Supporting sister and baby niece with feeding (long)

[awkwardpenguin]

My sister had a baby 8 weeks ago. It’s her third and she had major problems breastfeeding her first two and ended up combo feeding both older kids. She was really hoping this time would be different. She sought out a breastfeeding friendly pediatrician and worked with an IBCLC since birth.

Baby was 9 lbs 15 oz at birth. Dropped to 9 lbs 3 oz at day 5. When she hadn’t regained even close to her birth weight by day 12 the pedi suggested supplementing with formula. Sister wanted to give it more time. Baby finally regained birth weight at 4 weeks. Has been gaining slowly since then and continues to drop percentiles. Had a tongue tie revised at 4 weeks 3 days, and sister thinks that’s the root of the issues. Sister is pumping about 4x a day after feeds and supplementing after feeds with the pumped milk. But baby still isn’t gaining enough. She started at the 97th percentile and now is at the 46th. She borrowed a scale from the IBCLC so she hasn’t had her weight checked at the pedi since her 1 month appointment.

We came to visit from out of town a week ago and the baby only gained 2 oz in that week. I kind of freaked out and talked to my sister about making a plan to get her gaining weight. Sister agreed to feed every two hours, pump after every feed, and supplement with the pumped milk. This is more frequent feeding than she has been doing and more pumping, with the goal of increasing her supply and getting the baby more milk. We said we’d give it a few days and I’d extend my trip to help her make it happen.

Baby’s 2 month appointment is on Wednesday and now my sister is talking about finding a new pediatrician because she thinks the current one pushes formula. On one hand I think there’s no point in getting advice from a doctor she doesn’t trust, on the other I think it’s just another excuse to say there’s not really a problem. Sister is convinced that because the baby is alert and (mostly) happy that she’s fine. Thinks everyone is too focused on weight and not looking at the whole picture. The IBCLC seems to be telling my sister to keep doing what she’s doing, and she’s really the only one my sister trusts.

I’m honestly not sure what to do. I can stay longer but I don’t feel like my presence is making much difference. I could encourage her to go to her regular pedi appointment while she looks for a new doctor and go with her to the appointment. To complicate matters, my sister lives abroad and will be returning to her home country in two weeks. So then it’ll just be up to her judgment and any pediatrician she works with there. I’m worried that even if the pedi in her home country has concerns she will dismiss them just like she does American doctors.

I guess I’m just trying to figure out how I can help them, and get advice on what level of concern is appropriate. I’m fairly worried but don’t want to overstep.

[hermione]

I didn't want to read and not answer but my answer is probably not helpful.

I'd overstep. I'd say what you said here: "Sister, I love and support you but I am concerned for baby. I think there is a problem here that you don't want to see and that seeking a new pediatrician is another way for you to avoid that problem."

[Patsy Baloney]

I have a lot of random thoughts and will say that I’m a 2xs exclusively FF mom, the first because of uncooperative boobs, the second because of a medical issue, so I don’t understand a lot of the passion surrounding breast feeding. That’s likely to color my response.

She sounds...sick. Obsessive in a way that is beyond the give it 110% of your effort and a little bit more. I know it takes a lot to breastfeed, but I think most are rational in their approach and know when help (supplementing) is needed.

Her baby had a pretty high birth weight, so there is definitely room to fall on the growth chart and settle into the curve, but if the doctor is alarmed at slow weight gain, it is time to take feeding issues very seriously.

I would agree that it’s time to overstep and voice concerns.

[lilac05]

I’ve seen an article here before about how supplementing with formula early can actually help preserve a breastfeeding relationship. Maybe look and see if you can find that.

Having had two giant babies, I think some people are less worried about weight gain because they feel there’s more of a “cushion”. When a 6lb baby doesn’t gain weight, people seem to respond a little more urgently than when they’re already the size of some 3 month olds at birth. I’ve also read that a pretty quick drop in percentiles can happen after birth if baby’s weight was because of a lot of excess fluid; however, that didn’t happen with either of my ~10lb babies. Stuff like that may, however, be where she’s basing her lack of concern. I don’t know if there is any actual truth behind any of those positions, but they are things I picked up from having big babies.

