WEBER STATE UNIVERSITY BACHELOR OF INTEGRATED STUDIES PROGRAM
Name: Paula Loe
Date: Spring Semester 2013
Project Title:
Breastfeeding, Feeding Issues and Infant Reflux and how this Impacts Weight Gain
and can Lead to a Failure to Thrive
Diagnosis.
Brief Summary of Project: This is a creative project that
includes a website with videos, a blog and a 17 page support paper with 19
scholarly references.
Area of Emphasis 1:
Health Promotion
Committee Member from that discipline:
Ken Johnson
Area of Emphasis 2: Health Science
Committee Member from that discipline: Kathryn Newton
Areas of Emphasis 3:
Nutrition Education
Committee Member from that discipline:
Joan Thompson
Breastfeeding, Feeding Issues and Infant Reflux and how this Impacts Weight Gain and can Lead
to a Failure to Thrive Diagnosis
Paula Loe
Bachelor of Integrated Studies
Capstone Project
ABSTRACT
Breastfeeding is not only an important consideration to the health of an
infant, but it can be challenged by many complications that pediatricians are not
necessarily aware of. This paper brings many issues to light and may explain why
some children have difficulties gaining weight. The paper explains fully how failure
to address breastfeeding and infant growth issues early on will lead to more
complications later. Also this paper addresses the need for more lactation education
for health providers working with pediatric populations. Further, mothers need to
educate themselves so they can have a successful breastfeeding relationship with
their children.
Introduction
In this paper I will explain how breastfeeding, feeding issues and infant
reflux can impact weight gain and lead to a failure to thrive diagnosis. In the
last two years I have endured chronic scrutiny of my choice to breastfeed a
child who was diagnosed as failure to thrive. In this paper I will explain how
this diagnosis has underlying issues that were missed initially and her weight
gain could have been better if these issues would have been addressed sooner.
This paper will address each section of my capstone separately followed by a
summary and conclusion.
Health Promotion
One of the strongest reasons to breastfeed is that infants that are
breastfed are healthier than their formula fed friends. According to Pediatrics
the official journal of American Academy of Pediatrics,
"Breastfeeding and human milk are the normative standards for infant feeding and nutrition.
Given the documented short and long term medical and neurodevelopmental
advantages of breastfeeding, infant nutrition should be considered a public
health issue and not only a lifestyle choice…The Periodic Survey of a large
sample of practicing pediatricians reveals that although a majority of
respondents recommend breastfeeding a distinct proportion of pediatricians do
not do so along current guidelines. A majority of pediatricians believe that
breastfeeding and formula-feeding are equally acceptable methods of feeding
infants” (pg. 1, 7)
Basically, any pediatrician would usually whole heartedly encourage a woman to breastfeed
however, when it comes to having issues along the way the pediatrician that in
theory advocates for breastfeeding may soon be recommending supplementing with
formula. According to Kramer, et al (2008),
“Protection against infections in developed country settings does not have the
life and death implications for infant and child health that it does in less
developed settings. Cognitive benefits may be among the most important
advantages for breastfed infants in industrialized societies.” (pg. 6) The
results of the large randomized trial go on to state that breastfeeding
“provide(s) strong evidence that prolonged and exclusive breastfeeding improves
children’s cognitive development.” (pg.1)
In some cases, even though many mothers start out with a goal of doing what is
best for their children a lot of women are met by uninformed pediatricians and health
care workers that add to the difficulty of attaining their goals. Even if a
mother is fortunate to get a pediatrician who is familiar with breastfeeding
their knowledge set is influenced by thier family experiences.
According to Schanler, O’Connor, and Lawrence (1999), “Of all respondents, 60%
had children who breastfed, whereas the remainder either never had children or
their children never breastfed.” (pg.6) If there were no feeding issues in the family there
may be limitations for finding solutions for breastfeeding issues.
According to Schanler, O’Connor, and Lawrence (1999), “Most pediatricians agree
on the importance of breastfeeding and support breastfeeding promotion
activities. However, many primary care physicians believe their training in
breastfeeding management has been inadequate, and they lack confidence in their
breastfeeding management abilities.” (pg. 2) If the pediatrician did not know
the answer to the mother’s problem or was concerned about appropriate weight
gain of a breastfed child the pediatrician could consult or refer thier client to someone who could offer solutions for breastfeeding issuessuch as a lactation consultant/educator. If pediatricians
sought practical information really wanted to know more they could obtain the book, The
Womanly Art of Breastfeeding which is endorsed by the La Leche League, and contains
excellent, practical infromation about enabling a mother to continue successfully breastfeeding
her infant.
A useful anaglogy to make the point about the power of a health care provider would be, if a
person showed up to an emergency room (ER) with a nasty gash on their face that would require
stitches any ER physician would be capable of stopping the bleeding and suchering the person
back together. However, if their was a board certified plastic surgeon available, the expertise
of this specialized physician to provide the medical care would optimize the outcome. The emergency
room physician although capable of putting stitches in does not have the same level of skills and
knowledge that a board certified plastic surgeon would have and the ER doctor would most likely leave
a bigger scar. It is no different in the lactation field, the scar that a pedicatrician could leave on a
breastfeeding relationship or on a mother who was simply tring to do her best is no less damaging.
