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      <h1 id="top">7.5 Inadequate weight gain</h1>
      <div>
    <p>
	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.
</p>
  </div>
      <div class="section" id="Definition_of_failure_to_thrive_FTT_"><h2>Definition of failure to thrive (FTT)</h2>
    <div>
      <p> In the younger baby weight loss of &gt;7 - 10% of birthweight, or failure to regain birthweight by the second week is considered abnormal. </p>
      <p class="listTitle">In the older baby it may be defined in several ways</p>
      <ul>
        <li>an infant whose weight or height for age is less than the 3<sup>rd</sup> or 5<sup>th</sup> percentile</li>
        <li>an infant whose weight for age falls through 2 major percentile curves on their growth chart</li>
        <li>weight less than 80% of ideal body weight for age</li>
      </ul>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/tip.png" class="icon" alt="" /><h3></h3>
      <div>Review the WHO Child Growth Standards as covered in <a href="topic_6-3.html">Topic 6.3</a> . It is important to have a good understanding of normal growth and to be competent to recognise sub-optimal growth patterns. <br /> All infant measurements should be plotted on these charts only.</div>
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  </div>
      <div class="section" id="Cause_of_failure_to_thrive"><h2>Cause of failure to thrive</h2>
    <div>
      <ul>
        <li>poor absorption and/or the inability to use absorbed nutrients, or</li>
        <li>increased metabolic demands, (eg heart disease, undiagnosed infection, etc) or</li>
        <li>
          <p class="listTitle">inadequate energy intake from</p>
          <ul>
            <li>an insufficient supply of breastmilk, or</li>
            <li>regulation of breastfeeding such that the baby is unable to take sufficient breastmilk, or</li>
            <li>inability of the baby to suckle effectively at the breast.</li>
          </ul>
        </li>
      </ul>
    </div>
  </div>
      <div class="section" id="What_to_do_when_you_suspect_FTT"><h2>What to do when you suspect FTT</h2>
    <div class="section" id="Record_a_thorough_history"><h3>Record a thorough history</h3>
      <div>
        <p>
			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. <span class="aside">[Discuss in the forums or with your colleagues why each of these could be significant.]</span>
		</p>
        <ul>
          <li>
				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.
			</li>
          <li>
				Ask the mother to describe typical breastfeeding behavior.
				<p class="listTitle">If necessary prompt the mother to include:</p><ul><li>type of feeding cues and her response to them,</li><li>describe when the baby feeds, not just how many times per day or night,</li><li>baby's behavior before, during and after breastfeeds,</li><li>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. </li></ul>
			</li>
          <li>
				Ask the mother about complementary foods, or other fluids given to baby, or the use of a pacifier - How much? How often? Why? ...
			</li>
          <li>
				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.
			</li>
          <li>
				Ask her to describe her baby's temperament. If crying behavior sounds excessive, ask for a more detailed description of frequency and type.
			</li>
          <li>Ask her about her baby's recent state of health.</li>
          <li>Does she give the baby any medications (prescription or non-prescription), vitamins, 'tonics', etc?</li>
          <li>
				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.
			</li>
          <li>
				Ask about her recent state of health, medications (prescription and non-prescription) and postpartum recovery, particularly her lochia. <span class="aside">[Why ask about lochia?]</span>
			</li>
          <li>
				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?
			</li>
          <li>
				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.
