20 week old: breast and bottle fed, but refusing bottles on 4 hour schedule

[AliciaS]

My 20 week old is both breast and bottle fed. I have chronic low supply (I've tried everything and now accept it) so I supplement him with donor milk so he only has breastmilk. I produce about an ounce an hour. On a 3 hour schedule He gets breastfed 3 ounces and he normal would need an ounce of supplemented milk so he would consume a total of about 4 ounces. Now on the 4 hour schedule he will get breastfed about 4 ounces and most of the time refuses the bottle after. Then 2 hours later when I'm putting him down for his nap he is hungry. I have been trying to push him to wait until he wakes up before feeding him thinking he will take a bigger feeding, but the same thing happens and he just nurses and won't take the supplement bottle and then is hungry again before his next nap. I would think this is contributing to his poor napping and sleeping. He's never wanted more than 4 ounces at a time. I don't want to have to feed him every 2 hours unless it's necessary. Sometimes I wonder if I did feed him before and after naps if he would nap better? How long should I continue to get him to go 4 hours between feedings? He has his 5 month checkup soon so I will see if his weight has decreased percentiles.

Here's his schedule:

E: 7a; wake up
A: 2 hrs
S: 9a; wakes after 40 mins then is patted for up to 40 mins then falls back asleep
E: 11a; breastfed 3 ounces and refuses bottle
A: 2 hrs
S: 1p; wakes after 40 mins then is patted for up to 40 mins then falls back asleep
E: 3p; breastfed 3 ounces and refuses bottle
A: 2 hrs
S: 5p; 40 mins
E: 5:45p; just breastfed 2-3 ounces
A: 1-1.5 hrs
E: 7p; just bottle fed about 3 ounces (only time he seems to consistently not refuse bottle)
S: 7:30p
E: 10:30p; df breastfed around 4 ounces?
NW: 11p-4; wakes a few times and is given pacifier prop
E: 4a; breastfed around 4 ounces or maybe more
NW: 4:30-7; wakes a couple times and is given pacifier prop

Thanks for any help!

[Lolly]

I'll get our breastfeeding ladies to have a look, but a few things jump out to me!

It's totally normal for a breastfed baby not to be able to get to 4 hours between feeding until they start solids. Breast milk is digested much more quickly than formula so many aren't able to get to 4 hours. It's often recommended to do a top up feed around this age before a nap which should help him nap, he's edging towards needing more than just milk so the extra feeds top his calories up until he is ready in couple of months.

The other thing is that he is probably taking more during a breastfeed than you think. I'm not sure how you have worked out how much you think he gets, if it's by pumping babies are much more efficient than a pump at getting milk out so it's not a good indicator of how much you are producing. Plenty of the ladies here can't pump at all but have plenty of milk for their babies. If it's by weighing him before and after a feed that is also a method that doesn't give an accurate result and isn't recommended anymore (I believe).

The fact that he is refusing the bottle suggests to me that he is getting enough at a feed. Which flow teat are you using too?

I would offer a top up feed before a nap which should help, you may also need to push his A times out a bit too, short napping can be because he is a bit under tired for the nap.

What do you think?

Laura

[AliciaS]

Thank you so much for your insight! I didn't know about the breastfed babies getting on the 4 hour schedule later. I will try nursing him before his naps and see how it goes. It's nice to know there is hope of the 4 hrs schedule with the introduction of food around 6 months.

Another thought is going back to the 3 hour schedule and not intervening to extend his naps. Then I can stick to the EASY routine and he will be fed every 3 hours instead of every 2. My mom has been visiting and taking care of LO1 which allowed me the time to extend LO2's naps. It's been about about 2 weeks and not much improvement anyway. I don't want to go backwards, but want to be realistic.

I believe I know about how much I can breastfeed based on pumping (really good pump) and weighted feeds (hadn't heard they aren't accurate before). My body was the same way with LO1. I'm open to other thoughts though and would love it if he was getting more than I thought.

I haven't increased nipple size because my lactation consultant advised me not to so LO won't refuse the breast. I have thought about it though. I certainly will if he isn't gaining enough weight. He's been 50% for weight and 80% for height so he's already leaner. This has been consistent so the dr hasn't been concerned.

I try to push A times, but he acts so tired and cranky. It's such a fine line between UT and OT, you know?

I appreciate your help!

[Lolly]

Breastfeeding knowledge has moved on a lot since Tracy wrote the books and as she is no longer here to update the routines we try and share the info on the boards instead.

His weight and height centiles are just fine - there's no issue with where he is, they would only be concerned if he dropped more than 2 centile brackets really. Hopefully he has stayed the same, but the fact that he has stayed the same for the last 5 months is a good indication he is getting enough milk!

I would just do a top up feed before a nap for now, if you plan to keep breastfeeding for a while yet that will help your supply anyway. It is a fine line between OT and UT and as they get older sleepy cues get less reliable. They do get used to going to sleep at certain times and do need us to help them push through it, cranky can be bored sometimes too! Just extend his a times by 10 mins for the next few days, and then 10 mins again. If he short naps don't cut the next A time by too much as that can just create another UT nap.

You can just go back to a 3 hour feed routine, but I would work on extending the naps as they will have an impact on night sleep too.

Laura

[AliciaS]

Thank you!!! That's good to know about babies being bored instead of tired! I think we've made some progress.

[Lolly]

Yeah for progress!

Laura

[*Ali*]

You are already getting great advice from Laura but I just wanted to add a few points that jumped out at me.

24oz in 24hrs is nowhere near low supply so I do wonder what makes you think you have supply issues. 24oz is the average intake of breast milk for babies aged 1-6mo (it doesn't really change). Anything from 19-32oz is considered a normal range though. As Laura said your baby will be more efficient than any pump so whatever you can pump you can be sure your baby is getting more. Plus the breasts are never really empty, they continue making milk all the time your baby is feeding. In fact milk made when breasts are emptied and are being fed from more frequently is more fatty and calorific than the milk that is there if you wait longer between feeds and let breasts "fill up".

Frequent feeds and night feeds will only help your supply. Assuming you want to increase your own supply I'd ditch the dummy and just feed when LO wakes up in that first part of the night. The hormones that control supply are highest at night so withholding feeds by instead offering a dummy will be harming your supply because you're telling your body there is no demand for milk at that time.

Offering top up feeds before naps is definitely a good idea. You could also try doing breast compressions while feeding which will aid the flow of milk and help to dislodge more of the fatty molecules from your milk ducts thus increasing the calories in your milk.

I don't think Laura was suggesting using a faster teat. Normally a slower teat is best for breastfed babies so they dont develop a bottle preference because they dont have to work for it from the bottle. Look up paced bottle feeding to help ensure you are feeding appropriately to mimic breastfeeding.

And lastly as Laura said if he is following the lines on the centile charts it doesn't matter if they are the same percent. He may just be tall and lean. Perhaps you or his dad are a similar shape?

Anyway, it sounds like you are doing a fabulous job with your son so I hope you are proud of that ☺