[awkwardpenguin]

Thanks. I guess “overstep” isn’t the right word. I feel like right now she’s willing to listen to me so I’m worried about pushing too hard and losing that.

[lemoncupcake]

Oct 19, 2019 11:40:06 GMT -5 lilac05 said:

I’ve seen an article here before (maybe posted by pugz?) about how supplementing with formula early can actually help preserve a breastfeeding relationship. Maybe look and see if you can find that.

Having had two giant babies, I think some people are less worried about weight gain because they feel there’s more of a “cushion”. When a 6lb baby doesn’t gain weight, people seem to respond a little more urgently than when they’re already the size of some 3 month olds at birth. I’ve also read that a pretty quick drop in percentiles can happen after birth if baby’s weight was because of a lot of excess fluid; however, that didn’t happen with either of my ~10lb babies. Stuff like that may, however, be where she’s basing her lack of concern. I don’t know if there is any actual truth behind any of those positions, but they are things I picked up from having big babies.

But if that were the case you’d see a big drop after birth but then a normal growth rate after week-to-week, which doesn’t seem to be happening here.

I’d push her to keep her existing 8 week appointment time - will she let you go with her? If you give her some tough love how do you think she’d take it? I’d be concerned if I were in your shoes too. Thank you for advocating for your sister and niece.

[SusanBAnthony]

So the only red flag on all this for me is that apparently she was nursing less than every two hours? And is now nursing only every two hours?

I'm sure someone here will chime in that their 100% BF baby went over two hours between feeding but no BF baby I've met IRL did that as a newborn. They were on the boob freaking constantly. So I'm wondering if she just isn't feeding enough, and whether that is because baby doesn't want to eat or she isn't initiating, or what.

IBCLC's are usually excellent (they have a ton more training than garden variety "lactation consultants" who can have very little training). But the fact that I. 3 weeks she won't have the lactation consultant is very concerning.

[namasteak]

Oct 19, 2019 11:26:15 GMT -5 hermione said:

I didn't want to read and not answer but my answer is probably not helpful.

I'd overstep. I'd say what you said here: "Sister, I love and support you but I am concerned for baby. I think there is a problem here that you don't want to see and that seeking a new pediatrician is another way for you to avoid that problem."

100%

Maybe give her some info on why formula feeding isn’t a bad thing? The fearless formula feeder is a good resource.

[awkwardpenguin]

She’s counting the two hours from the beginning of the nurse/pump/supplement cycle, so it feels like pretty frequent feeding. It adds up to 10 feedings in 24 hours. Before that she was feeding “on demand” and the baby was feeding about 7 times a day, which is the low end of average for 2 months. The baby doesn’t seem hungry, and this past week she wasn’t taking the full supplement when it’s offered. But today she seemed hungrier even with nursing more and took all the supplement and would probably have taken more if we’d had more milk. So I’m not sure what’s going on with her hunger levels.

[awkwardpenguin]

Oct 19, 2019 21:15:59 GMT -5 al dente said:

Have they done a weighted feed to see how much the baby is getting when nursing? If baby is nursing and then mom is able to pump and the baby is eating that as well it seems like they’re not emptying the breast and getting full.

She did a weighed feeding a month ago before the tongue tie revision and she transferred 1.75 oz. My sister says since the revision it seems like baby is getting more than before, based on hearing her gulping and swallowing.

I’m also not sure if my sister was pumping at the right times before. Doing just after feeds she’s only getting a half ounce or ounce. Before she was doing at least two of the pumping sessions in place of feeds so she’d get enough milk to “supplement”, but that shouldn’t really count as a supplement. Basically she’d pump while the baby slept rather than waking the baby to feed, which I didn’t realize.

[tacom]

I have a bunch of disconnected thoughts.

1) Honestly, I would trust the IBCLC unless there’s a reason not to. If you’re concerned, maybe you can offer to help her get a second opinion with another IBCLC? But I would trust them over my pedi on bf’ing advice - which my pedi would support.

2) 46th percentile alone doesn’t alarm me. Some drop in %ile after birth for a 9lb+ baby (especially for a third pregnancy) wouldn’t alarm me— baby could be finding their “normal” curve now. A continual drop in percentiles after birth would give me worry— but are these just small numbers or is the baby truly falling off the curve?

