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    <meta name="author" content="Denise Fisher" />
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      <h1 id="top">4.3 Causes of inadequate infant growth</h1>
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            <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study D</h3>
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			Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
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		<dl><dt><a href="topic_4-1.html"><cite>Topic 4.1: Initial assessment</cite></a></dt><dd class="topic-paragraph">To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.</dd></dl>
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			Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.
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		<dl><dt><a href="topic_4-2.html"><cite>Topic 4.2: Milk production</cite></a></dt><dd class="topic-paragraph">Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.</dd></dl>
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			What may cause inadequate growth in breastfed infants such as Emily?
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		<dl><dt><a href="topic_4-3.html"><cite>Topic 4.3: Causes of inadequate infant growth</cite></a></dt><dd class="topic-paragraph">The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.</dd></dl>
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			What may cause inadequate growth in breastfed infants such as Emily?
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		<div class="section" id="Reduced_milk_intake_due_to_feeding_patterns_or_routines"><h3>Reduced milk intake due to feeding patterns or routines</h3><div class="section" id="">
			<dl><dt>Frequency</dt><dd>
					As mentioned earlier, most infants require at least eight breastfeeds a day in the early months of life (i.e. at least every three hours). However, breastfeeds are not usually spaced evenly throughout the day. At times the infant may want to feed every 3060 minutes (cluster feeds) while they may go for a longer stretch during the night. Feeding frequency is positively correlated with milk volume in the early weeks<sup><a href="#note1">1</a></sup>. Additionally, because of the differences in maternal storage capacities and infant feeding cues, stipulating a specific number of breastfeeds at equal intervals throughout the day limits the volume of milk the infant receives and reduces breast stimulation and drainage necessary for further milk production. Night-time feeds are also important for ongoing breastfeeding, especially in the early weeks and months.
				</dd><dt>Length of feeds</dt><dd>
					In the first few weeks postpartum, most infants will take between 20 and 40 minutes to feed; however, the length of effective sucking will vary between infants and between feeds by the same infant. However, limiting the time at the breast, or removing the infant from the breast after a specified time, may not allow the infant to receive as much milk as he or she needs, especially if the milk-ejection reflex is slow. Conversely, infants who spend a long time at the breast (&gt;50 minutes routinely) may not be feeding effectively for some or all of that time, and the breastfeeds may need to be assessed by a trained observer.
				</dd><dt>One breast or two</dt><dd>
					<p>
						Fat concentration of breast milk is correlated with the degree of breast fullness – with the fat concentration increasing as the breast is drained. Concern has been expressed that infants feeding from both breasts at each feed when their mothers' milk supply is large would receive a low-fat, high-volume feed resulting in symptoms of lactose intolerance and large, or rarely low weight gain<sup><a href="#note2">2</a></sup>. Conversely, mothers may initially be encouraged to feed from only one breast at each feed while their breasts are very full or engorged, or to ensure their infant receives the higher fat milk when the breast is drained. This advice can be interpreted as only ever feeding from one breast at each feed. For many infants, this routine will not provide sufficient milk volume for adequate growth.
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						The ideal situation is to allow the infant to feed from one breast for as long as he or she is feeding effectively, and then offer the second breast. Most infants (57%) will take one breast at some feeds and two breasts at others, while some infants will only ever use one breast at each feed (30%) and others will always use two breasts (13%)<sup><a href="#note3">3</a></sup>. Most infants with signs and symptoms of lactose overload respond well when allowed to determine whether they feed from one breast or two at a feed. Lactose-free formula is not necessary nor appropriate management.
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				</dd><dt>Use of breast/breast milk substitutes</dt><dd>
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						Dummy or pacifier use has been associated with reduced breastfeeding duration (<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup>). Dummies are thought to reduce the desire of the infant to feed at the breast, especially if used to quieten the infant rather than feeding him or her, or alter the infant's sucking pattern. However, it is difficult to determine whether dummies initiate breastfeeding problems or are used because of them.
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						Complementary feeds also reduce the infant's desire to feed at the breast. If the complement is infant formula, the infant's weight may not be affected, but milk supply will invariable decrease unless measures are instituted to increase milk production.
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						Feeding routines that reduce breast drainage not only affect infant growth, but also adversely affect ongoing milk supply.
