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7.5 Inadequate weight gain

Inadequate weight gain, or failure to thrive (FTT) is a sign of poor health that is caused by other factors. It's not a condition in its own right.

Definition of failure to thrive (FTT)

In the younger baby weight loss of >7 - 10% of birthweight, or failure to regain birthweight by the second week is considered abnormal.

In the older baby it may be defined in several ways

  • an infant whose weight or height for age is less than the 3rd or 5th percentile
  • an infant whose weight for age falls through 2 major percentile curves on their growth chart
  • weight less than 80% of ideal body weight for age

Review the WHO Child Growth Standards as covered in Topic 6.3 . It is important to have a good understanding of normal growth and to be competent to recognise sub-optimal growth patterns.
All infant measurements should be plotted on these charts only.

Cause of failure to thrive

  • poor absorption and/or the inability to use absorbed nutrients, or
  • increased metabolic demands, (eg heart disease, undiagnosed infection, etc) or
  • inadequate energy intake from

    • an insufficient supply of breastmilk, or
    • regulation of breastfeeding such that the baby is unable to take sufficient breastmilk, or
    • inability of the baby to suckle effectively at the breast.

What to do about excessive newborn weight loss

All newborns lose weight after they are born regardless of whether breastfed or formula-fed. Mean weight loss of between 5.5% for infants optimally breastfed and born in a Baby Friendly designated hospital, 1 and 7% is considered normal.
This weight loss is attributed to the infant correcting his fluid status in the first 24 hours. Infant weight loss is greater than the average when mothers receive 1200ml or more intravenous fluids in the 2 hours prior to birthing. In these cases it is suggested that the infant's weight at 24 hours should be the benchmark against which further weight recordings are compared. 2

History and examination

A good history followed by examination of the mother and infant should allow you to identify why the infant is losing weight. You may identify maternal medical, surgical or medication-use reasons, however the most common reason will be that the infant has not been breastfeeding frequently or effectively enough.

Management

Encourage:
  • extended skin-to-skin care (hours at a time)
  • responding immediately to the earliest feeding cues
  • good, deep latch and effective suckling
  • observe for milk transfer (ie swallowing appropriate to the volume of intake expected by age)
Other tips to improve breastmilk production and transfer include:
  • breast compression while breastfeeding
  • hand expressing between breastfeeds (give the milk to baby via cup, spoon or finger-feed)
  • hands-on pumping if secretory activation (lactogenesis II) has occurred
  • (refresh your memory of hand expressing and hands-on pumping at Topic 6.1)
Supplementing
Additional supplementation (with artificial infant formula) may be required if the above measures do not result in an improvement.
Refer to Topic 7.3 on how to supplement.

The volume of supplement given should be individualized to the infant's immediate needs and age. Thoughtful supplementation can rescue a dangerous situation and support the mother to continue to successfully breastfeed. Thoughtless supplementation can cause further ill health for the infant and risk the success of breastfeeding.

What to do when you suspect FTT

Record a thorough history

Your routine history intake form should allow you to identify issues that may be significant, eg. gestational age at birth, weight at birth, weight at hospital discharge, interventions in birthing, early postnatal breastfeeding history, jaundice, ill health since birth, maternal medical, surgical, obstetric and lactation history, etc. [Discuss in the forums or with your colleagues why each of these could be significant.]

  • If the mother has been concerned about her baby's growth, ask her what actions she has taken to date; eg. doctor review, pumping additional breastmilk, using breast compression, taking a galactagogue, giving supplements, etc.
  • Ask the mother to describe typical breastfeeding behavior.

    If necessary prompt the mother to include:

    • type of feeding cues and her response to them,
    • describe when the baby feeds, not just how many times per day or night,
    • baby's behavior before, during and after breastfeeds,
    • the mother's active involvement, eg. waking baby to feed, delaying feeding to fit a schedule or her busy lifestyle, stimulating baby to continue to breastfeed, stopping baby after a time-limit, etc.
  • Ask the mother about complementary foods, or other fluids given to baby, or the use of a pacifier - How much? How often? Why? ...
  • Ask her to describe her baby's urine and stool output in a typical day. It would be an advantage if you could see a wet and a dirty diaper/nappy.
  • Ask her to describe her baby's temperament. If crying behavior sounds excessive, ask for a more detailed description of frequency and type.
  • Ask her about her baby's recent state of health.
  • Does she give the baby any medications (prescription or non-prescription), vitamins, 'tonics', etc?
  • If you don't already have it, plot as many weight and length measurements onto the WHO Growth Chart as the mother is able to provide you with. From this you will be able to determine a trend.
  • Ask about her recent state of health, medications (prescription and non-prescription) and postpartum recovery, particularly her lochia. [Why ask about lochia?]
  • Ask her about the growth patterns of her other children, if applicable. If they followed a similar growth pattern did she do anything to try to influence it? Was it successful?
  • Social issues could be significant: if appropriate, ask about the family structure, their living conditions, stressors, other children. Observe the interaction between mother and baby during your consultation - also other relationships if someone else has accompanied the mother.