3) I agree that feeding and pumping frequency both seem infrequent for someone pushing to EBF a baby with weight concerns. Been there, done that. Worked with multiple IBCLCs who all wanted me to feed every 2 hours and pump after each feeding. One even instructed me to manually express for 5 min after nursing and pumping. That was fun! In any event, a second opinion might not be a bad idea...

4) I would definitely not suggest exclusively pumping to measure output. Babies are generally more efficient at removing milk from a breast so you might inadvertently limit milk intake ... if numbers are important I’ve done weighted feeds in the past with IBCLCs but have always been told that even those are just estimates. Weight gain and dirty diapers are the gold standard for gauging intake

[pooh8402]

As a nurse, all of this is very alarming to me. I agree with the first 2 replies. I fear that she's becoming obsessive and has bought into the "breast is best" mentality that has hurt babies. Definitely watch for signs of postpartum depression. Dropping percentiles like that is not normal. And the fact that she doesn't want to see a healthcare provider is alarming as well.

[joy]

I am also hung up on the obsessive nature of all this. I was thinking about feeding every two hours followed by pumping. That is a tremendous time dedication and she has two other children. I think her strive is admirable but it’s reading a bit more than that now.

That being said - my child also lost too much weight and wasn’t gaining well on breastmilk alone. I supplemented from the beginning and felt a mixture of shame and relief from it. I did the feed then pump. I would give pumped milk from last feeding after she tried to breastfeed the current time. Then I’d pump to repeat the process. My pediatrician stressed doing this over night, as well. I went whole hog and got the hospital-grade pump from Children’s Hospital. I eventually looked at my life, recognized my dread of *everything* related to feeding and finally said eff it all at 7 weeks. I wanted to enjoy my baby. It shouldn’t be **this** hard and it was okay to go a different way if other areas of my life improved.

My pediatrician suggested a dual feeding system where the baby got breastmilk and formula at the same time. As she was explaining it, I must have made a sad face and she stopped. I told her I didn’t want to force this anymore and I was going to move to formula. She smiled and said that while this system is great for some, I looked relieved the moment I said I was done and *that* was the right choice in this situation. I’m so grateful that she would have supported ends of earth breastfeeding solutions but also equally supported my choice to stop. I felt so validated and buoyed to go forward.

Best of luck to your sister and baby.

[isabel]

Oct 19, 2019 11:26:15 GMT -5 hermione said:

I didn't want to read and not answer but my answer is probably not helpful.

I'd overstep. I'd say what you said here: "Sister, I love and support you but I am concerned for baby. I think there is a problem here that you don't want to see and that seeking a new pediatrician is another way for you to avoid that problem."

This.

That was disturbing to read. That child is not getting enough nutrition. That’s scary. I would feel immense guilt if I left without straight up telling her that she is not feeding her child enough and she needs to listen to the doctor and figure out how to get her child fed.

Could she have PPD/PPA? That’s a factor to consider. She doesn’t sound well.

(Removed comment re purchasing breastmilk.)

[raangoli]

Oct 20, 2019 7:53:26 GMT -5 pooh8402 said:

As a nurse, all of this is very alarming to me. I agree with the first 2 replies. I fear that she's becoming obsessive and has bought into the "breast is best" mentality that has hurt babies. Definitely watch for signs of postpartum depression. Dropping percentiles like that is not normal. And the fact that she doesn't want to see a healthcare provider is alarming as well.

I’m not a nurse and this is the same thought process I had.

I do think there is more at play here than just breast is best and I worry for your sister’s mental health post-partum.

[lilac05]

Oct 19, 2019 13:10:35 GMT -5 lemoncupcake said:

But if that were the case you’d see a big drop after birth but then a normal growth rate after week-to-week, which doesn’t seem to be happening here.

I agree with you.  Sometimes I feel like the best way to solve a problem like this is to try and figure out where the person is coming from.  If you can identify that, you might be more successful in guiding her towards better decisions.  My two comments were not in any way to support what is happening, but to offer a possible reason why she may think what she is doing is best beyond just “breast is best.”