			</li>
        </ul>
      </div>
    </div>
    <div class="section" id="Examination_of_the_baby"><h3>Examination of the baby</h3>
      <div><p style="font-weight: bold;"> Observe the baby naked. </p><p> 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. </p><ul><li> Behavioral state, and transition between states. Reaction to being undressed, laid down flat, picked up and cuddled/soothed by mother. </li><li> Muscle tone and position that the infant assumes (well flexed, partially flexed, extended, hyperextended, head turned one particular direction exclusively) </li><li> Shape of the infant's head particularly noting presence of forceps or vacuum marks (first few weeks), cephalhaematoma, asymmetry. </li><li> Skin: turgor, subcutaneous fat, rashes, integrity, bruises; color - jaundice (extent); pale; mottled; cyanosis - where, what precipitated it </li><li> Mucous membranes: color, moisture, inflammation, integrity, infection </li><li> Respiratory effort, presence of sweating; response to exertion </li><li> Does the infant feel hot (febrile), or unusually cool to touch? </li><li> If you have received instruction on how to assess for intact cranial nerves, note your findings. Note facial movement and symmetry. </li><li> Weigh the infant. (Review the information in <a href="topic_6-3.html"> Topic 6.3</a> ) - Length and head circumference could also be recorded if you have an accurate means of doing so. <br /> </li></ul><span style="font-weight: bold;"> Oral assessment </span><ul><li> Response to stimulation of rooting reflex </li><li> Visual examination - size, shape of tongue; uvula (bifid or not); intact palate, labial and lingual frenulum, condition of mucous membranes (moist/dry; candida; etc) </li><li> 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) </li></ul><span style="font-weight: bold;"> Observe a breastfeed </span> - if the infant is not in immediate danger, observation of a breastfeed is essential. (Review <a href="topic_5-2.html">Topic 5.2</a> ) <br /> <ul><li> Note position adopted by mother and how she holds her baby </li><li> Note sucking pattern and ability - <span style="font-style: italic;"> 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. </span> <span style="font-style: italic;"> Milk supply is usually compromised too due to the poor feeding, so this needs to be assessed and addressed. </span> </li></ul> <br /> 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. <br /> <br /></div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Modelling observational skills</h3>
        <div>
          <p>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. <br /> 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.</p>
        </div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/warning.png" class="icon" alt="" /><h3 class="warning">RED FLAG</h3>
        <div>
          <p> 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. </p>
        </div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 7.8</h3><p>Complete Activity 7.8 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
      <div class="section" id="Test_weighing"><h4>Test weighing</h4>
        <div><p> 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. </p><p class="listTitle">This procedure must be used sensitively and its limitations explained to the mother:<br /></p><ul><li>From one test weigh it is not possible to conclude how much milk the baby is consuming in a 24-hour period,<br /></li><li>nor how much milk is available for the baby in the breast either at this feed or for the 24-hour period.<br /></li></ul>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. <p>Accuracy is dependent on attention to weighing technique.</p></div>
      </div>
      <div class="section" id="What_do_you_see_"><h4>What do you see?</h4>
        <div class="captionBox"><img width="302" height="400" src="images/FTT_bi.jpg" alt="" /><p> <br />&copy; B.Ingle, IBCLC</p></div>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
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      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
  </div>
      <div class="section" id="Management"><h2>Management</h2>
    <div>
      <p>
		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.
	</p>
    </div>
    <div class="section" id="Parent_education_and_counseling"><h3>Parent education and counseling</h3>
      <div>
        <p>
			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.
		</p>
      </div>
    </div>
    <div class="section" id="Step_1"><h3>Step 1</h3>
      <div>
        <p> The <strong>first action</strong> 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. </p>
      </div>
    </div>
    <div class="section" id="Step_2"><h3>Step 2</h3>
      <div>
        <p> Next, <strong>feed the baby!</strong> 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.<sup><a href="#note1">1</a></sup> </p>
        <p> 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. <br /></p>
        <p>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! <br /></p>
        <p style="font-weight: bold;">Be very careful that you don't jeopardise breastfeeding completely with a management plan that doesn't take normal breastfeeding physiology into consideration. </p>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>A quick calculation</h3>
        <div>Let's look at that from a practical viewpoint.<br /><br />Total daily intake = approx 800ml<br />8 feeds/24 hrs = 100ml/feed<br />11 feeds/24 hrs = 70ml/feed<br />12 feeds/24 hrs = 65ml/feed<br /><br />The volume of supplement will be a<span style="font-style: italic;"> portion</span> 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.<br /><br />The supplement is to enhance the infant's current intake, not to act as a total replacement feed.<br /></div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
      <div class="section" id="What_supplement_shall_I_use_"><h4>What supplement shall I use?</h4>
        <div>
          <p> 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. </p>