In the last few years the federal government has revised the standard growth charts used to evaluate
infant growth. On the CDC website it states, “Growth charts are not intended to be used as a sole
diagnostic instrument. Instead, growth charts are tools that contribute to
forming an overall clinical impression for the child being measured.” They even
recommend using the World Health Organizations growth charts. Unfortunately they
are not very clear that there are other charts available for certain conditions
or ethnicities that will impact the interpretation of expected growth.
According to Hren, et al (2008), “Exclusive breastfeeding for 6 months is
the best nutrition for infants. It is the duty of health professionals to
promote breastfeeding.” (pg. 4) Unfortunately some doctors are still operating
on the old advice of introducing solids between four and six months. According to
Schanler, R.J., O’Connor, K. G. and Lawrence, R.A.(1999),
“Of concern is that pediatricians now are likely
to recommend semi-solid foods, iron and vitamins before 5 months of age, and to
recommend supplementing feeding and pacifiers in the first few days after
delivery. These infant feeding practices are known to impede successful
breastfeeding and may be unnecessary.” (pg. 8) Granted some people do this
without doctor’s advice because of the mistaken idea that it will help the baby
sleep better at night or that the child was starving and needed extra food.
Those reasons mostly come from the mistaken beliefs that infants can be
scheduled and only need to nurse when it is convenient for the mother. Infants
only source of language is to cry when the baby needs something. Breastfeeding
or not they still are quite high maintenance.
According to LI, Fein, Chen and Grummer-Strawn, (2008)
“Among mothers who stopped breastfeeding through the first 8 months or their infant’s
life, the perception of their child’s dissatisfaction with breast milk alone and
concerns about milk supply were both consistently cited as important reasons for
stopping…when a mother does not have confidence that she is providing an
adequate quantity or quality of milk for her infant she is likely to stop
breastfeeding regardless of her infant’s age…They also suggest that most mothers
can overcome temporary breastfeeding problems without resorting to
supplementation if they receive appropriate guidance from health professionals,
including reassurance that what they perceive to be a low milk supply is
actually sufficient and that their infant growth is uneven and often occurs in
spurts” (pg. s73-s74)
When looking at the last three cited articles in this paper, one can
easily assume that a major issue of breastfeeding advocacy is the attitude
education, and first hand family experiences of feeding infant's of the infant's peditrician.
As referenced to above 40% of pediatricians have
limited first-hand knowledge and limited education on breastfeeding. Further, I
personally have witnessed many mothers over the course of the last 24 years who have given
up breastfeeding because they were told by their pediatrician that they had
either dried up, or have an inadequate breastmilk supply that resulted in a wrongful solution
to supplement with formula. When these issues arise referral to lactation experts may improved
breastfeeding success and more importantly help an infant to gain weight. In my own experience
I have had three pediatricians and two nutritionists tell me that I needed to supplement formula because I had dried up or had an inadequate breastmilk supply in the last year. How
many more women in this area have been given that same advice from these health
care professionals?
Health Science
One of the road blocks to success in breastfeeding is if the child has a condition
or underlying cause as to why breastfeeding may not be working. The common
standard for weight gain in a breastfed infant according to ask Dr. Sears.com,
who is a fellow of the American Academy of Pediatrics, “is that they gain 4-7oz
per week in the first six months.” If the infant does not gain this much weight
then according to Krugman and Dubowitz (2003), “Failure to thrive is best
defined as inadequate physical growth diagnosed by observation of growth over
time using a standard growth chart.” (pg. 1) They go on to
state:
“Infants who have had intrauterine growth retardation or premature infants may appear to
have failure to thrive (FTT) when they grow at less than the fifth percentile.
As long as the child is growing along a curve with a normal interval growth
rate, FTT should not be diagnosed.” In addition using modified growth charts for
specific populations such as premature infants, exclusively breastfed infants,
specific ethnicities (e.g. Asians) and infants with genetic syndromes (Down
Syndrome) can help reassure the physician that these children are growing appropriately.” (pg. 2)
Some women just produce small children. It is important that the pediatrician take
this into account. Most women who are small are not going to have children in
the 95 percentile or even in the 10th percentile.
According to Saenger, Czernichow, Hughes, and Reiter, (2008)
“Weight at birth is an inherited trait through the maternal line. It is likely that
variation in the mitochondrial genome plays an important role in determining
infant birth weight because it is exclusively transmitted through the maternal
line.” (pg. 10) Babies that are born small will probably stay small also. Unfortunately one of the red flags for a child that is failure to thrive is that they may be abused or neglected, butthis scenario should only be looked at after a search for an underlying disease.