I would have the hard conversations about both her mental health and feeding baby.  These are both especially important as she’s about to leave her bigger support system.

[pooh8402]

Oct 20, 2019 8:45:56 GMT -5 isabel said:

ETA: Could she purchase breastmilk to supplement with? Do you think that would be an option she’s open to in order to avoid formula?

Please don't do this. It's not safe and has not been screened for diseases or medications or drugs. Plus it adds to the mentality of "breast is best" at all costs rather than simply feeding a child.

[isabel]

Oct 20, 2019 8:59:39 GMT -5 pooh8402 said:

Oct 20, 2019 8:45:56 GMT -5 isabel said:

ETA: Could she purchase breastmilk to supplement with? Do you think that would be an option she’s open to in order to avoid formula?

Please don't do this. It's not safe and has not been screened for diseases or medications or drugs. Plus it adds to the mentality of "breast is best" at all costs rather than simply feeding a child.

Sorry, I didn’t realize. I thought there were screened banks for this. I’ll remove that comment.

[pooh8402]

Oct 20, 2019 9:04:27 GMT -5 isabel said:

Oct 20, 2019 8:59:39 GMT -5 pooh8402 said:

Please don't do this. It's not safe and has not been screened for diseases or medications or drugs. Plus it adds to the mentality of "breast is best" at all costs rather than simply feeding a child.

Sorry, I didn’t realize. I thought there were screened banks for this. I’ll remove that comment.

The milk banks prioritize the donated milk for those with medical needs and there is not enough left to sell. Those who sell breastmilk are doing so on the gray market.

[awkwardpenguin]

Oct 19, 2019 21:41:50 GMT -5 tacom said:

2) 46th percentile alone doesn’t alarm me. Some drop in %ile after birth for a 9lb+ baby (especially for a third pregnancy) wouldn’t alarm me— baby could be finding their “normal” curve now. A continual drop in percentiles after birth would give me worry— but are these just small numbers or is the baby truly falling off the curve?

She has continually dropped percentiles.  Was 97th at birth (she was born at 41w3d), was 94th at 5 days, 71st at one month, and 46th when she weighed her Friday.  She dropped at all the weighings in between as well.

The pediatrician wants her gaining an ounce a day, but my sister is going by the AAP range of 4-7 oz and she’s still behind the low end of that.  If you measure from her lowest weight she’s gained 27 oz in 52 days.  If you measure from the tie revision, she’s gained 12 oz in 24 days, so the same overall rate as before the tie revision.

I did say to her that no matter how you measure she hasn’t gained enough and she said she knows that.  I’m not sure how she reconciles knowing she hasn’t gained enough with not doing more about it.

She’s doing more frequent feeding for two days now, so I’m hoping that makes a difference.  We haven’t had as much to supplement with as before but hopefully that’s because she’s getting more at the breast.

I am fairly certain that any medical provider will be concerned, so I’m going to make sure she either keeps the appointment or finds someone new who can see her right away.  She’s already seeing the only doctor in her area who specializes in breastfeeding medicine so I think finding a new doctor who will say she doesn’t need to supplement is a pipe dream.

[pooh8402]

Yea if she's already seeing a doctor who specializes in breastfeeding medicine and THAT doctor is telling her to supplement, she's not going to find another reputable doctor who will tell her otherwise.

[pooh8402]

Maybe this will help?

pediatrics.aappublications.org/content/131/6/1059.short

www.ncbi.nlm.nih.gov/m/pubmed/29550235/

[vmars]

I agree def have her supplement with formula. My friend did that with her first and I think she said there was some different options for formula abroad that she felt more comfortable using (she is French so her mom sent it to her to use). You could tell her to look into that since she will be abroad. She may benefit from talking to another mom who has been there too. I am sure there’s a lot of emotions going on, so I’d be gentle with her, but also encourage her that using formula makes her a good mom.

[brooke77]

I agree with PP’s. My gut reaction was that your sister may have some PPA/PPD. You mentioned that she supplemented with formula with her first 2. Is it possible that her milk doesn’t contain enough fat and supplementation is necessary? I know it’s rare, but it sounds possible in her case.

I would intervene. She needs it and your niece needs it. Does she have a SO who would support you?

