“Your baby isn’t gaining enough weight” – words every breastfeeding mother dreads to hear. It immediately makes you doubt yourself, your milk and your instincts. Of course, before you panic, you should make sure that your baby really has a problem; often the problem is actually with the health care worker’s interpretation of the growth chart (see this post on how to correctly interpret a growth chart). But sometimes the truth is inescapable: your exclusively breastfed baby is not growing as he should. Does this mean the end of breastfeeding? Not at all! In this post I’ll walk you through a number of steps to take when you get this distressing news, so that you can preserve your breastfeeding relationship while making sure that your baby is getting enough nutrition.
Start by identifying the problem
There are a number of reasons why a baby can have problems with weight gain. Before I start listing them, let me make one thing very clear: it’s never because your milk is not nutritious enough! Nature only has one recipe for making breast milk, and it has worked for billions of years. Instead, you probably have one or more of the following problems:
A milk production problem
A small minority of women will have some anatomical or medical condition that prevents their breasts from making enough milk. This can include problems with the breasts or with the hormone systems that regulate milk production.
Let’s look at breast problems first. There are two main problems to be aware of:
- Insufficient glandular tissue in the breast is a rare condition where the breast tissue never adequately developed. You may have this condition if your breasts didn’t grow or change at all during pregnancy, your breasts are shaped like a Coke-bottle (instead of like a ball or bowl), your one breast has always been a lot bigger than the other or you have a very wide space between your breasts. IMPORTANT: the size of the breast doesn’t matter – small breasts don’t necessarily have less glandular tissue!
- If you’ve had breast reduction surgery in the past. If not done carefully, breast reduction surgery can easily cut through the nerves and milk ducts that are needed for lactation. Modern surgical techniques tend to do as little damage as possible, but it is important that you be aware that this could damage your ability to make enough milk.
In cases where there is a problem with the breast, you should definitely work with a lactation consultant to help you make as much milk as possible, but also to ensure that your baby is getting adequate nutrition. Sadly, it is often not possible to bring in a full milk supply if you simply don’t have the breast tissue to do it, and formula top-ups may be necessary. The most important thing is that baby must get enough milk to allow him to grow and develop. Your motto in this situation should be: “any amount of breast milk is better than none.”
Next, let’s look at the hormonal problems. As if PMS and baby blues were not bad enough, our hormones can also mess with our ability to make milk. Milk production is influenced by a number of hormones, not just by those directly related to lactation. Fortunately, hormonal problems are a bit easier to address. The following hormones are the important ones to look out for:
- Prolactin is the main hormone that drives milk production, especially in the early days. Prolactin is produced whenever the breast is emptied of milk: removing milk from the breast leads to increased prolactin secretion, and the prolactin then stimulates the breast to make more milk. It follows, then, that if you do not have enough prolactin, you won’t have enough milk. This is especially true in the early days of breastfeeding, when your breasts are still figuring out how much milk to make. The most common cause of low prolactin levels is simply that the breast is not being emptied effectively – see the discussion on milk removal problems in the next section. However, you can also have lower prolactin levels if your baby was premature, if you lost a lot of blood during the birth or for an unfathomable number of other reasons. Luckily, there are a number of pills that increase prolactin levels – this is how all the pills that are prescribed for milk production work (and it’s also why they don’t always work – higher prolactin levels will only help you if you had low prolactin levels to begin with!)
- Thyroid hormones are often overlooked as a cause of low milk supply. Both an underactive and an overactive thyroid can cause problems. An underactive thyroid will lead to low levels of thyroxine, which will cause you not to produce enough milk. Luckily this is easily treatable with synthetic thyroid hormone in tablet form. An overactive thyroid, on the other hand, will not reduce your milk production, but it can inhibit your let-down reflex. This makes it very difficult to pump milk.
- Sex hormones are the last culprit. If you have PCOS, or you struggled to get pregnant in the first place, there is a good chance that your sex hormone levels are out of balance. It’s not a given that you will have low milk supply – I know of a number of women with PCOS or IVF babies who have successfully breastfed – but it is important that you need to monitor your milk supply very closely (want to know how to do that? Look at this post). Contraceptive pills, implants and injections also contain sex hormones, which is why some of them can also reduce your milk supply – be sure to mention to your doctor that you’re breastfeeding when you go to choose your contraception!
Fortunately, as I mentioned earlier, hormonal problems are mostly treatable, so you should be able to get your milk production back up to speed fairly easily once you receive the right treatment.
A milk removal problem
The next group of problems are by far and away the most common reason why breastfed babies don’t gain enough weight: they simply don’t get enough milk out of the breast! The milk is there, the breast is producing beautifully, but the baby just can’t get at it. There are a number of reasons why a baby might struggle to get enough milk out of the breast:
- Not spending enough time at the breast is the most basic reason why a baby wouldn’t get enough milk. Some so-called experts still recommend only feeding for a certain number of minutes per breast, or only after so many hours. Nonsense! A baby needs to feed for as often and as long as they want to. So if you have in any way been limiting baby’s time at the breast, stretching out feeds or trying to get baby to drop feeds, stop. Just feed baby on demand. (Of course, it is equally possible that baby is not “demanding” enough – this is often the case in babies who are very sleepy due to e.g. jaundice or a rough birth. In this case it’s probably best to wake baby up every 2-3 hours to ensure he gets enough feeds)
- A poor latch will also make it difficult for baby to get enough milk out of the breast. Check out this post to make sure you know what a good latch looks like and how to achieve one!
- Prematurity will have a major effect on your baby’s ability to breastfeed effectively. Premature babies simply don’t have a mature suckling reflex. Any baby born before the end of 37 weeks of pregnancy is at risk of having an ineffective suck – indeed, some babies are still struggling even at 38 weeks. In this case you should absolutely call in the help of a lactation consultant or speech therapist who will teach you some exercises to help your baby learn to suck more effectively. In the meantime, you may need to do breast compressions or top up with expressed breast milk to ensure that your baby gets enough nutrition.
