Evaluation & Treatment of the Slow Growing Breastfed Infant
Transcript of Evaluation & Treatment of the Slow Growing Breastfed Infant
Evaluation & Treatment of the Slow Growing
Breastfed InfantLaurie B. Jones MD, FAAP, FABM, IBCLC
Agave PediatricsU of A Clinical Assistant Professor Pediatrics
Disclosures
As a speaker/consultant for Willow Pump Company, I do not intend to discuss specific, trademarked agents/products of this commercial interest.
Learning objectives
1. Recognize normal/abnormal human milk fed growth trajectories
2. Discuss longitudinal milk supply principlesAnatomy: storage capacity Physiology: apoptosis, FIL factor
3. Build differential diagnosis skills for the feeding dyadHypolactation DMX (Dysfunctional Milk Extraction)
4. Create collaborative treatment plans for slow growth Respect family feeding goals Ensure a well growing infant
5. Prevention of the slow growing breast milk fed infantAnticipatory guidance at well checks
There is no way that I can cover these objectives in 40 minutes
However, I can hit HIGHLIGHTS
And give you resources for more self-directed learning
Adult learners
● Time to displace old knowledge
● Practical application
● References for later
Ambitious objectives
Busy day in the office….
6 month well check
Healthy, happy infant breastfed only; ready to start solidsWeight % has dropped from 45th%-53rd% at last two visits to 17th% todayNBS #1/#2 normal Length/HC tracking on curveDevelopment is on track, No changes in social determinants of health
…… now the visit is rapid fire questions about feeding type, frequency, volumes, intervals, maternal history, freezer info, feeding goals, and plan
Challenging scenario
To make a plan we have to understand:How breasts make milkHow babies take milk out of breastsNormals for milk volume over time
DYAD: two person differential diagnosis
Fix the problem without creating new ones
Learn how to predict/prevent slow growing infants
- Finding genetic curve?
- Sign of problem ?
- Controversy over exact criteria
- Below 3rd%- “Plummeting”
Slow growth definitions
Slow drift FTT/Pediatric undernutrition
Growth charts – using the right one?
? EMRWHO Birth – 5 yrs
7 countriesAll human milk for 2 yearsVery consistent patterns
Does your inpatient EMR use CDC 2010/WHO?
Outpatient?
CDC 2010
Birth – 24 mo: WHO data2y-24y: 2000 data
All infants measured against human milk
standards
- No one wants to be average
- Not understanding Gaussian distribution of humans
- Unhealthy focus on infant length to predict adult height
- Obsessed over “two lines” crossed
- Not looking at bigger picture or genetics
- Bringing back too soon to recheck
Over-reading growth charts
Parent worry Physician worry
From AAP Breastfeeding Curriculum for residents (FREE and effective)
● You need 1 breast to feed 1 baby● Capable of making enough for two infants● Ductal glandular wedges don’t connect to
each other; apoptosis not inter-dependent
● Storage capacity: amount breast can hold without downregulating volume made
○ EXCEED storage capacity -> milk supply goes down
How breasts make milk
Milk
synthesis
Dopamine
(-)
Prolactin
Milk
secretion
Oxytocin
Anterior
pituitary
Posterior
pituitary
Paraventricular
nucleus
(+)
Milk ejection
reflex
Placenta
Progesterone (-)
Hypothalamus
(+)Cortisol
T3, T4
Insulin
Growth hormone
How breasts make milk: HORMONAL control
A. Stuebe with permission
How breasts make milk
Autocrine control
MAGIC NUMBER PRINCIPLES (Nancy Mohrbacher!!)
