FALTERING GROWTH
Excessive weight loss in the first weeks of life is covered separately. This page does not cover general medical management of faltering growth, only issues related to breastfeeding/chestfeeding.
NICE recommends defining faltering growth as
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A fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
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A fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles
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A fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
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When current weight is below the 2nd centile for age, whatever the birthweight.
In a breastfed/chestfed baby with faltering growth NICE recommends (as part of a comprehensive assessment) that a person with 'appropriate training and expertise' directly observes feeds - ie expert face to face breastfeeding/chestfeeding support. This will help to decide whether the faltering growth may be caused by ineffective feeding, feeding routines that are restricting the infant's access to the breast/chest or how the parents respond to the infant's feeding cues.
If a decision is made to recommend infant formula to a baby with faltering growth, NICE recommends:
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Supporting the parent to continue breastfeeding/chestfeeding (as supplementation often results in complete cessation of breastfeeding/chestfeeding)
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Advising the parent to express milk to promote milk supply
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Feeding the infant with any available human milk before giving any infant formula
Both of these aspects (assessment and support if formula if required) should be done by lactation experts. If the hospital team does not include lactation experts then close communication with community experts is necessary.
Concern over milk supply
A NICE Clinical Knowledge Summary describes the causes of low milk supply. The most common cause is reduced milk intake by the baby, either because of difficulties with positioning and attachment to the breast/chest or lack of access to the breast/chest. Lack of access may be due to parental expectations of feed frequency, restriction of night feeds, use of a pacifier or maternal/parental mental health problems leading to reduced response to feeding cues.
The NICE Clinical Knowledge Summary recommends that everyone with breastfeeding/chestfeeding problems, including low milk supply, be assessed by an expert in lactation (such as a community feeding specialist) for advice on positioning, attachment and responsive feeding. Health professionals should also:
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Provide printed information and direct parents to community breastfeeding/chestfeeding support organisations, including national helplines (links are provided in the CKS).
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Advise on increasing skin-to-skin contact (if appropriate); to feed the infant with no restrictions on the frequency or length of feeds; offering both sides at each feed, and alternating between sides to stimulate more sucking.
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Advise on expressing milk after feeds, to stimulate milk production.
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If these measures do not improve a true low milk supply and prolactin deficiency is a possible cause, consider referral to an endocrinologist for advice on prescribing a galactogogue drug (such as domperidone, off-label indication) to help improve milk supply.
The voice of the breastfeeding/chestfeeding family
