4 month old poor weight gain

[SukieCat]

Hey all,

My 4 month old DD is EBF and she is gaining weight very very slowly.  The same thing happened with my older son, and I ended up supplementing him with formula at about this age.  I was really hoping not to do that with DD.  I thought nursing was going really well with her.  She's content between feedings, takes decent naps and sleeps pretty well at night.  Diaper output is good.  Meeting milestones.  She is gaining in length and head circumference.  The only indication that things aren't going well is her poor weight gain, and I'm not sure what to do about it.  I had her assessed and treated for upper lip and posterior tongue tie at 10 weeks.  We saw a LC early on who said latch looked good and she was able to take about 3 oz at a feeding at that time.  She currently eats every 2.5-3 hrs during the day and once or twice overnight.  Here's what her weight has looked like with WHO growth chart percentiles:

Birth 9 lbs = 90%
lowest weight 8.4lb = 82nd%
2w 9lbs = 73rd%
1m  10 lbs = 72nd%
2m 11.2 lbs = 46%
3m + 1w 12.6 lbs = 35%
4m 12.8 lbs = 20%

All same scale (except birth), all nude.  She was an unmedicated VBAC baby, so no IV fluids at birth.  Ped says we can wait and weigh her again in a month, or I could start supplementing her with formula, expressed milk, or solids.  My supply isn't really robust enough to support a lot of pumping to supplement, so it would probably be formula.  I'm just feeling really discouraged and I'm not sure what the best course of action is.  Does anyone have any thoughts, advice, or words of encouragement?  TIA.

[SukieCat]

Can anyone help me?  Do y'all think I need to start supplementing? So far I've just been trying to nurse as much as possible, but I think she's just snacking all day long instead of eating bigger meals, and she's probably getting the same amount of food either way.  Plus it's exhausting nursing all the time, not to mention I have my son to take care of too.  Should I be worried that she's gone down so many percentiles? 

[MasynSpencerElliotte]

Honestly I don't know much about percentiles! I personally would not do solids this early as that will leave her less room for nutrient dense milk (whether breastmilk or formula). Has she hit the 4 month growth spurt yet? Any chance the tongue tie could still be an issue (I have read that they can re adhere, not sure how likely that is). 

[*Ali*]

I'd just keep feeding her directly from the breast. Don't worry about snacking. Getting those feeds in is more important, have you tried putting her back on the first breast after she eats the second? Or are you only feeding from one side at each feed? You could also try to pump after she feeds at times when it is convenient like the evening when your son is in bed. Those things should all increase your supply in line with her new demand.

Was she born much after her due date?

I'd also check the tie again in case there was another that was missed or it re-adhered. We're you given exercises to do to prevent that?

[SukieCat]

Thanks for your replies.  I'm not sure if she's hit her 4 month growth spurt, but the past few days she's been getting up 2x per night instead of 1, and she's been napping poorly.  It would be nice if it were a growth spurt but I can't say for sure.

Regarding the ties - our symptoms were pretty minor, mostly her poor weight gain and me feeling like her latch wasn't great even though we'd seen LCs who said it was good.  The dentist we took her to is a highly recommended expert in ULT and PTT, and she confirmed the presence of the ties.  However, I didn't see a lot of improvement directly following the procedure, like some people describe.  It was a laser cut, and we did exercises for 4 weeks post-op, so it seems unlikely that it would re-adhere.  The dentist we took her to is 2 hours away, so that's why I'm a bit hesitant to take her back. 

We feed both sides, unless she falls deeply asleep after the first side.  She's more likely to fall asleep nursing when I try to nurse her more frequently.  I haven't tried switching back to the first breast.  She would hang out at the breast all day if I let her, she's never really "come off" the breast like I sometimes hear people talk about.  So I don't know how much nutrition she's really getting after the first few minutes of vigorous nursing, but I let her stay on 15-20 min per side sometimes.  She never would take a pacifier, so I think she uses me for comfort.

She was born a day before her due date!  I make big babies. 

[*Ali*]

So do you have other kids who were big at birth? How did they follow the graph? If it is similar to your  littlest DD then it could just be how they are made.

At the end of the feeds does she stop swallowing regularly? That is what I would look for to stop a feed or switch sides. If she is still following a kind of suck, suck, swallow rhythm then I'd let her carry on until that changes.

Have you tried any measures like supplements or foods to increase your supply at all? There are some good ideas here. I'm worried I may have low milk supply

How do you feel about pumping? I've been giving my DD a bottle of expressed milk at bedtime and she takes 6-7oz. I know she wouldn't get that from me at BT as supply is typically lower then. I wait until 10pm to pump as I have filled up enough by then. Even if you didn't get a whole feed (some ladies just don't respond well to pumping even with great supply) you could use it to top her up and increase supply.