Frequent emptying: 8-12 times in 24 hours
Leave milk in the breast: supply goes down
Apoptosis: cell death, remodeling- back pressure on lactocyte- cuboidal shape vs. columnar- FIL mystery: Feedback Inhibitor
of Lactation
Remove milk = make more milk
Day & Night
- Expectations- Night parenting
duties
No PAUSE button
- Breasts make milk 24/7 at relatively constant rate
UNICORN BREASTS
- Breasts that can hold milk for 10-12 hours without emptying
- Just like your teen thinks he/she will be a millionaire YouTube Star
“Hits” to supply
- Some lactating parents can exceed storage capacity frequently and have minimal effect on supply
- Others are extremely sensitive to degree of emptying
How breasts make milk
• All lactating parents with female breasts make similar volumes
(exception: Hypoplasia, IGT, surgeries )
• 24-30 ounces in 24 hours750-900 mL
• 1 – 1.25 oz/hour combined breast output
How breasts make milk
Birth to 1 month : climbs to steady-state(then enters Lactogenesis Stage III)
1 month – 6 months: 24 – 30 oz per 24 hourSame as 1 – 1.25 oz per hour
Slow slide to 12 mo : average is 18 oz/24 hours by one year of age
Growth/calories of human-milk-fed humans
• C, Daymont, Hoffman N, Schaefer Ew, and Fiks Ag. “Clinician Diagnoses of Failure to Thrive Before and After Switch to World Health Organization Growth Curves.” Academic pediatrics, April 2020. https://doi.org/10.1016/j.acap.2019.05.126.
• C, Garza, and Butte Nf. “Energy Intakes of Human Milk-Fed Infants during the First Year.” The Journal of pediatrics, August 1990. https://doi.org/10.1016/s0022-3476(05)80009-5.
• Ct, Wood, Skinner Ac, Yin Hs, Rothman Rl, Sanders Lm, Delamater Am, and Perrin Em. “Bottle Size and Weight Gain in Formula-Fed Infants.” Pediatrics, July 2016. https://doi.org/10.1542/peds.2015-4538.
• Je, Stuff, and Nichols Bl. “Nutrient Intake and Growth Performance of Older Infants Fed Human Milk.” The Journal of pediatrics, December 1989. https://doi.org/10.1016/s0022-3476(89)80750-4.
• Ka, Bell, Wagner Cl, Feldman Ha, Shypailo Rj, and Belfort Mb. “Associations of Infant Feeding with Trajectories of Body Composition and Growth.” The American journal of clinical nutrition, August 2017. https://doi.org/10.3945/ajcn.116.151126.
● Kg, Dewey. “Growth Characteristics of Breast-Fed Compared to Formula-Fed Infants.” Biology of the neonate, 1998. https://doi.org/10.1159/000014016.
● Nc, de Bruin, Degenhart Hj, Gàl S, Westerterp Kr, Stijnen T, and Visser Hk. “Energy Utilization and Growth in Breast-Fed and Formula-Fed Infants Measured Prospectively during the First Year of Life.” The American journal of clinical nutrition, May 1998. https://doi.org/10.1093/ajcn/67.5.885.
● Nf, Butte, Wong Ww, Hopkinson Jm, Heinz Cj, Mehta Nr, and Smith Eo. “Energy Requirements Derived from Total Energy Expenditure and Energy Deposition during the First 2 y of Life.” The American journal of clinical nutrition, December 2000. https://doi.org/10.1093/ajcn/72.6.1558.
● Ps, Davies. “Energy Requirements for Growth and Development in Infancy.” The American journal of clinical nutrition, October 1998. https://doi.org/10.1093/ajcn/68.4.939S.
● Sw, Jones, Lee M, and Brown A. “Spoonfeeding Is Associated with Increased Infant Weight but Only amongst Formula-Fed Infants.” Maternal & child nutrition, July 2020. https://doi.org/10.1111/mcn.12941.
● Z, Karatas, Durmus Aydogdu S, Dinleyici Ec, Colak O, and Dogruel N. “Breastmilk Ghrelin, Leptin, and Fat Levels Changing Foremilk to Hindmilk: Is That Important for Self-Control of Feeding?” European journal of pediatrics, October 2011. https://doi.org/10.1007/s00431-011-1438-1.