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		<div class="section" id="Low_milk_supply"><h3>Low milk supply</h3><div class="section" id="">
			<dl><dt>Hormonal reasons</dt><dd>
					<ul><li><span class="term">Retained products of conception</span>. A rapid decrease in progesterone levels is essential for the initiation of lactation. When progesterone levels fail to fall to pre-pregnancy levels due to retained products of conception, milk production is often slow to begin and does not reach normal levels. Removal of the retained products usually results in a rapid increase in milk volume (<sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup>).</li><li><span class="term">Sheehan's syndrome and postpartum haemorrhage</span>. Sheehan's syndrome, due to ischaemic necrosis of the pituitary gland following hypotension related to severe postpartum haemorrhage, may present initially with failure to lactate. Some authors report women experiencing a delay in the initiation of lactation, or low milk supply following episodes of postpartum hypotension (usually due to postpartum haemorrhage), although the remainder of the pituitary function is intact (<sup><a href="#note8">8</a>,</sup><sup><a href="#note9">9</a></sup>). Another study showed a relationship between postpartum anaemia and apparent insufficient milk, leading to early weaning<sup><a href="#note10">10</a></sup>. Although the study did not report the reasons for anaemia, excessive peripartum blood loss may have contributed.</li><li><span class="term">Thyroid disorders</span>. As thyroxine is also required for ongoing milk production, women with hypothyroidism are at risk of having a low milk supply. Adequate treatment with thyroxine allows breastfeeding to commence and continue normally<sup><a href="#note11">11</a></sup>. Postpartum thyroiditis often presents initially with hyperthyroidism, with many women becoming hypothyroid with time<sup><a href="#note12">12</a></sup>.</li><li><span class="term">Other hormonal disorders</span>. There is some evidence that women with polycystic ovaries (<sup><a href="#note13">13</a>,</sup><sup><a href="#note14">14</a></sup>) and theca-lutean cysts (<sup><a href="#note15">15</a>,</sup><sup><a href="#note16">16</a></sup>) are more likely to have difficulty establishing their milk supply or produce a low milk volume. In rare instances, an isolated prolactin deficiency leads to alactogenesis (<sup><a href="#note17">17</a>,</sup><sup><a href="#note18">18</a>,</sup><sup><a href="#note19">19</a></sup>).</li></ul>
				</dd><dt>Smoking</dt><dd>
					Women who smoke are less likely to initiate lactation and breastfeed for a shorter length of time. However, it is uncertain whether this effect is due to a lack of maternal motivation or a direct effect of nicotine or other substance on milk production (<sup><a href="#note20">20</a>,</sup><sup><a href="#note21">21</a>,</sup><sup><a href="#note22">22</a></sup>).
				</dd><dt>Obesity</dt><dd>
					As described previously, women who are overweight or obese have difficulty establishing breastfeeding are less likely to continue to breastfeed.
				</dd><dt>Medications</dt><dd>
					Some medications such as the oral contraceptive pill<sup><a href="#note23">23</a></sup>, pseudoephedrine<sup><a href="#note24">24</a></sup> and herbal preparations such as sage tea<sup><a href="#note11">11</a></sup> are known to inhibit milk production.
				</dd><dt>Anatomical problems</dt><dd>
					Some women lack sufficient mammary tissue to produce enough milk for their infant<sup><a href="#note25">25</a></sup>. These women are more likely to have asymmetric underdeveloped breasts that are more widely spaced than normal (&gt;4 cms). In extreme cases, the breasts sit on a small base with severe breast constriction and large nipple-areola complexes (tubular breasts)<sup><a href="#note26">26</a></sup>. Lack of breast development during pregnancy and lack of postpartum breast fullness are often noted (<sup><a href="#note26">26</a>,</sup><sup><a href="#note27">27</a></sup>).
				</dd><dt>Breast surgery</dt><dd>
					Disturbance of ductal structures, reduction in the amount of glandular tissue and the severing of the afferent arm of the milk-ejection reflex (usually the lateral cutaneous branch of the 4th intercostal nerve) as a consequence of breast surgery can all impact on the mother's capacity to produce milk<sup><a href="#note27">27</a></sup>. Breast reduction surgery nearly always results in reduced milk volume. Periareolar incisions, although cosmetically desirable, are more likely to interfere with the major lactiferous ducts and the milk-ejection reflex and have been associated with a reduction in nipple sensitivity (<sup><a href="#note11">11</a>,</sup><sup><a href="#note27">27</a></sup>).
				</dd></dl>
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		<div class="section" id="Difficulty_transferring_milk"><h3>Difficulty transferring milk</h3><div class="section" id="">
			<dl><dt>Poor positioning and attachment</dt><dd>
					Breast drainage is facilitated by optimal positioning and attachment of the infant at the breast. Case E describes the assessment of effective positioning and attachment.
				</dd><dt>Efficacy of the milk-ejection reflex</dt><dd>
					Contraction of the myoepithelial cells around the lactiferous ducts (the milk-ejection reflex), either stimulated by the infant or by expressing, is essential for the removal of milk from the breasts. Stress, pain or other factors may inhibit this reflex and must be considered when an infant is not gaining weight. While most mothers will be aware of this reflex working, it is often less noticeable for women with a low milk supply. Watching for changes in the infant's sucking pattern (from suck-suck-suck-swallow to suck-swallow, suck-swallow) may be a more reliable sign that milk is flowing.