[boiler717]

This brings up a lot of emotion for me as I was in a similar situation myself. I’ll share my story and hopefully offer some advice but want to be open that this is from my experience so may not be completely unbiased and our situations are a bit different.
My son was a very slow gainer. He took 2 weeks to get back to 24 hour weight but 4 weeks to birth weight (c-section baby). He consistently gained 0.5/oz a day but continued to drop percentiles because the weight charts are based on a gain of 1-1.5 oz/day (can’t remember exactly which one). My pedi and LC focused more on the weekly weight gain vs. percentile for him, which I still think makes sense. I’m concerned that he’s gain 2 oz/week because that is well below 3.5 oz/week he should be (but your follow-up post made it sound like she’s at 0.5 oz/day so I’m not totally sure). Are the following good practices for taking weights (same scale, clean diaper/naked, not moving the scale between)?
She needs to do more weighted feeds. I highly suggest having a scale at home, and doing 24 hours of weighted feeds to see what he’s getting in a day. My son was getting 28-31 oz/day and 3-4 oz/feed (I fed around 8-10 times a day). Be sure to use a good scale and follow the recommendations for weighted feeds (keep baby in same clothes/diaper (don’t change even for poop) before and after feed and don’t move the scale).
I did not have a low supply problem, so I’m not sure how comparable this is. But for one week I offered my son a bottle of expressed milk after every feed and he never once took it. He would take a bottle in place of a feed so it wasn’t a case of bottle refusal, he was just full. If her baby is still hungry after supplementing I would recommend mixing formula with the breast milk when supplementing. Formula can be very helpful in preserving a breast-feeding relationship — it’s not all or nothing!
Does pumping after every feed include overnight? I would make sure she’s getting in pumps overnight as that is peak prolactin release and milk supply is the greatest. I would recommend for one feed a day (probably pre-bed time) that she ONLY give a bottle, as much as the baby needs, and do a power pump instead.
Instead of q2 around the clock, I would recommend every 90 min while awake — my son would generally eat, be awake for a bit, then I would feed again and he’d nap. I would wake from naps during the if they got to 2 hours since last feed. After 1m my son was waking once per night and I did not wake to feed but I could see your sis doing it.
I also ended up switching pediatricians at 2 weeks. One was because she was adamant that I completely stop nursing. My LC was a close friend and neighbor of my pedi, and she recommended that I find another pedi if I wanted more BFing support. I also got conflicting messages from my first pedi and another doc in her office I saw for a weight check. I would encourage your sis to follow up with her doctor to see what they say before switching without follow up. The new doc probably won’t make any changes at a first visit though.
Is your sis a single mom? How does her partner feel about all this? I think it’s great you are giving so much support but I’d also focus on empowering her to be confident in her decision making since she will be on her own soon, assuming she’s of sound mental health. I do think a PPA/PPD screening would be helpful.
In the end, the cause of my son’s slow gain ended up being a combo of a dairy allergy and high calorie needs. I ended up BFing for 3.5 years so all is not lost at this point. I do think there are some concerning flags that are different than my story (2 oz/week, not doing weighted feeds in particular, and baby being hungry after supplementing) that are a cause for concern and I would focus on those 3 areas.

[SusanBAnthony]

Reading your response about nursing frequency, I'll just day that no matter what the internet says is normal for a baby that age, I think many/most would say that actually nurse more. Like a LOT more than 7 nursing sessions a day.

Starting a nurse every two hours and then offering pumped milk after every nurse sounds about right. I don't know how she could maintain that but whatever. My coworker with premie twins is on an every two hours feeding schedule for his girls so that seems like standard advice.

I also agree that doing lots more weighted feeds seems advisable.

[tacom]

Oct 20, 2019 10:54:25 GMT -5 SusanBAnthony said:

Reading your response about nursing frequency, I'll just day that no matter what the internet says is normal for a baby that age, I think many/most would say that actually nurse more. Like a LOT more than 7 nursing sessions a day.

Echoing this. My 14 month old, who eats steak and potatoes, has only recently dropped to 7 nursing sessions in a 24 hour period.