This brings us to gastroesophageal reflux. According to Fike, Montellaro,
Pettiford-Ostlie and St. Peter (2004), “Gastroesophageal Reflux is a common
phenomenon in the pediatric population…65-95% of these patients experience
spontaneous resolution of their symptoms by 2 years of age.” (pg.1) There are
two types: one is silent and produces little if any spit up the other type comes
with lots of spit up. The latter is usually the type that most people see and
can understand how this affects weight gain in the child. This can become an
even worse problem then an infant who just spits up frequently some children
will then go on to recognize that eating is painful and won’t fill themselves
thereby causing themselves to gain weight poorly. According to Kaczmarski
(2008), “Acid gastroesophageal reflux (GER) is defined as a recurrent return of
the stomach contents back up into the esophagus.” (pg. 293) One of the major
causes of this issue could be a food allergy. According to Kaczmarski (2008),
(it is important to) “perform immunoallergologic tests at a preliminary stage of
investigation.” (pg. 298) This can be critical because if an infant has an
allergy to milk protein the baby will not gain weight as expected.
Another reason for frequent regurgitation is pyloric stenosis. According to the Mayo
Clinic website, “In pyloric stenosis, the pylorus muscles thicken, blocking food
from entering the baby's small intestine. Pyloric stenosis can lead to forceful
vomiting, dehydration and weight loss.” A pediatrician will usually ask the
parents if the child has projectile vomiting which would differentiate this from
reflux.
Interestingly, when a woman has a child that is born at 36 weeks the doctors prefer not to call
the baby premature, even if the child was also born small for gestational age.
This becomes a problem when the pediatricians are using a standard chart to
compare an apple to an orange, growth patterns are not the same and the growth
pattern will be misinterpreted. However, according to Saenger, Czernichow,
Hughes and Reiter, “most small for gestational age children can get caught up to
their peers by age 2.” (pg. 19) So again, if a doctor does not know this to be the case, his concerns will become paramount and even with evidence that the child is in good health he will
encourage the mother to go to formula supplementation. One only has to think for
a moment that a child who is born prematurely may not have all that it needs to
grow and develop correctly. Further, the possibility that a food allergy to
something the mom has eaten makes it all the more plausible that there is going
to be issues.
In my experience, this led the pediatrician to exert constant pressure on
me to help my child gain weight. Each time I would take the child in for a
weight check I felt more and more like a failure. It also led me to force feed
my child when the child started to eat solid foods just to make those numbers
reflect my hard work. The problem with this scenario was then my child could
have developed a case of infant anorexia further complicating any efforts to
make the child gain weight. On the other hand it could have made the child
constantly overeat because the child could not recognize when she was full, this
could have led to some serious issues down the road. According
to Steinberg, C. (2007),
Feeding disorder associated with insults to the gastrointestinal tract. Food refusal
follows a major aversive event or repeated noxious insults to the oropharynx or
gastrointestinal tract (e.g., choking, severe vomiting, reflux, insertion of
nasogastric or endotracheal tubes, suctioning). This infant or young child
consistently refuses food in one of the following forms: bottle, solids, or
both. Reminders of the traumatic event(s) cause distress, and are manifested by
anticipatory distress. (pg. 184)
One issue that is poorly understood is hypotonia otherwise known as low muscle tone.
This is a condition of late preterm infants. According to Walker, M.
(2008)
“Late preterm infants are at a disadvantage in terms of feeding skills. Born with low
energy stores (both subcutaneous and brown fat) and high energy demands, the
poor feeding skills of developmentally immature infants are challenged to meet
the hydration and nutritional needs of this population…Late preterm infants have
a weak suck and low tone that may diminish milk volume per suck.” (pg.693)
If the infant has this condition diagnosed in their lips, tongue, cheeks and chest
this will cause the child issues with reflux because of the floppiness of the
under-developed muscles that cover the stomach and chest. As it has been in my
case, when you put these two conditions together you get an infant that will
willingly forgo eating because of pain and therefore fail to gain weight
adequately.
Nutrition Education
A measure of how much nourishment an infant has taken in could be how
much output they have produced. Weighing of diapers can be a good measure to go
on. According to a Women Infants and Children handout, six to eight diapers in a
24 hour period is adequate to show that the child is receiving enough nutrition.
Another measurement that gives a good indication is if the infant looks well
hydrated. Further the breast milk can be tested for calories. According to
Kelly Bonyata R.N., IBCLC, the amount of calories in breast milk is 22 calories
per ounce. Sometimes the infant that has issues will nurse more frequently
forcing the calorie count to climb and the breast milk that is provided is
solely hind milk with a calorie count of 27 calories per ounce.
The recommendation from the American Academy of Pediatrics (2012), is
“exclusive breastfeeding for about 6 months, followed by continued breastfeeding
as complementary foods are introduced, with continuation of breastfeeding for 1
year or longer as mutually desired by mother and infant.” The problem with this
recommendation is most pediatricians will only recommend it if the child is
gaining adequately. Some women have been told after the first several months
that they cannot provide enough milk for their child. In the second six months
infants weight gain slows down to two to four ounces per week and at this point
is perfectly fine to feed the infant cereal and other foods. Also about this
time period according to notes that I received from Intermountain Healthcare in
Layton, Utah, “the child should not be nursing at night and should be sleeping
through the night.” A mother who reads these notes might start to think that
her child does not need to be nursed and will initiate a plan to make this so. A
potential resulting problem with this is that the production of breast milk is
influenced by the amount of suckling stimulus. If the sucking stimulus is
diminished, breast milk production is reduced. The infant may then slow the
weight gain which will lead the mother to believe that she has dried up and
then she might wean altogether. As you can see conflicting advice from
pediatricians causes mothers to doubt their abilities to feed their child.