Examination of the baby

Observe the baby naked.

Ask the mother to lie the infant down and undress him/her (reducing chance of distress caused by unfamiliarity). Observation should include the infant lying flat on his back (if tolerated), turned gently from one side to the other, and laid prone with head turned to face both sides.

  • Behavioral state, and transition between states. Reaction to being undressed, laid down flat, picked up and cuddled/soothed by mother.
  • Muscle tone and position that the infant assumes (well flexed, partially flexed, extended, hyperextended, head turned one particular direction exclusively)
  • Shape of the infant's head particularly noting presence of forceps or vacuum marks (first few weeks), cephalhaematoma, asymmetry.
  • Skin: turgor, subcutaneous fat, rashes, integrity, bruises; color - jaundice (extent); pale; mottled; cyanosis - where, what precipitated it
  • Mucous membranes: color, moisture, inflammation, integrity, infection
  • Respiratory effort, presence of sweating; response to exertion
  • Does the infant feel hot (febrile), or unusually cool to touch?
  • If you have received instruction on how to assess for intact cranial nerves, note your findings. Note facial movement and symmetry.
  • Weigh the infant. (Review the information in Topic 6.3 ) - Length and head circumference could also be recorded if you have an accurate means of doing so.
Oral assessment
  • Response to stimulation of rooting reflex
  • Visual examination - size, shape of tongue; uvula (bifid or not); intact palate, labial and lingual frenulum, condition of mucous membranes (moist/dry; candida; etc)
  • Suck assessment - (only perform after instruction and supervision by experienced practitioner) feeling for intact palate (hard and soft), notches on palate, shape of palate, grooving of tongue, tongue action during sucking (or preventing sucking)
Observe a breastfeed - if the infant is not in immediate danger, observation of a breastfeed is essential. (Review Topic 5.2 )
  • Note position adopted by mother and how she holds her baby
  • Note sucking pattern and ability - Note: Sucking will be sub-optimal and with notable non-nutritive sucking. Observing the feeding process will help determine whether poor sucking caused the failure to thrive or whether the failure to thrive is the end result of another cause. Milk supply is usually compromised too due to the poor feeding, so this needs to be assessed and addressed.

As the mother prepares to breastfeed ask permission to examine her breasts, looking for marked differences in size, hypoplasia, state of health of the breasts and nipples and surgical scars.

Modelling observational skills

By following the flow of the consultation above, (until you assessed the cranial nerves or performed the oral assessment) you were modelling to the parents good general observational skills.
If you also talked with the parents as you made each observation you will be giving them the confidence to be objective in their observations of their baby too, preventing unnecessary anxiety but ensuring prompt attention is sought when needed.

RED FLAG

If the infant appears ill (pale, lethargic, sunken fontanelle, poor skin turgor, minimal urine output, hot or cool to touch) organise for the infant to be seen by a doctor urgently or for immediate transfer to hospital.

Workbook Activity 7.8

Complete Activity 7.8 in your workbook.

Test weighing

Some practitioners find test weighing a baby to determine the volume of breastmilk received at a single breastfeed to be beneficial, while other practitioners do not.

This procedure must be used sensitively and its limitations explained to the mother:

  • From one test weigh it is not possible to conclude how much milk the baby is consuming in a 24-hour period,
  • nor how much milk is available for the baby in the breast either at this feed or for the 24-hour period.
Accurate test weighing requires quality, digital scales that are sensitive to within 2g and are re-calibrated regularly. The infant is weighed immediately before and again after breastfeeding without removing any of the clothing or wraps the baby was in at the first weighing. The difference between the second weight and the first weight is an indication of how much breastmilk the baby consumed.

Accuracy is dependent on attention to weighing technique.

Management

Management of failure to thrive in a breastfed baby requires a multidisciplinary team approach. The ultimate goal is to have baby exclusively breastfeeding and gaining weight normally.

Parent education and counseling

While the management below is focussed on clinical issues, your communication skill and care and understanding for the parents is as important an aspect of the consultation as getting nutrients into the baby. You must build trust and understanding between you and the parents.

Step 1

The first action you will take is to discuss with the mother the importance of having her baby reviewed by the baby's doctor. This is important, even if you think it is a feeding problem that you can resolve that has caused the problem. The infant has been compromised and needs a medical review.