				</dd><dt>Sucking problems</dt><dd>
					Some infants, even though they are positioned and attached to the breast well, have a poor or ineffective suck. Contributing factors include hyper or hypotonia, thumb-sucking in-utero, prematurity or illness. However, other infants may have tonic bites or are not able to coordinate tongue movements or maintain sufficient negative pressure to extract milk. These infants tend to slip off the breast easily and may "click" during the feed every time suction is broken. Their mothers often have damaged nipples.
				</dd><dt>Tongue-tie (ankyloglossia)</dt><dd>
					Further information about tongue-tie and its effect on breastfeeding is found in Case E.
				</dd></dl>
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		<div class="section" id="Increased_energy_expenditure"><h3>Increased energy expenditure</h3><div class="section" id="">
			<dl><dt>Other medical conditions</dt><dd>
					Congenital heart disease, urinary tract infections and other medical conditions may initially present with low weight gain and failure to thrive. As well as having an increased energy expenditure, the infant may not be robust enough to adequately stimulate the breast, resulting in a secondary low supply problem.
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            <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
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	{ c : '\n			<p>\n				<strong>Miriam is one month old, weighs 3.5 kg and has gained on average 80g a week since birth. She is otherwise well and is not compromised. What history would you obtain and what examinations would you perform on Miriam and her mother to assess causes of her slow weight gain?</strong>\n			</p>\n		', r : '\n			<p>\n				History would include:\n				<ul>\n					<li>number, length and pattern of breastfeeds;</li>\n					<li>breastfeeding difficulties (painful nipples, difficulty attaching baby to the breast, inhibited milk-ejection reflex);</li>\n					<li>use of breast milk substitutes or a dummy;</li> \n					<li>previous hormonal problems (eg thyroid disorders, PCOS);</li>\n					<li>delivery complications (large PPH, retained products of conception);</li>\n					<li>maternal smoking, medications, breast surgery.</li>\n				</ul>\n			</p>\n			<p>\n				Examination would include:\n				<ul>\n					<li>mother\'s breasts and nipples;</li>\n					<li>positioning and attachment;</li>\n					<li>sucking efficiency;</li>\n					<li>infant oral anatomy;</li>\n					<li>other infant medical conditions (eg. congenital heart disease, UTI)</li>\n				</ul>\n			</p>\n		' }
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<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('a');</script>
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      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#hill05a" title="See full details">#</a> Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants</li>
          <li id="note2"><a href="references.html#wool88" title="See full details">#</a> Woolridge MW et al. (1988) Colic, "overfeeding", and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management?</li>
          <li id="note3"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
          <li id="note4"><a href="references.html#howa03" title="See full details">#</a> Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding</li>
          <li id="note5"><a href="references.html#kram01a" title="See full details">#</a> Kramer MS et al. (2001) Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial</li>
          <li id="note6"><a href="references.html#ande01" title="See full details">#</a> Anderson AM (2001) Disruption of lactogenesis by retained placental fragments</li>
          <li id="note7"><a href="references.html#neif81" title="See full details">#</a> Neifert MR et al. (1981) Failure of lactogenesis associated with placental retention</li>
          <li id="note8"><a href="references.html#will95" title="See full details">#</a> Willis C et al. (1995) Infant insufficient milk syndrome associated with maternal postpartum hemorrhage</li>
          <li id="note9"><a href="references.html#livi06" title="See full details">#</a> Livingstone V (2006) Failure to thrive while breastfeeding</li>
          <li id="note10"><a href="references.html#henl95" title="See full details">#</a> Henly SJ et al. (1995) Anemia and insufficient milk in first-time mothers</li>
          <li id="note11"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
          <li id="note12"><a href="references.html#desw95" title="See full details">#</a> de Swiet M (1995) Medical disorders in obstetric practice</li>
          <li id="note13"><a href="references.html#vank08" title="See full details">#</a> Vanky E et al. (2008) Breastfeeding in polycystic ovary syndrome</li>
          <li id="note14"><a href="references.html#mara00" title="See full details">#</a> Marasco L et al. (2000, May) Polycystic ovary syndrome: a connection to insufficient milk supply?</li>