A stumbling block that can get in the way of achieving this goal is the
lack of knowledge about how frequently an infant should nurse. This question
causes mothers to question their supply and ultimately give up. What is normal
for one infant may not be normal for another. Keep in mind that a one to two day
old infants stomach is marble size and can hold 1/6 to 1 /4 an ounce. A three
day old infant’s stomach is ping pong ball size and can hold 3 /4 to 9/10 an
ounce. By day ten the stomach size is that of a large egg and can hold two to
three ounces. Finally at 21 years old a stomach can hold approximately two cups
or 16 ounces and is the size of a softball. There are also growth spurts that
happen at three and six weeks and three and six months and this will make the
baby want to nurse very frequently. Eventually babies get into a regular routine
and they become somewhat predictable.
Another issue that mothers face with infants is that they want to sleep and the babies keep them up at night nursing. First the fat content in milk is higher at night so pumping a bottle earlier and
having a partner feed them does not give them all the nutrition that they could
have had. According to Kelly Bonyata (2011), fat content depends on the degree of
emptyness of the breast (empty breast = high fat, full breast = low fat). The
average fat content of human milk is 1.2 grams/oz. Alsobreastfeeding is a supply and demand operation and not nursing for several hours will impact supply. To survive these times mothers should learn how to nurse in the side laying position and view these times as short moments thatwill quickly pass. The partners can always help with the diaper duty.
If a mother needs to pump because she is returning to work and finds that
she can’t pump much out, this is not an indication that she cannot provide
enough milk for her child. It is important to pump on a regular schedule as that
will get the body used to the pump and will initiate a better response. Also a
mother finds that if she pumps on one side while nursing on the other it also
stimulates a better response. Furthermore, a mother should never feel
intimidated by the amount that she pumps. According to Shaw, G., (2011) At its
best, a baby's suck is far more efficient at removing milk from the breast than
any pump, but some babies don't have the best latch. (pg.1)
Adequate nutrition for mothers can become an area of concern. With having
a new baby it is difficult to get to thinking about what to eat, let alone
making something to eat. Thinking ahead is definitely a huge help. For instance,
before the baby comes a mother can freeze some well balanced, protein rich meals
ahead and make it easier on herself. Also keeping fresh fruits, vegetable, and
calcium rich foods such as yogurt or cottage cheese around is a big help for
those time when you need a quick snack.
According to my plate as quoted by Brown, J.(2011), “lactating mothers
should eat 8 ounces of grains, 3 cups of vegetables, 2 cups of fruit, 3 cups of
milk/dairy and 6 ½ ounces of meat and beans per day.” (pg. 177). Each mom is
different and may require more or less calories depending on her own metabolism
and health. Keep in mind that lactating woman will burn an extra 500 calories
per day to support breast milk production. This is why it is important to think
about a mom’s diet. If the mom is not taking in the nutrients and energy needed
she will lose weight, and the impact on the quality and volume of her breast
milk will be a problem. Further, some women actually lose weight while nursing
and some women don’t. Yet again evaluating her dietary intake will determine if
there is a problem.
If it is determined that a child has food allergies and the mom needs to
avoid certain foods, for example, dairy products, it is vitally important that
she replace the missing nutrients richly provided by dairy products to not only
to achieve adequate maternal nutrient needs but also the nourishment needed to
ensure the supply of breast milk.
Summary
Lactation is a complex process and many things go in to establishing a
solid breastfeeding relationship. Getting through a successful first six weeks
of breastfeeding is critical to establishing a good feeding relationship. If there are any issues in this critical
time period this could make it near impossible to achieve successful
breastfeeding. Further, the establishment of a successful breastfeeding
experience can be impeded by well-meaning pediatricians who encourage
supplementing at the first possible sign of a problem.
Pediatricians go to school for a long time however, they are not thoroughly educated in infant nutrition and make a lot of misleading statements. This is very unfortunate because their lack of specific
knowledge about lactation is a huge problem to mothers who want to breastfeed
their children. According to Davis, L, (2013)
What do doctors learn about breast-feeding in
medical school? “We learned that it’s what’s best for baby,” said my own
pediatrician. “But that’s it.” They’re introduced to evidence that prolonged
breast-feeding reduces the possibilities of obesity, SIDS and allergies, but the
science of it, what’s happening at the anatomical level? Not so
much.“It’s an hour, or a half a day, and [students]
don’t remember anything,” says Dr. Todd Wolynn, a Pittsburgh pediatrician and
executive director of the Breastfeeding Center of Pittsburgh. There were years,
he says, when there was literally nothing said about breast-feeding at all.
Furthermore, according to Newton, Edward., (1992), “a quick review of the major general textbooks in obstetrics and pediatrics reveals minimal information concerning the anatomy and endocrinology,
and inadequate and sometimes incorrect information on management of breastfeeding mechanisms.”