Volume is 24 – 30 ounces per 24 hours
1. Jc, Kent, Hepworth Ar, Sherriff Jl, Cox Db, Mitoulas Lr, and Hartmann Pe. “Longitudinal Changes in Breastfeeding Patterns from 1 to 6 Months of Lactation.” Breastfeeding medicine, August 2013. https://doi.org/10.1089/bfm.2012.0141.
2. Jc, Kent, Mitoulas L, Cox Db, Owens Ra, and Hartmann Pe. “Breast Volume and Milk Production during Extended Lactation in Women.” Experimental physiology, March 1999. https://pubmed.ncbi.nlm.nih.gov/10226183/.
3. Jc, Kent, Mitoulas Lr, Cregan Md, Ramsay Dt, Doherty Da, and Hartmann Pe. “Volume and Frequency of Breastfeedings and Fat Content of Breast Milk throughout the Day.” Pediatrics, March 2006. https://doi.org/10.1542/peds.2005-1417.
How baby removes milk from the breast
• Vacuum with jaw drop• Strength of head/neck• Tongue peristalsis• Shape of palate/facial
bones
© Laurie B. Jones
DMX: cause for low supply➢ Infant does not remove milk effectively from the breast
Drinking through BENT STRAW
➢ Lactating parent’s supply dwindles down from incomplete emptying, nipple injury/pain, callous/blisters, plugged ducts, mastitis, abscess
➢ Multi-factorial function diagnosis (VERB)Not a visual diagnosis (NOUN)
➢ Requires intervention with combination of: PT, feeding therapy, ENT, frenectomy, OMM
➢ Triple feeding: direct breastfeeding, pumping after feeding, supplementing (PACED BOTTLE FEEDING. SNS/LactAid)
Growth:Human milk fed infants
Grow slower3-12 months
Caloric needDecreases over time
Grow faster0-2 months
Same volume grows a baby at 6 weeks as 6 months of age!
Peter Davies 1998, Dewey amazing work too
Kcalper Kg
Goes down over time
WEIGHT BASED
VOLUME
CALCULATIONS
*ARE NOT* for
human milk fed
babies
Treatment Plan
More emptyingReferrals for DMX
Labs for parentFeed more milk
4
1
2
3
Fix the fixables
Lactating parentInfant
While homeWhile separatedPin down details
Detailed history
Newborn screen results, sweating with feeds, bloody
stools, renal disease,vomiting, dysmorphic features, recurrent infections
ROSShows true concerning
pattern
Growth chart
DDx: Detailed feeding history
Type of milk
From the tapFrozen parent milkDonated peer milk
Formula
Longest stretch of sleep
Infant did on own?Parent sleep trained ?
# of feeds
Direct BF pump only
Pump after direct BF
Freezer
Is parent freezing milk daily?How much frozen milk exists
in house?
# of pumpHow many oz pumped
when pump only
Sides
Both at each feedingOne makes >>> than other
Denial/bargaining
Can’t argue with growth chart that has accurate measurements on it
“Happy to starve”/content babies are the scariest
“He/she seems full. I can’t get baby to take more even when I offer.
All my kids are small.”
DDx: Signs of DMX
Nipple shape
? Lipstick shape? Crease down the middleImmediately after feeding
Plugged ducts
From callous – FRICTION-keratin BLEB
Milk stasis leads to plugs
Painful feedings-Should not have chomping, chewing, tongue thrust-Should not need nipple shield or salves daily
One side not painful
Neck tight from in utero positioning
Clicking
Fast flow all babies clickContinuous METRONOME
clicking is abnormal Snap back of tongue
MastitisSkin infection (a sign of DMX/poor
latch) or milk stasis Recurrent mastitis is DMX until proven otherwise
● Making enough for a future baby and current baby is oversupply
● Oversupply leads to milk stasis if pumping isn’t maintained
● Oversupply masks DMX problems until parent slows down pumping
● Direct feeding in massive oversupply can have slow growing infant (% fat start of feed is very low)
● Normal milk supply and freezing daily WILL LEAD to a slow growing infant
● Feed the baby not the freezer
● Always always always ask where the pumped milk is going. We assume into baby but often it’s going into freezer
● How much is being frozen per day?