          <p class="listTitle"> In order of preference: <sup><a href="#note2">2</a></sup> </p>
          <ul>
            <li> mother's own expressed breastmilk </li>
            <li> donor breastmilk from a trusted, infection-free source, eg a milk bank <br /> If neither of those are available: </li>
            <li> artificial infant formula. Discuss with the mother whether a regular or a hypoallergenic formulation is required. </li>
            <li><strong>ONLY</strong> if baby is &gt;6 months - commence complementary foods, replacing nutrient-poor foods with nutrient-dense, high calorie foods if necessary. </li>
          </ul>
        </div>
      </div>
      <div class="section" id="How_will_the_supplement_be_given_to_the_infant_"><h4>How will the supplement be given to the infant?</h4>
        <div>
          <p class="listTitle">Different circumstances dictate different methods of supplementation. (<span style="font-style: italic;">Click on supplement feeding method below for additional information and technique</span>)<br /></p>
          <ul>
            <li>A <strong><a href="topic_7-5-1.html">tube-feeding device at the breast</a></strong> is the method of choice when the infant is willing and able to suck at the breast - he has good underlying sucking ability but the suck may be weak and/or the mother has insufficient milk supply. <br /></li>
            <li><strong><a href="topic_7-5-2.html">Cup-feeding</a></strong> is the preferred choice for an alert baby who cannot suckle for any reason (absence of mother, suck abnormality, etc)</li>
            <li><strong><a href="topic_7-5-3.html">Finger-feeding</a></strong> is a useful technique to help teach an infant to suck. When small quantities are to be given (ie colostrum) using this technique with just a syringe containing the milk is convenient.</li>
            <li><strong><a href="topic_7-5-4.html">Bottle feeding</a></strong> is the least preferred method, but may be the method of choice of the parents. Bottle feeding should not be used for infants while still in the hospital setting.</li>
          </ul>
        </div>
        <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 7.9</h3><p>Complete Activity 7.9 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
      </div>
      <div class="section" id="When_to_supplement"><h4>When to supplement</h4>
        <div>
          <p> 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. </p>
        </div>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3>Individualise your care</h3>
        <div>
          <p>
				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.
			</p>
        </div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
    <div class="section" id="Step_3"><h3>Step 3</h3>
      <div>
        <p> You must also <strong>determine and treat the cause</strong>, if possible. Is the cause maternal or infant in origin? <br /> </p>
        <ul>
          <li><span style="font-style: italic;"> Protect the milk supply </span> - insufficient breastmilk supply is addressed in <a href="topic_8-4.html">Topic 8.4</a> </li>
          <li> 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. </li>
          <li> 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. </li>
          <li> The management of the infant with poor absorption of nutrients or increased metabolic demands will be managed by a medical specialist. </li>
        </ul>
      </div>
    </div>
    <div class="section" id="Step_4"><h3>Step 4</h3>
      <div>
        <p><strong>Follow-up</strong>. 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.</p>
        <p class="listTitle">To this end you will discuss with them ...</p>
        <ul>
          <li> 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. </li>
          <li>Observation of infant's appearance. Baby should be bright-eyed and alert, and skin should not be pale.</li>
          <li> Observation of infant's behavior. Baby should be active, alert and happy for some time each day, waking for feeds and feeding enthusiastically. </li>
        </ul>
        <p> 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.</p>
      </div>
    </div>
  </div>
      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
      <div>
        <ul>
          <li>The signs of failure to thrive.</li>
          <li>The possible underlying causes of poor weight gain.</li>
          <li>The significant history information which will help to identify the cause of the problem.</li>
          <li>The steps to appropriate management of failure to thrive.</li>
          <li>The indications for choosing the method of supplementation.</li>
          <li>How to teach safe preparation and storage of breastmilk substitutes, when necessary.<br /></li>
        </ul>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="Self-test_quiz"><h2>Self-test quiz</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div></div><div class="activity" id="activity_rd">
<script type="text/javascript">
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	new MCQ('At your breastfeeding clinic you meet a mother who is exclusively breastfeeding her one month old infant. He takes 5 - 6 sleepy feeds per day, sleeps well between feeds and has infrequent bowel motions and 5 moderate wet nappies per day. He appears of reasonable health, but has minimal subcutaneous fat. The scales reveal he has just regained his birth weight of 3.7kg (8lb 2oz).After your examination of the infant and taking a thorough history of events, what feeding management strategies will you implement for this mother and infant?', [{text:'Perform a breastfeeding assessment, assisting the mother to correct a poor latch. Ask the mother to wake baby to breastfeed at least 8 - 10 feeds per 24 hours, and to express any remaining milk after most feeds to give to her baby.',feedback:'Correcting the poor latch will result in increased drainage of the breast which will stimulate milk production. This infant needs to be fed more frequently and expressing is also another way to increase milk volume.',score:1},{text:'Suggest small