Mothers can educate themselves about this process and may be able to resist the recommendations to supplement their children; however, constant concerns over weight gain are going to eventually
lead women to give up. The federal government and the American Academy of
Pediatricians recognizes that breastfeeding is important, which is good however,
they give no other guidance to pediatricians to help them understand lactation.
Neither is there a requirement to rectify the problem.
Conclusion
In conclusion, if a mother is going to breastfeed her child the most
important thing she can do is educate herself on the matter. There are many
books written on the subject. Some that I would recommend are: “The
Breastfeeding Book, Everything You Need to Know About Nursing Your Child from
Birth to Weaning” by William Sears M.D. and “The Womanly Art Of
Breastfeeding” by Ina Mae Gaskin. I suggest reading these books before the
baby is born. This will not only instill confidence but will let her know that
the pediatricians, although well meaning, may give some really poor advice at
times. Another thing she can do is to surround herself with supportive people.
This can be accomplished by seeking out a La Leche League group or if she
qualifies she can get support through the Women Infants and Children
program. There are also support groups online that she can go to for some good advice and support. As for the pediatricians they can also educate themselves about infant nutrition even if
they are not required to do so.
Lastly, this project has helped me to want to continue on in my chosen
field. There are so many mothers out there that have been given poor advice and
really need somebody in their corner who might be able to advocate for them at
this critical time. I want to be that person.
References:
Bonyata, K.
(2011) What affects the amount of fat or calories in mom’s milk. Downloaded
from
http://kellymom.com/nutrition/milk/change-milkfat/
Breastfeeding and the Use of Human Milk. (2012) Downloaded from
pediatrics.aappublications.org/content/early/2012/02/22/peds.2011-3552 doi:10.1542/peds-3552
Brown, J.E.,
(2011), Nutrition through the life cycle. Belmont, California: Wadsworth,
Cengage Learning.
Centers for disease control (2013), Retrieved from
on January 15, 2013 www.cdc.gov/growthcharts
Davis, L. (2013, January 2) Is the medical community failing breastfeeding moms.
Time Magazine. Downloaded
from http://healthland.time.com/2013/01/02/is-the-medical-community-failing-breastfeeding-moms/#ixzz2L5fceJ5V
February 15, 2013
Fike, F., Mortellaro, V., Pettiford, J., Ostlie, D., & St. Peter, S. (2011), Diagnosis
of Gastroesophageal reflux disease in infants. Pediatric
Surgery International, 27 (8), 791-797. Doi: 10.1007/s00383-011-2897-1.
How much
weight will my breastfeeding baby gain. (2013) Downloaded
from,www.askdrsears.com/topics/breastfeeding/faqs/how-much-weight-will-my-breastfeeding-baby-gain.
Hren, I.,
MIs, N., Brecelj.,Capma, A., Sedmak, M., Krzisnick, C., Koletzko, B. (2009)
Effects of Formula supplementation in breastfed
infants with failure to thrive. Pediatrics International, 51 (3),
346-351. Doi:10.111/j.1442-200x.2008.02732.x
Kaczmarski, S., (2008), Acid gastroesophageal reflux and intensity of comparison of primary
Symptoms in children with gastroesophageal reflux disease comparison of
primary Gastroesophageal reflux and reflux secondary to food allergy. Advances
in Medical Sciences, 53 (2), 293-299. Doi:
10.2478/v10039-008-0053-5.
Kramer, M.,
et al (2008), Breastfeeding and child cognitive development, New evidence from a Large randomized trial, Arch. Gen. Psychiatry, 65(5) 578-584. Downloaded
from Http://archpsych.jamanetework.com on Jan. 9, 2013
Krugman, S.,
Dubowitz, H., (2003), Failure to thrive, American Family Physicians, 68 (5)
879-884 Downloaded from
www.aafp.org/afp January 10, 2013
Pyloric
Stenosis (2012), Downloaded from,
http://www.mayoclinic.com/health/pyloric-stenosis/DS00815 on
February 18, 2013
Li, R. Fein,
S., Chen, J., Grummer-Strawn, L., (2008), Why mothers stop breastfeeding:
Mothers’ self reported reasons for
stopping during the first year, Pediatrics, 122 (2) s69-s76. Doi:
10.1542/peds.2008-1315i).
Newton,
Edward., (1992),
Breastfeeding/Lactation and the medical school curriculum, Journal
of Human Lactation, 8 (3) 122-124.
Saenger, P.,
Czernichow, P., Hughes, L., Reiter, E., (2007), Small for Gestational Age:
short Stature and beyond. Endocrine Reviews, 28 (2), 219-251. Downloaded from
http://edrv.endojournals.org/content/28/2/219.long
Schaler,
R.J. MD, O’Connor, K.G, Lawrence, R.A MD (1999), Pediatricians’ practices and
attitudes
Regarding breastfeeding promotion. Pediatrics, 103 (3) (e)35-47.