          <li id="note15"><a href="references.html#betz04" title="See full details">#</a> Betzold CM et al. (2004) Delayed lactogenesis II: a comparison of four cases</li>
          <li id="note16"><a href="references.html#hoov02a" title="See full details">#</a> Hoover KL et al. (2002) Delayed lactogenesis II secondary to gestational ovarian theca lutein cysts in two normal singleton pregnancies</li>
          <li id="note17"><a href="references.html#sait07" title="See full details">#</a> Saito T et al. (2007) A case of prolactin deficiency with familial puerperal alactogenesis accompanying impaired ACTH secretion</li>
          <li id="note18"><a href="references.html#douc01" title="See full details">#</a> Douchi T et al. (2001) A woman with isolated prolactin deficiency</li>
          <li id="note19"><a href="references.html#kaup97" title="See full details">#</a> Kauppila A (1997) Isolated prolactin deficiency</li>
          <li id="note20"><a href="references.html#dona04" title="See full details">#</a> Donath SM et al. (2004) The relationship between maternal smoking and breastfeeding duration after adjustment for maternal infant feeding intention</li>
          <li id="note21"><a href="references.html#gigl06" title="See full details">#</a> Giglia R et al. (2006) Maternal cigarette smoking and breastfeeding duration.</li>
          <li id="note22"><a href="references.html#mcaf07" title="See full details">#</a> McAfee G ( 2007) Drugs of abuse and breastfeeding.</li>
          <li id="note23"><a href="references.html#hale07a" title="See full details">#</a> Hale TW (2007) Medications that alter milk production</li>
          <li id="note24"><a href="references.html#alja03" title="See full details">#</a> Aljazaf K (2003) Pseudoephidrine: effects on milk production in women and estimation of infant exposure via breastmilk</li>
          <li id="note25"><a href="references.html#neif85" title="See full details">#</a> Neifert MR et al. (1985) Lactation failure due to insufficient glandular development of the breast</li>
          <li id="note26"><a href="references.html#hugg00" title="See full details">#</a> Huggins K et al. (2000) Markers of Lactation Insufficiency: A study of 34 mothers</li>
          <li id="note27"><a href="references.html#neif90" title="See full details">#</a> Neifert MR et al. (1990) The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain</li>
        </ol>
      </div>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>0.1 <a href="topic_0-1.html">Introduction</a></li>
        <li>1.0 <a href="topic_1-0.html">Case Study A (Joanne)</a><ol><li>1.1 <a href="topic_1-1.html">Discussing breastfeeding</a></li><li>1.2 <a href="topic_1-2.html">What information to give</a></li><li>1.3 <a href="topic_1-3.html">Effects of Breastfeeding alternatives</a></li><li>1.4 <a href="topic_1-4.html">Common breastfeeding concerns</a></li><li>1.5 <a href="topic_1-5.html">Breast examination</a></li><li>1.6 <a href="topic_1-6.html">Contraindications to breastfeeding</a></li><li>1.7 <a href="topic_1-7.html">Conditions related to lactation outcomes</a></li><li>1.8 <a href="topic_1-8.html">Medications</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Case Study B (Joanne)</a><ol><li>2.1 <a href="topic_2-1.html">Preparation Before Birth</a></li><li>2.2 <a href="topic_2-2.html">Birthing Factors that Affect Breastfeeding</a></li><li>2.3 <a href="topic_2-3.html">Management After Birth</a></li><li>2.4 <a href="topic_2-4.html">Poor Attachment</a></li><li>2.5 <a href="topic_2-5.html">Hypoglycaemia</a></li><li>2.6 <a href="topic_2-6.html">Relationship between Jaundice and Breastfeeding</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Case Study C (Joanne)</a><ol><li>3.1 <a href="topic_3-1.html">Early problems</a></li><li>3.2 <a href="topic_3-2.html">Risk of SIDS</a></li><li>3.3 <a href="topic_3-3.html">Contraception</a></li><li>3.4 <a href="topic_3-4.html">Milk composition</a></li><li>3.5 <a href="topic_3-5.html">Slowing of growth</a></li><li>3.6 <a href="topic_3-6.html">Introducing solids</a></li><li>3.7 <a href="topic_3-7.html">Weaning</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">Case Study D (Sally)</a><ol><li>4.1 <a href="topic_4-1.html">Initial assessment</a></li><li>4.2 <a href="topic_4-2.html">Milk production</a></li><li class="current">4.3 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_4-3.html">Causes of inadequate infant growth</a></li><li>4.4 <a href="topic_4-4.html">Increasing milk supply</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Case Study E (Anna)</a><ol><li>5.1 <a href="topic_5-1.html">Sore nipples</a></li><li>5.2 <a href="topic_5-2.html">Factors causing nipple damage</a></li><li>5.3 <a href="topic_5-3.html">General treatment for sore nipples</a></li><li>5.4 <a href="topic_5-4.html">Further causes of nipple pain</a></li><li>5.5 <a href="topic_5-5.html">Mastitis – diagnosis</a></li><li>5.6 <a href="topic_5-6.html">Mastitis – treatment and complications</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">In conclusion</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
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