[becj86]

When you supplemented DS, did he climb back up the centiles to his birth centile or stay where he was when you started supplementing?

How's her length going along the centiles?

Her weight gain is slower than following the centiles but it looks reasonable at least initially. Does she have reflux? Just wondering as that can affect weight gain and can have LO wanting to hang out at the breast all day for the comfort.

Is she an active kid for her age? I know that's an odd question at 4 months but it can make a difference to weight gain - DS dropped down centiles the month or so before most gross motor milestones because he met them early and once all the other babies were moving too, he moved up the centiles again.

Hugs xx It can be so devastating when LO is not gaining along a centile. 

[SukieCat]

My DS (who is now 3yo) was 10lb 10oz at birth - something like 98%.  He was 10 days late, failed induction turned eCS.  Lots of fluids, lots of difficulty getting BFing established, but his lowest weight was still something like 9.5lb.  He did ok at first but then started falling off the centiles.  At 4m he was 25th% for weight, but long.  His weight-for-length was something like the 0.8 percentile.  (DD is sitting at 3% weight-for-length).  Started supplementing DS with formula at 4m and he right away shot back up to 90th percentile and is still there today for both weight and length.

DD is following the 75th percentile pretty well for length, not dropping centiles there.

She spit up a lot in the beginning, but didn't have any other symptoms that suggested GERD to me (or her doc).  In the last week or so her spit up has gotten a lot better.

I would say she is somewhat active.  In the week before her last check up she'd just learned to roll back to tummy, so she was practicing that every chance she got.  People always comment that she's very alert, and she's very engaged with the world.  I still swaddle her to sleep, but she's started busting out of those pretty regularly - she is strong.  I also find myself frequently saying to her "You're so wiggly today!" So I guess she is active, haha.

I've been eating more oatmeal and drinking the Mother's Milk Tea.  I can't really tell if it's helping.  When I pump at night, I only get about 2oz total, so it would take a few days just to get enough for one bottle.  If I pump during the day I always feel like DD is fussy at the next feed because there's not as much there as she wants.  I've been pumping somewhat regularly before I go to bed at night, but last night DD woke up at about 10 so I had to nurse her instead.

Another couple things I've forgotten to mention - she hasn't pooped in about a week.  Normally she goes 3-4 days, but this time is much longer and I have no idea why.  I know it can be normal for BF babies but it certainly wasn't my experience with DS.  When she does go it's usually an epic explosion.  She has plenty of wet diapers though.  Also, lately (past few days) she's been really trying to adjust her latch to be very shallow.  I have to really put pressure on her back when she eats or she'll purposefully move back on the breast.  It's not so shallow that it hurts, it's just not as deep as she starts out.  Not sure what that is about. 

[*Ali*]

Teething?

[SukieCat]

No visible signs of teething, although I guess it's possible...

[becj86]

Is that shallow latch since you've tried anything new to increase your supply? Sounds like what DS did with over active letdown. Our issue with slow weight gain was down to oversupply, counterintuitive as that seems.

What are her poos like?

I presume you've upped your good fats and protein intake?

[SukieCat]

I'd say the shallow latch started around the time I started trying to up my supply, but I just don't feel like I could have oversupply. I feel very empty after feeds and like I mentioned, I don't seem to have extra to pump. I may have overactive let down though. Could I have overactive let down with low supply?

Her poop, when she finally goes, is usually bright orange to brownish yellow with some seedy looking bits.

I could probably do better on the good fats and protein. Any suggestions for good sources of good fats?

[becj86]

Yes, OALD and OS are different.

Unless insufficient, your diet actually doesn't have a big effect on the amount of fat in your milk. Have a read here:
http://kellymom.com/nutrition/milk/change-milkfat/
http://kellymom.com/nutrition/mothers-diet/mom-diet/

It seems it comes down to getting out the fat that's there. Odd as it may seem, massaging the breasts near the chest wall can help liberate the fats from the walls of the milk glands/ducts.

Does her tummy gurgle at feeds?

[SukieCat]

I haven't noticed any obvious gurgling.  I'll have to pay closer attention.  Is it something I'd notice while she's eating or right after?  Sound or just feel?  What might that mean if it did?

[becj86]

For us, it was both during and after eating and it was loud enough to hear. For DS, it was when my milk was just too much for him and there wasn't much requirement to swallow - its just squirted out with some velocity that it must have bounced, yk?