Doi 10.1542/peds.103.3.E35
Shaw, G.,
(2011), Breast pumps for nursing moms. Downloaded February 18, 2013 from www.webmd.com
/parenting/baby/breastfeeding-9/breast-pump
Steinberg, Carolyn
M.D., (2007), Feeding disorders of infants, toddlers and preschoolers. BCMJ 49 (4) 183-186. Downloaded from
www.bcmj.org/article/feeding-disorders-infants-Toddlers and preschoolers. on February 18, 2013
Walker, M,
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Journal of Obstetric, Gynogological, and Neonatal Nursing, 37, 692-701 Doi: 10.111/j.
1552-6909-2008.00293.x
Name: Paula Loe
Date: Spring Semester 2013
Project Title:
Breastfeeding, Feeding Issues and Infant Reflux and how this Impacts Weight Gain
and can Lead to a Failure to Thrive
Diagnosis.
Brief Summary of Project: This is a creative project that
includes a website with videos, a blog and a 17 page support paper with 19
scholarly references.
Area of Emphasis 1:
Health Promotion
Committee Member from that discipline:
Ken Johnson
Area of Emphasis 2: Health Science
Committee Member from that discipline: Kathryn Newton
Areas of Emphasis 3:
Nutrition Education
Committee Member from that discipline:
Joan Thompson
Breastfeeding, Feeding Issues and Infant Reflux and how this Impacts Weight Gain and can Lead
to a Failure to Thrive Diagnosis
Paula Loe
Bachelor of Integrated Studies
Capstone Project
ABSTRACT
Breastfeeding is not only an important consideration to the health of an
infant, but it can be challenged by many complications that pediatricians are not
necessarily aware of. This paper brings many issues to light and may explain why
some children have difficulties gaining weight. The paper explains fully how failure
to address breastfeeding and infant growth issues early on will lead to more
complications later. Also this paper addresses the need for more lactation education
for health providers working with pediatric populations. Further, mothers need to
educate themselves so they can have a successful breastfeeding relationship with
their children.
Introduction
In this paper I will explain how breastfeeding, feeding issues and infant
reflux can impact weight gain and lead to a failure to thrive diagnosis. In the
last two years I have endured chronic scrutiny of my choice to breastfeed a
child who was diagnosed as failure to thrive. In this paper I will explain how
this diagnosis has underlying issues that were missed initially and her weight
gain could have been better if these issues would have been addressed sooner.
This paper will address each section of my capstone separately followed by a
summary and conclusion.
Health Promotion
One of the strongest reasons to breastfeed is that infants that are
breastfed are healthier than their formula fed friends. According to Pediatrics
the official journal of American Academy of Pediatrics,
"Breastfeeding and human milk are the normative standards for infant feeding and nutrition.
Given the documented short and long term medical and neurodevelopmental
advantages of breastfeeding, infant nutrition should be considered a public
health issue and not only a lifestyle choice…The Periodic Survey of a large
sample of practicing pediatricians reveals that although a majority of
respondents recommend breastfeeding a distinct proportion of pediatricians do
not do so along current guidelines. A majority of pediatricians believe that
breastfeeding and formula-feeding are equally acceptable methods of feeding
infants” (pg. 1, 7)
Basically, any pediatrician would usually whole heartedly encourage a woman to breastfeed
however, when it comes to having issues along the way the pediatrician that in
theory advocates for breastfeeding may soon be recommending supplementing with
formula. According to Kramer, et al (2008),
“Protection against infections in developed country settings does not have the
life and death implications for infant and child health that it does in less
developed settings. Cognitive benefits may be among the most important
advantages for breastfed infants in industrialized societies.” (pg. 6) The
results of the large randomized trial go on to state that breastfeeding
“provide(s) strong evidence that prolonged and exclusive breastfeeding improves
children’s cognitive development.” (pg.1)
In some cases, even though many mothers start out with a goal of doing what is
best for their children a lot of women are met by uninformed pediatricians and health
care workers that add to the difficulty of attaining their goals. Even if a
mother is fortunate to get a pediatrician who is familiar with breastfeeding
their knowledge set is influenced by thier family experiences.
According to Schanler, O’Connor, and Lawrence (1999), “Of all respondents, 60%
had children who breastfed, whereas the remainder either never had children or
their children never breastfed.” (pg.6) If there were no feeding issues in the family there
may be limitations for finding solutions for breastfeeding issues.
According to Schanler, O’Connor, and Lawrence (1999), “Most pediatricians agree
on the importance of breastfeeding and support breastfeeding promotion
activities. However, many primary care physicians believe their training in
breastfeeding management has been inadequate, and they lack confidence in their
breastfeeding management abilities.” (pg. 2) If the pediatrician did not know
the answer to the mother’s problem or was concerned about appropriate weight
gain of a breastfed child the pediatrician could consult or refer thier client to someone who could offer solutions for breastfeeding issuessuch as a lactation consultant/educator. If pediatricians
sought practical information really wanted to know more they could obtain the book, The
Womanly Art of Breastfeeding which is endorsed by the La Leche League, and contains
excellent, practical infromation about enabling a mother to continue successfully breastfeeding
her infant.