I also want to make it clear that increasing feeding frequency and pumping + supplementing after each feed may help with the weight gain, but then it’s up to your sister to decide if that lifestyle is acceptable to her. I only had to do that for a very short period of time, and 1) it was hell 2) I didn’t have any other kids to care for

[awkwardpenguin]

I think it’s possible PPA is in play, but this is fairly in character for my sister. She’s all about all natural everything, is suspicious of the medical profession, especially about birth and breastfeeding. Her partner is supportive of whatever she thinks is best. He went back home when baby was 10 days old, so he’s not very close to what’s going on. He’s also not as concerned because her birthweight was so high, and he thinks maybe she’s “meant to be a smaller baby” because it’s uncommon for babies in his family to be born so large.

She has a WIC appointment on Tuesday and I expect they’ll also say something. Today she mentioned switching her WIC to combo feeding to get formula covered by WIC. That’s a huge change from how she was thinking a few days ago before I talked to her, so maybe some progress? She does seem to be taking this a little more seriously than before I talked to her, and following through on increasing nursing and pumping.

[sillygoosegirl]

Did she have per placenta encapsulated? If so, get her to throw away any remaining pills, as they can be super harmful to breastmilk supply (kinda like being pregnant kills milk supply for many women). Unfortunately this practice is often promoted as helpful to breastfeeding, including by a lot of "crunchies" and even still some LCs, and it's often something women who are very serious about being successful breastfeeding do to set themselves up for success, but it turns out it is very much bad for breastfeeding. (Eating an encapsulated placenta over weeks or months is very NOT comparable to a wild animal eating the whole thing immediately after giving birth.)

I think working on frequent feeds and properly timed pumping is a great start. You mentioned baby not always finishing the expressed milk. Did that just happen once, or does it happen often? Or does it vary with growth spurts? Because if baby isn't hungry for more, I'm not sure how adding formula would really help. (Unless maybe baby can't digest the milk well due to an intolerance or something... that happened to a friend of mine, but she was told it was a very rare situation.)

How long is baby nursing and how is she deciding to stop feeding at the breast and switch to pumped milk? I ask because I had one of those babies who wanted to nurse for like an hour or more at a time, every 2 hours or so. She never had a problem gaining weight, but I think there's a strong possibility she would have if I'd limited her time at the breast. (Granted, I'm not sure I'd choose to spend 8-12 hours/day breastfeeding again over using formula... and I'm not sure I'd recommend it to anyone... but from what I understand it is pretty normal for that to be what it takes, and it seems to me that an honest discussion of that is warranted, especially for a mother who really really wants to EBF.) At any rate, limiting baby to a reasonable feeling 10 minutes per side, and then giving pumped milk under the assumption that the breasts have been emptied, will generally result in a much lower supply over time than letting baby nurse for an hour... or however long they want. Obviously there are cases where a newborn baby doesn't have the strength for that, hence triple feeding, but I do feel like sometimes triple feeding is recommended in cases where baby does have the strength to stay awake and alert after feedings, but without thought to the milk supply consequence of shortening time at the breast with pumping.

I'd encourage her to go back to the current pediatrician for the upcoming appointment. She can always get a second opinion afterwards. This pediatrician is the one whose been working with her baby so far and has the full record and she should hear him/her out, if for no other reason than that this doctor has the most knowledge about the baby. If she hears stuff she doesn't agree with, she should note it so she can ask a new pediatrician about it, so she can be sure the new pediatrician is giving different advice for a good reason, not because the new pediatrician missed something important in baby's chart.

[awkwardpenguin]

sillygoosegirl, I don’t think she encapsulated her placenta this time. She did last time but I haven’t heard anything about it this time. But I’ll double check.

The baby didn’t finish the pumped milk several times last week but that hasn’t happened in the last two days. Since switching the timing of pumping she’s had less pumped milk to supplement with, so right now baby has two or three feeds where she’s not getting pumped milk or only getting a half ounce. I think she’d take formula if offered at this point.

She nurses for 15-20 minutes a side, it seems. She switches sides when baby stops actively sucking, often because the baby’s fallen asleep. My best guess is baby is too sleepy to nurse effectively longer than that and the bottle is easier for her, but I think it’s good to think about supply long term.