- Problems with the mouth or tongue can make it difficult for baby to breastfeed effectively, since the muscles of the mouth and tongue are doing all the work to get the milk out. There are a number of anatomical problems in the mouth that can cause sucking problems: lip and tongue ties, submucosal soft palate clefts, arched palates and buccal ties are just a few. You should suspect an anatomical problem if baby simply can’t stay latched on to the breast, or if it is downright impossible to get a good latch. In this case, you should again have it checked out by a lactation consultant or speech therapist – they will know exactly what to look out for and how to treat it.
So you see that in all these cases the problem is not that there isn’t enough milk, but that baby isn’t able to access the milk that is there. Of course, if the breast is not being emptied regularly, your milk supply will begin to decrease – but as soon as you address the problem and start emptying the breast more thoroughly, your milk supply will quickly recover (Want to know how that works? Check out this post).
A medical problem
Sometimes the reason why baby is not growing has absolutely nothing to do with the milk: there is enough milk and baby is drinking enough, but the growth just isn’t what it should be. In this case, you need to start looking for a medical reason, and that is a job best done by your baby’s doctor. Here are a few things to look out for, though:
- Infections increase the body’s demand for calories. Sometimes baby has an underlying infection that you don’t even notice – urinary tract infections are a common culprit. Lung infections, especially TB, also cause poor weigh gain. Your doctor can do a simple blood test to check for infections, and treat them if necessary.
- Iron deficiency or other types of anaemia can cause poor weigh gain. This is most common in premature babies. Insist on a blood test for iron levels before you give any supplements – giving unnecessary iron will do more harm than good!
- Heart problems that were present from birth also cause poor weight gain. These can sometimes be overlooked at the time of birth, especially if your baby was not seen by a paediatrician (such as in most of the smaller government hospitals)
Ways to increase your baby’s weight gain
As with most things, once you have an idea of what caused the problem, you will have a pretty good idea of how to fix it (just look at the suggestions included in the discussion above). However, while you are addressing the problems, your baby still needs to eat! Here are some suggestions for ensuring that your baby takes in more milk:
- Feed more often. Simple, really – wake baby up for a feed every two hours or so. Baby doesn’t even need to be fully awake – even a half asleep (or mostly asleep!) baby can suckle quite well. Check if you can see baby swallowing – that’s the best way to know that baby is getting some milk out of the breast.
- Take a babymoon: get into bed with baby for a day (or two or three, depending on what you can get away with!) Go topless, undress baby down to his diaper, keep him on your chest and just feed, feed, feed. The skin-to-skin contact will entice baby to drink more often and also stimulate your body to make more milk.
- Do breast compressions while baby is feeding. This is a bit like hand expressing and feeding at the same time: baby is sucking and you’re “pushing” the milk to help him. It works like this: When baby is latched, grab a hold of your breast, but put your hands far to the back so that your fingers won’t get in baby’s way. As soon as baby suckles, squeeze the breast – it will cause the milk to flow a bit faster, and baby will get more milk with each suck. This works really well for babies who are struggling to suck, such as premature babies, sleepy babies or babies who have a latching problem.
- Express milk from the breasts after feeds. You can either do this by hand or with a pump. This will do two things:
- It stimulates the breast to make more milk. Remember, removing more milk means more prolactin is secreted, which increases the amount of milk the breast makes
- It gives you extra milk to use as a top-up
- Give a top-up of expressed breast milk after feeds. If your baby is having any latching or suckling problem whatsoever it is very, very important that you do not use a bottle for this! Giving a bottle at this point will only make thing worse. Feed the milk to baby with a syringe or a cup.
- If baby is over 6 months, you can also focus on giving more nutrient-dense foods. Adding healthy fats like peanut butter, olive oil, coconut oil or avocado can give baby’s weight gain a boost (my personal favourite: mashed banana mixed with peanut butter. Yum!).
- If you were giving any water, juice or tea, stop. Babies under 6 months need only milk; babies over 6 months still need mainly milk, and water only if they are constipated. Tea contains no nutritional value and it takes the place of more nutritious foods; leave it out.
- If all else fails, formula may need to enter the picture. But please note: formula is the last resort, not the first one! If it is the first thing your doctor suggests, the I highly recommend you find someone else to help you solve this problem – a lactation consultant would be best, but even most dietitians (especially at government hospitals) can do a decent job.
While doing this, you will of course have to keep a close eye on baby’s weight gain to make sure it’s working. Have baby weighed once a week – and remember, always weigh naked, and always on the same set of scales!
Wow, that was a mouthful! A suitably complicated answer for a pretty difficult question! Let’s just simplify it all and recap what the important things are:
- First, make sure you really do have a weight gain problem – check out this post on how to read a growth chart.
- Secondly, try to figure out why baby is not gaining weight:
- Is it a problem with your breasts or hormone levels?
- Is it a problem with how often or how effectively baby is suckling?
- Is it a medical problem unrelated to feeding?
- If you can’t figure out the problem by yourself, enlist the help of a lactation consultant!
- Thirdly, make a plan to address the problem you identified – look at some of the suggestions I’ve offered in this post.
- And finally, make sure that baby is getting more milk by feeding more often, keeping baby skin-to-skin, doing breast compressions and/or expressing your milk and using your expressed breast milk for top-ups.
I hope that this post has given you the tools that you need to get your baby’s weight gain back on track, or that it at least pointed you in the right direction. As always, I love to read your comments on what you found helpful. If you have any more tips for helping a baby gain weight, please share them in the comments below!