A useful anaglogy to make the point about the power of a health care provider would be, if a
person showed up to an emergency room (ER) with a nasty gash on their face that would require
stitches any ER physician would be capable of stopping the bleeding and suchering the person
back together. However, if their was a board certified plastic surgeon available, the expertise
of this specialized physician to provide the medical care would optimize the outcome. The emergency
room physician although capable of putting stitches in does not have the same level of skills and
knowledge that a board certified plastic surgeon would have and the ER doctor would most likely leave
a bigger scar. It is no different in the lactation field, the scar that a pedicatrician could leave on a
breastfeeding relationship or on a mother who was simply tring to do her best is no less damaging.
In the last few years the federal government has revised the standard growth charts used to evaluate
infant growth. On the CDC website it states, “Growth charts are not intended to be used as a sole
diagnostic instrument. Instead, growth charts are tools that contribute to
forming an overall clinical impression for the child being measured.” They even
recommend using the World Health Organizations growth charts. Unfortunately they
are not very clear that there are other charts available for certain conditions
or ethnicities that will impact the interpretation of expected growth.
According to Hren, et al (2008), “Exclusive breastfeeding for 6 months is
the best nutrition for infants. It is the duty of health professionals to
promote breastfeeding.” (pg. 4) Unfortunately some doctors are still operating
on the old advice of introducing solids between four and six months. According to
Schanler, R.J., O’Connor, K. G. and Lawrence, R.A.(1999),
“Of concern is that pediatricians now are likely
to recommend semi-solid foods, iron and vitamins before 5 months of age, and to
recommend supplementing feeding and pacifiers in the first few days after
delivery. These infant feeding practices are known to impede successful
breastfeeding and may be unnecessary.” (pg. 8) Granted some people do this
without doctor’s advice because of the mistaken idea that it will help the baby
sleep better at night or that the child was starving and needed extra food.
Those reasons mostly come from the mistaken beliefs that infants can be
scheduled and only need to nurse when it is convenient for the mother. Infants
only source of language is to cry when the baby needs something. Breastfeeding
or not they still are quite high maintenance.
According to LI, Fein, Chen and Grummer-Strawn, (2008)
“Among mothers who stopped breastfeeding through the first 8 months or their infant’s
life, the perception of their child’s dissatisfaction with breast milk alone and
concerns about milk supply were both consistently cited as important reasons for
stopping…when a mother does not have confidence that she is providing an
adequate quantity or quality of milk for her infant she is likely to stop
breastfeeding regardless of her infant’s age…They also suggest that most mothers
can overcome temporary breastfeeding problems without resorting to
supplementation if they receive appropriate guidance from health professionals,
including reassurance that what they perceive to be a low milk supply is
actually sufficient and that their infant growth is uneven and often occurs in
spurts” (pg. s73-s74)
When looking at the last three cited articles in this paper, one can
easily assume that a major issue of breastfeeding advocacy is the attitude
education, and first hand family experiences of feeding infant's of the infant's peditrician.
As referenced to above 40% of pediatricians have
limited first-hand knowledge and limited education on breastfeeding. Further, I
personally have witnessed many mothers over the course of the last 24 years who have given
up breastfeeding because they were told by their pediatrician that they had
either dried up, or have an inadequate breastmilk supply that resulted in a wrongful solution
to supplement with formula. When these issues arise referral to lactation experts may improved
breastfeeding success and more importantly help an infant to gain weight. In my own experience
I have had three pediatricians and two nutritionists tell me that I needed to supplement formula because I had dried up or had an inadequate breastmilk supply in the last year. How
many more women in this area have been given that same advice from these health
care professionals?
Health Science
One of the road blocks to success in breastfeeding is if the child has a condition
or underlying cause as to why breastfeeding may not be working. The common
standard for weight gain in a breastfed infant according to ask Dr. Sears.com,
who is a fellow of the American Academy of Pediatrics, “is that they gain 4-7oz
per week in the first six months.” If the infant does not gain this much weight
then according to Krugman and Dubowitz (2003), “Failure to thrive is best
defined as inadequate physical growth diagnosed by observation of growth over
time using a standard growth chart.” (pg. 1) They go on to
state:
“Infants who have had intrauterine growth retardation or premature infants may appear to
have failure to thrive (FTT) when they grow at less than the fifth percentile.
As long as the child is growing along a curve with a normal interval growth
rate, FTT should not be diagnosed.” In addition using modified growth charts for
specific populations such as premature infants, exclusively breastfed infants,
specific ethnicities (e.g. Asians) and infants with genetic syndromes (Down
Syndrome) can help reassure the physician that these children are growing appropriately.” (pg. 2)
Some women just produce small children. It is important that the pediatrician take
this into account. Most women who are small are not going to have children in
the 95 percentile or even in the 10th percentile.
According to Saenger, Czernichow, Hughes, and Reiter, (2008)
“Weight at birth is an inherited trait through the maternal line. It is likely that
variation in the mitochondrial genome plays an important role in determining
infant birth weight because it is exclusively transmitted through the maternal
line.” (pg. 10) Babies that are born small will probably stay small also. Unfortunately one of the red flags for a child that is failure to thrive is that they may be abused or neglected, butthis scenario should only be looked at after a search for an underlying disease.