Step 2

Next, feed the baby! The normal range of daily intake of breastmilk by healthy infants aged from 1 month to 6 months is 500ml - 1350ml (17oz - 44oz), with the average being 780ml (26oz) irrespective of the infant's weight or age. This volume is consumed over 11 feeds a day (range 6-18). Infants generally consume significantly more breastmilk during the morning and nighttime breastfeeds than during the day and evening breastfeeds.3

The baby will need supplementation. Determining how much milk to supplement will depend firstly on the infant's condition, and secondly on how much is required to produce a normal urine and stool output and consistent weight gain.

The infant's stomach will be unaccustomed to large volumes of milk. Introducing frequent small volumes of supplement will prevent overdistention and possible vomiting. Bear in mind the very wide range of normal - being pedantic about a set volume to be consumed at a predetermined number of feeds without considering what is normal is not helpful to the mother or baby. Individualize your care!

Be very careful that you don't jeopardise breastfeeding completely with a management plan that doesn't take normal breastfeeding physiology into consideration.

A quick calculation

Let's look at that from a practical viewpoint.

Total daily intake = approx 800ml
8 feeds/24 hrs = 100ml/feed
11 feeds/24 hrs = 70ml/feed
12 feeds/24 hrs = 65ml/feed

The volume of supplement will be a portion of these total feed amounts. Some babies wake frequently because they are hungry. Other babies have no energy reserves so they are very difficult to rouse and will feed poorly when woken.

The supplement is to enhance the infant's current intake, not to act as a total replacement feed.

What supplement shall I use?

The aim is for the infant to have as much of his mother's breastmilk as is available, while ensuring the infant receives sufficient nutrition to correct the deficit and permit normal growth. Sometimes the mother's milk supply is still adequate to meet her baby's needs - correcting poor positioning may be all that is required.

Choose the appropriate supplement and method of delivery according to the information in 7.3 Supplementation

  • ONLY if baby is >6 months - commence complementary foods, replacing nutrient-poor foods with nutrient-dense, high calorie foods if necessary.

When to supplement

With the information you have gained during your history-taking and clinical examination you should be able to decide whether the baby needs supplementing after all breastfeeds, or only from the afternoon, or even just the evening feeds as most mothers have fuller breasts in the morning.

Individualise your care

No two babies will be in the same situation therefore every strategy you and the parents devise will be unique. Don't look for a 'solution' you can apply in every situation.

Step 3

You must also determine and treat the cause, if possible. Is the cause maternal or infant in origin?

  • Protect the milk supply - insufficient breastmilk supply is addressed in Topic 8.4
  • Inability of the infant to suckle effectively at the breast could be caused by poor positioning and poor latching, or by ineffective suckling. Positioning and latch is well within your area of expertise, however you may need to refer the infant with poor suckling ability to a lactation consultant, pediatric speech therapist or other appropriate specialist.
  • Restrictive scheduling of breastfeeding, excessive non-nutritive sucking (pacifier or dummy use), denial of night-feeding, etc is addressed by education and discussion of normal behavior with the parents. Encourage the mother to join mother-to-mother support groups.
  • The management of the infant with poor absorption of nutrients or increased metabolic demands will be managed by a medical specialist.

Step 4

Follow-up. It is absolutely essential that the parents are competent, and feel confident, to observe their infant, recognise a problem early and seek assistance at any time.

To this end you will discuss with them ...

  • Observation of infant's output. Baby must have at least 5 thoroughly wet with clear urine nappies (diapers) per day; stooling should be regular and copious. Keeping a feeding and output diary will provide them and you with accurate information on which to base changes to the management plan.
  • Observation of infant's appearance. Baby should be bright-eyed and alert, and skin should not be pale.
  • Observation of infant's behavior. Baby should be active, alert and happy for some time each day, waking for feeds and feeding enthusiastically.

How soon and frequently you follow-up will depend on the baby's condition. Daily phone follow-up could be indicated to get reports on feeding and output, with a weight check again in two or three days if output was satisfactory until then. Revise the plan as necessary with the ultimate goal to have the baby fully breastfed and thriving.

Workbook Activity 7.9

Complete Activity 7.9 in your workbook.

What should I remember?

  • The signs of failure to thrive.
  • The possible underlying causes of poor weight gain.
  • The significant history information which will help to identify the cause of the problem.
  • The steps to appropriate management of failure to thrive.

Self-test quiz

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 7 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 7.

Notes

  1. # Grossman X et al. (2012) Neonatal weight loss at a US Baby-Friendly Hospital.
  2. # Noel-Weiss J et al. (2011) An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss.
  3. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day