 120g per week since birth (usually around 100g/week with a few bumper months) and at 7 months she has wrist fat rolls. if it was 200g average she would look like a sumo.