Oversupply Freezer Theft
Over 6 months
❖ How much do we all HATE the phrase solids under 1 are just for fun ?
❖ DANGEROUS for growth and iron stores and zinc deficiency
❖ Baby led solids vs. purees vs. combination
❖ Fear of gagging, choking. Fear of allergies. Trying to make all organic or perfectionism in the baby foods
❖ Slow solids are a major contributor to slow weight gain over six months
DDx: Maternal questions
Chest or pituitarysurgery
Chest tubeRadiation
Central line
New medicationsHerbs, vitamins
TobaccoPseudophed
Estrogen
Breast surgery
ReductionImplant (above/below)
Hypoplasia?Peri-areolar biopsies/incisions
Contraception
Implanted devicePills (? E ?P)
Lack of …. And there’s a new placenta!!
Medical history
PCOS, hypothyroidism, infertility, insulin resistance, gestDM,
retained placenta, Post partum hemorrhage
Dietary restrictionsVegan (B12)
Rapid weight loss
Family feeding goals
PMAD
Perinatal Mood and Anxiety DisorderCheck EPDS score
Shared decision making – avoid paternalistic approach
Reassess goals
How important is breastmilk only for feeding?Exclusive pumping- nightmare or relief?
INCLUSIVE BREASTFEEDING
You aren’t defined by how many ounces you make
Pressured feeding can lead to oral aversion
Feeding trauma
What happened with previous children?
Transmitting concern without trauma is challenging
Social Determinants of Health
Return to work/school
- Infant becomes a “project”- Less direct breastfeeding
Breast pump
- WIC pump- Private insurance
DME companies
Family support
- Caregivers are bottle feeding
- No help at night
Specialist appts
- Cost and travel to appointments
- Out of pocket for some services
- Copays
Treatment Plan
More emptyingReferrals for DMX
Labs for parentFeed more milk
4
1
2
3
Fix the fixables
Lactating parentInfant
While homeWhile separatedPin down details
Detailed history
Newborn screen results, sweating with feeds, bloody
stools, renal disease,vomiting, dysmorphic features, recurrent infections
ROSShows true concerning
pattern
Growth chart
Best galactogogue
GOOD EMPTYINGFREQUENT EMPTYING
- cookies: time sink, eat any calories, pump more- Pills: no quick fix plenty of side effects (Reglan, Domperidone)- Herbs: expensive, know what you are treating- Nasal oxytocin: tachyphylaxis, challenging to find
Effectiveness depends on how far into apoptosis the lactocytes/alveoli/quadrants/breast have gone
Treatment Booby Traps
❑ Pump volume for 24 hours does NOT equal what infant is taking in. Breasts can hold more than infant removes and not all parents can let down as well for pump as infant
❑ Adding unsterile formula powder to breast milk does not solve a volume problem and adulterates the milk
Give formula mixed with water properly if there is low milk production and there is none of parent’s own milk to use
❑ When there is extra milk – don’t use formula – feed it directly and can Lactoengineer excess frozen milk: thaw in fridge, fat separates out, scoop with spoon and add to bottles the next day
o Extra milk beyond normal volume,
fresh or thawed frozen milk
o Set aside 3+ ounces of milk in
wide opening container (closed lid)
for 24 hours in fridge
o Scoop out fat spoon or spatula
add to one bottle of EBM per day
o Label the remaining milk for other
purposes (eczema, etc.)
