By Molly Mustafa, BSN, RN, IBCLC

Protecting Breastfeeding Goals, Milk Supply, and Your Baby’s Growth

Breastfeeding can sometimes present challenges, leaving parents with questions and concerns about how to proceed. In moments like these, it’s crucial to have a care plan that prioritizes your feeding goals while optimizing your baby’s health and growth. Whether you’re working with a physician, nurse, or lactation consultant, here are the key questions to ask to safeguard your breastfeeding goals:

Assessing Your Baby’s Weight

• What is my baby’s current weight?
• Is my baby still losing weight? If so, what is their percentage of weight loss from their birth weight or 24-hour weight?

It is common for newborns to lose weight after birth, regardless of whether they have human milk or formula. Weight loss of up to 7-10% of their birth weight is considered typical. At around 7% weight loss, it’s advisable to evaluate feedings more closely and develop a plan to improve milk transfer while monitoring weight. Automatic supplementation is not always necessary at this point. Some research suggests that using a 24-hour weight as a baseline may be more accurate than birth weight, particularly when abundant IV fluids are used during delivery, as these can artificially inflate newborn weight.

Understanding Weight Gain

• Is my baby gaining weight at a slower rate than recommended?
• What does my baby’s growth look like on the World Health Organization (WHO) growth curves?

If your baby’s medical provider uses growth charts, verify that they are based on the WHO growth charts, as the data standard is specifically designed for breastfed infants. If your baby is preterm, please be sure that your provider uses the Fenton to give accurate information. The most crucial part of using the growth chart is ensuring that an infant roughly follows their growth curve. If they are in the 35^th percentile, we expect them to remain near that same percentile as they grow over the next two years. One common misconception is that babies must increase their percentiles to grow well, which is untrue. They just need to follow their growth curve to be considered growing well. Some babies are petite at birth and will measure in the 5^th percentile at their birth weight. Others are larger and will fall into the 90^th percentile at their birth weight. They are both considered healthy. The baby in the 5^th percentile doesn’t need to gain extra weight or improve their percentiles; it just needs to continue following their curve for healthy weight gain. 

• If my baby is gaining weight but the provider feels it’s less than ideal, what is their average daily weight gain? How much average daily weight gain does the provider recommend?

After the initial weight loss after delivery, the average daily weight gain for infants during the first four months of life is approximately 1 ounce (28 grams) per day. Most babies should regain their birth weight by 2 weeks, but a small percentage take a bit longer to reach it. There are many factors to consider when assessing this. Understanding any deviation can help you and your provider address underlying concerns.

Identifying Potential Challenges

• Why is my baby not gaining weight well? Is the provider concerned about any medical issues that may affect growth or feeding?

If your visit is not with an IBCLC (International Board Certified Lactation Consultant) skilled in latch, oral, and feeding assessments, the provider should refer you to one. A thorough and skilled evaluation is crucial to identify the root cause of feeding issues and inform the care plan effectively. If there are other medical concerns, appropriate referrals and testing should be planned for. 

Supplementation Questions

If supplementation is deemed necessary, it’s crucial to address these aspects in a way that aligns with your feeding goals and ensures proper growth for your baby:

• What type of supplement should be used?

If the mom has an appropriate volume of milk, that milk should be used as the first choice for supplementation. If low milk volumes are an issue, donor breast milk is the next best choice for supplementation. If donor breast milk is inaccessible or the parents prefer not to use it, a standard-term formula (for a full term baby) would be the next choice. 

• How much supplement should be given?

Average milk volumes for newborn babies are smaller than you might think. Here is a list of average milk volumes:

First 24 hours- 2-10 mL/feed

24-48 hours- 5-15 mL/feed

48-72 hours- 15-30 mL/feed

Day 4-Week 1- 30-60 mL/feed (1-2 oz)

Week 2-3- 60-90 mL/feed (2-3 oz)

Months 1-6- 90-120 mL/feed (3-4 oz)

Your provider should help you create individualized feeding volume goals based on your family’s feeding plan and your infant’s needs. It must be tailored to your family to support the goals you have. Getting data from a weighted feed on a sensitive lactation grade scale can be very helpful to guide supplementation plans.

• How often does the supplement need to be given?

How often your provider recommends supplementing will depend on your individual case. If your baby is gaining weight but at a slightly slower rate, supplementing with a small amount a couple of times per day may be okay. If your baby has lost a significant amount of weight, it may be essential to supplement every feed until their weight gain returns to normal. Again, this piece should be individualized to your specific needs. 

• What feeding device will be used to administer the supplement?

There are other options besides bottles that can be used to supplement your baby’s feeding, helping to protect the breastfeeding relationship and oral motor skills. Cup feeding, finger feeding with a syringe and tube, and the use of a supplemental nursing system can be great options. A skilled lactation consultant can help your family decide which options best align with your feeding goals. 

• What is the plan to support my milk supply until breastfeeding is reestablished?

If you need to start supplemental feedings with your baby, a plan to support milk supply is a crucial but often overlooked piece of the care plan. Sometimes, adding in a few extra pumping or hand expressions of milk is appropriate. At other times, it is essential to pump each time you feed your baby. If extra milk expression is needed, it’s necessary to determine the most effective way to achieve it. Hand expression, a manual pump, or a double electric pump are all options that can be utilized. If a pump is used, it is crucial to have someone demonstrate its use and properly fit your flange to ensure you are using the correct size. Incorrect flange size or pump setting can lead to sore nipples or inefficient milk removal. 

• When is the next follow-up appointment to reassess my baby’s weight and adjust the care plan?

Your provider should always offer a follow-up appointment to recheck your baby’s weight and adjust the care plan. The timing of this appointment will depend on your family’s specific circumstances, but you should never be left guessing what to do next or wondering if things are improving. You should be able to have confidence that your baby is gaining weight appropriately and a plan on when and how to stop supplementing or pumping.  

Conclusion

Addressing breastfeeding challenges requires a strategic and thoughtful approach. By asking the right questions and working closely with knowledgeable providers, you can create a care plan that protects your breastfeeding goals while ensuring your baby’s growth and well-being. Remember, seeking professional support when needed is a sign of strength and commitment to your family’s health and happiness.