supplements of artificial infant formula to be given by cup after each breastfeed.',feedback:'It is good to try using a cup for supplements. However, there is no indication that this baby is in immediate danger and regular supplements of infant formula will compromise the mother\'s milk supply.',score:0},{text:'Suggest that the mother totally express for 24 hours and bottlefeed the expressed milk to her baby so that she can see exactly how much milk she is producing.',feedback:'Hmm, the total expressing may actually stimulate the breast compared to the infant\'s current ability, however, the bottle will be harmful to breastfeeding and the emphasis here needs to be on frequent effective drainage preferably by the baby.',score:0},{text:'Recommend a galactogogue for her to commence after consultation with her doctor.',feedback:'A galactogogue will not work by itself - although a galactogogue may be a good additional strategy, frequent effective drainage is the most important factor in milk production.',score:0}]),
	new MCQ('The mother implements your suggested feeding plan and calls you the following day to report that the infant now has very wet nappies (diapers) with every feed and he is waking up easily and wanting to feed each time. Based on this report, what is the most obvious reason for this change in the infant?', [{text:'The mother now has an adequate milk supply.',feedback:'hmm, probably not after 24 hours but if this plan continues well, the milk supply will increase.',score:0},{text:'The infant may have been sleepy from breastmilk jaundice.',feedback:'Breastmilk jaundice is an extension of physiological jaundice in some breastfed infants - it should not cause an infant to fail to thrive.',score:0},{text:'The mother\'s milk supply now has a higher water content.',feedback:'How does this happen?',score:0},{text:'The increased number of feeds and expressing has increased breast drainage and milk synthesis.',feedback:'Yes, this is the most important basic breastfeeding management to attend to.',score:1}]),
	new MCQ('The mother and infant return to see you another 24 hours later. The mother has continued with the plan and reports the same as the day before. The infant still has passed only one small bowel motion each day for the past 24 hours. The infant\'s weight has not increased when you weigh him again. What is the best explanation for you to give to the mother about the situation and your plan for her baby?', [{text:'I am very happy about the increased wet nappies and that he is now waking and feeding willingly. Based on that, I don\'t want you to worry about his weight, keep up the good work and bring him back next week for another weight check.',feedback:'It is very good to encourage the mother, but he hasn\'t made enough progress and his lack of weight is an indicator of possible other problems.',score:0},{text:'That is not good. He should have gained at least 30grams per day since we started this plan. I don\'t think your milk supply is adequate.',feedback:'no! This is very demoralising for this mother. It appears that her milk supply is still low and further attention is necessary in a caring way.',score:0},{text:'It is concerning that your baby still hasn\'t gained weight. We\'ve waited for your milk supply, but now it\'s important to give him infant formula for him to grow adequately.',feedback:'It is true that the lack of weight gain is concerning, but dismissing her breastfeeding and implying that infant formula is the only solution is wrong.',score:0},{text:'We can see signs that your supply has started to increase and it will continue to increase the more often that your baby feeds well. His lack of weight gain indicates that he needs a bit more assistance. Let\'s discuss other forms of supplementation for him to help his progress.',feedback:'Yes. This acknowledges the efforts and results so far and is setting a future plan which will not compromise breastfeeding.',score:1}]),
	new MCQ('After consultation with the infant\'s doctor, you discuss the need for additional supplementation of the infant. If all methods were available, what would be the first choice of supplement and method?', [{text:'Donor breastmilk or hypoallergenic artificial infant formula via a feeding line at the breast.',feedback:'Good choice - always donor milk if available. This infant is still willing to feed at the breast, so a feeding line will optimise breastfeeding ability.',score:1},{text:'Artificial infant milk by bottle after each breastfeed.',feedback:'No, not first choice.',score:0},{text:'Artificial infant milk via feeding line at the breast.',feedback:'Feeding line is good, artificial infant milk only if donor milk not available.',score:0},{text:'Cup feeding donor breastmilk.',feedback:'Donor milk is great, cup feed if feeding line not available.',score:0}])
]};

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    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="Assessment_Quiz"><h2>Assessment Quiz</h2>
    <div>
      <p>
		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.
	</p>
    </div>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><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="note2"><a href="references.html#who03a" title="See full details">#</a> World Health Organisation (2003) Global Strategy for Infant and Young Child feeding</li>
        </ol>
      </div>
      <div id="footer"><a href="topic_7-4.html" rel="prev" class="prev">&laquo; Previous</a><a href="topic_7-5-1.html" rel="next" class="next">Next &raquo;</a><br style="clear: both" /><a href="#top" id="topLink">Back to top</a><a href="javascript: window.print()" id="printLink">Print this page</a><span class="noPrint"> | </span>&copy; 2012 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
    </div>
    <div id="menu">
      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li class="current">7.5 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</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>
      </ol>
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