● Works with oversupply and those who pump
● Divide a typical pump session time (in minutes) into thirds
● First 2/3rd of time collect & freeze for later
● Remaining 1/3rd of time collect and feed to infant
Lactoengineering
ACTIVE (skimming) PASSIVE (hindmilk)
Lactoengineering, hindmilk, crematocrit references
1. Meier, P., Engstrom, J., Murtaugh, M. et al. Mothers' Milk Feedings in the Neonatal Intensive Care Unit: Accuracy of the Creamatocrit Technique. J Perinatol 22, 646–649 (2002). https://doi.org/10.1038/sj.jp.7210825
2. S. Zibadi, R.R. Watson and V.R. Preedy (eds.) Handbook of dietary and nutritional aspects of human breast milk Human Health Handbooks no. 5 – DOI 10.3920/978-90-8686-764-6_11, © Wageningen Academic Publishers 2013 (Pages 193-213)
3. Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities, 3rd Ed. Pediatric Nutrition Practice Group; Caroline Steele, MS, RD, CSP, IBCLC, FAND and Emily Collins, MHA, RD, CNSC, 2019. Chapter Six: “Lactoengineering” pages 113 –128.
Treatment Booby Traps
❑ No such thing as low calorie milk
❑ Maternal diet (short of extreme starvation) does not impact milk quality or calories
❑ Cannot increase fat content of lactating parent’s milk by diet
❑ Fat sticking to bottle: PROBLEM
❑ Fat sticking to feeding tube: HUGE PROBLEM50% of the calories from human milk come from fat Warm the tubing, lechithin, bolus vs. drip
Treatment Booby Traps
❑ Misuse of milk transfer (weighted feeds) measured in office in a single time point
❑ Ounces that breasts “hold” at maximum are not equal to what baby is extracting/drinking
❑ Bottle demand volumes do not correlate with volume removed from breasts with on-demand feeding
❑ Wet diapers have no value after first days of life; stool counts drift lower as the casein: whey changes in the milk
Counsel carefully to avoid trauma
✓ #NQOYWD Never Quit On Your Worst Day
✓ Baby’s growth chart is not a report card on your parenting ability
✓ We will slowly correct this together
✓ Give parents TOOLS in tool belt: they decide which ones work
✓ Reassess with enough time to show change
✓ May have new tracking on lower curve as success
Anticipatory Guidanceto prevent slow growing infant
➢ 1 month WCC: milk volume is almost in steady state, on demand intuitive feeding key to robust supply
➢ 2 mo WCC: milk volume does not go up over time, paced bottle feeding by caregivers; rigid schedules not good
➢ Most WCC: sleep expectations, need 1-3 overnight feeds through first year of life depending on MAGIC # (storage capacity). Don’t give advice for unicorn breasts.
➢ Sleep training to go long stretches overnight will lower milk supply unless parent wakes to pump or dream feed.
Self-directed learning
www.lacted.org ** Non-profit ** “IABLE” Institute for the Advancement of Breastfeeding Lactation Education
1 hour, 3 hour, 8 hour, 2 day, 4 day courses GIVEN BY PHYSICIANS for physicians; “Little Green Book of Breastfeeding” for physicians
LactFact app, Podcasts, case series webinar Sunday nights, FREE & low cost to residents and medical students
www.bfmed.org Academy of Breastfeeding Medicine physician organization PROTOCOLS! Don’t reinvent the wheel. Annual meeting: great place for resident/student poster presentations!
International membership.
www.infantrisk.org
Never ever say pump and dump without looking (app) or calling.
Online communities
Dr. MILK on Facebook- helping physician (MD/DO/MBSS) parents reach breastfeeding goals- 31,000+ members from around the world- cis-gendered men not allowed in the group
Doctors Practicing Breastfeeding Medicine - on Facebook - how to incorporate BF into your practice- pursuing IBCLC or FABM- practice management- complicated cases you’ve seen - all genders/nonbinary welcome in this group
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