GOLD Learning Speakers

Breastfed infants who gain weight slowly can present a challenge to both parents and providers. Their quiet, content demeanor can delay diagnosis, and their anorectic behavior can make feeding very difficult. Moreover, as, Powers laments, our evidence base is clouded by confused definitions, contradictory growth standards, inadequate research, and no definitive standard of care. The medical literature has long suggested that, at minimum, infants should be back to birthweight by 2 weeks of age, and thereafter grow at least 20 gm/day, or 5 oz/week. However, data from the 2006 WHO Multicenter Growth Reference Study challenge these minimal standards. WHO data put infants of all percentiles back to birthweight before a week of age, and thereafter even female infants growing along the 1st percentile average 28 gm/day over weeks 2 to 8, while 1st percentile boys average 32 gm/day. At the 50th percentile, girls average 34 gm/day, boys 39 gm/day. Yet we do see exclusively breastfed babies who grow more slowly than the WHO standards. What’s going on? It was over 25 years ago that Dewey et al demonstrated in their classic DARLING studies that healthy infants who breastfeed on demand self-regulate their intake to steadily gain weight appropriately However, as many have observed, the sleepy underweight infant cues subtly and infrequently, thus defeating feeding strategies which rely on the baby’s presumptive good appetite to increase both infant weight and maternal milk production. We submit that once the infant’s appetite is impaired, the infant is NOT the healthy infant Dewey and WHO describe. Instead, apparent anorexia makes the infant incapable of the self-regulation that could break the vicious cycles of slow growth, low energy, and infrequent ineffective feeds.3 Importantly, ineffective milk removal also slows maternal breast milk production, further decreasing infant intake. In our breastfeeding medicine practice we’ve developed an approach to breaking these vicious cycles, using high-flow feeding methods to push infant intake towards rapid catch-up growth, while also offering strategies for increasing the rate of milk production. This requires significant maternal time, effort and energy, and can be hugely frustrating, so it is important to offer strategies that work with the mother’s real life, and permit her needed rest. Thus successful management also includes appropriate and intensive support to the mother, her energy, sleep, and emotional well-being. It’s our observation that, once caught up on weight, these infants become easy to feed, and do indeed achieve appropriate self-regulation to follow WHO growth standards.

Much has been written about the challenges of breastfeeding late preterm infants, the “great pretenders” who can fool us by looking almost full-term. But what about early preterm infants, who spend their first months in hospital? Their feeding issues are very different, complicated by their severe prematurity, medical issues and necessary clinical care, as well as by their mothers’ emotional experiences and challenges as they initiate mothering, milk production and breastfeeding in the NICU setting. We’ll look at how oxytocin and kangaroo mother can help optimize maternal milk production, maternal behaviors and competency, early breastfeeding, and infant growth, specifically looking at evidence based approaches to the early initiation of breastfeeding for these tiny infants. We’ll also look at a couple of broad initiatives—the Baby Friendly Hospital Initiative for Neonatal Wards and Family Integrated Care—that offer the promise of empowering mothers and improving health outcomes for their preterm infants.

A growing literature and widespread clinical experience support the role of simple frenotomy in improving breastfeeding function for infants with restrictive anterior frenula. The diagnosis and management of restricted tongue mobility and function involving the posterior tongue, however, remains confusing and controversial. Since Betty Coryllos’ seminal work just over a decade ago, subsequent literature has been limited. Definitions, diagnosis, indications for intervention, management choices and anatomic factors predictive of positive outcomes elude us. Over- and under-diagnosis can both lead to adverse outcomes. This presentation will look at these concerns through the lens of known infant anatomy and oral function in breastfeeding, the available literature, as well as the shared clinical experience and observations of those in the field.