This brings us to gastroesophageal reflux. According to Fike, Montellaro,
Pettiford-Ostlie and St. Peter (2004), “Gastroesophageal Reflux is a common
phenomenon in the pediatric population…65-95% of these patients experience
spontaneous resolution of their symptoms by 2 years of age.” (pg.1) There are
two types: one is silent and produces little if any spit up the other type comes
with lots of spit up. The latter is usually the type that most people see and
can understand how this affects weight gain in the child. This can become an
even worse problem then an infant who just spits up frequently some children
will then go on to recognize that eating is painful and won’t fill themselves
thereby causing themselves to gain weight poorly. According to Kaczmarski
(2008), “Acid gastroesophageal reflux (GER) is defined as a recurrent return of
the stomach contents back up into the esophagus.” (pg. 293) One of the major
causes of this issue could be a food allergy. According to Kaczmarski (2008),
(it is important to) “perform immunoallergologic tests at a preliminary stage of
investigation.” (pg. 298) This can be critical because if an infant has an
allergy to milk protein the baby will not gain weight as expected.
Another reason for frequent regurgitation is pyloric stenosis. According to the Mayo
Clinic website, “In pyloric stenosis, the pylorus muscles thicken, blocking food
from entering the baby's small intestine. Pyloric stenosis can lead to forceful
vomiting, dehydration and weight loss.” A pediatrician will usually ask the
parents if the child has projectile vomiting which would differentiate this from
reflux.
Interestingly, when a woman has a child that is born at 36 weeks the doctors prefer not to call
the baby premature, even if the child was also born small for gestational age.
This becomes a problem when the pediatricians are using a standard chart to
compare an apple to an orange, growth patterns are not the same and the growth
pattern will be misinterpreted. However, according to Saenger, Czernichow,
Hughes and Reiter, “most small for gestational age children can get caught up to
their peers by age 2.” (pg. 19) So again, if a doctor does not know this to be the case, his concerns will become paramount and even with evidence that the child is in good health he will
encourage the mother to go to formula supplementation. One only has to think for
a moment that a child who is born prematurely may not have all that it needs to
grow and develop correctly. Further, the possibility that a food allergy to
something the mom has eaten makes it all the more plausible that there is going
to be issues.
In my experience, this led the pediatrician to exert constant pressure on
me to help my child gain weight. Each time I would take the child in for a
weight check I felt more and more like a failure. It also led me to force feed
my child when the child started to eat solid foods just to make those numbers
reflect my hard work. The problem with this scenario was then my child could
have developed a case of infant anorexia further complicating any efforts to
make the child gain weight. On the other hand it could have made the child
constantly overeat because the child could not recognize when she was full, this
could have led to some serious issues down the road. According
to Steinberg, C. (2007),
Feeding disorder associated with insults to the gastrointestinal tract. Food refusal
follows a major aversive event or repeated noxious insults to the oropharynx or
gastrointestinal tract (e.g., choking, severe vomiting, reflux, insertion of
nasogastric or endotracheal tubes, suctioning). This infant or young child
consistently refuses food in one of the following forms: bottle, solids, or
both. Reminders of the traumatic event(s) cause distress, and are manifested by
anticipatory distress. (pg. 184)
One issue that is poorly understood is hypotonia otherwise known as low muscle tone.
This is a condition of late preterm infants. According to Walker, M.
(2008)
“Late preterm infants are at a disadvantage in terms of feeding skills. Born with low
energy stores (both subcutaneous and brown fat) and high energy demands, the
poor feeding skills of developmentally immature infants are challenged to meet
the hydration and nutritional needs of this population…Late preterm infants have
a weak suck and low tone that may diminish milk volume per suck.” (pg.693)
If the infant has this condition diagnosed in their lips, tongue, cheeks and chest
this will cause the child issues with reflux because of the floppiness of the
under-developed muscles that cover the stomach and chest. As it has been in my
case, when you put these two conditions together you get an infant that will
willingly forgo eating because of pain and therefore fail to gain weight
adequately.
Nutrition Education
A measure of how much nourishment an infant has taken in could be how
much output they have produced. Weighing of diapers can be a good measure to go
on. According to a Women Infants and Children handout, six to eight diapers in a
24 hour period is adequate to show that the child is receiving enough nutrition.
Another measurement that gives a good indication is if the infant looks well
hydrated. Further the breast milk can be tested for calories. According to
Kelly Bonyata R.N., IBCLC, the amount of calories in breast milk is 22 calories
per ounce. Sometimes the infant that has issues will nurse more frequently
forcing the calorie count to climb and the breast milk that is provided is
solely hind milk with a calorie count of 27 calories per ounce.
The recommendation from the American Academy of Pediatrics (2012), is
“exclusive breastfeeding for about 6 months, followed by continued breastfeeding
as complementary foods are introduced, with continuation of breastfeeding for 1
year or longer as mutually desired by mother and infant.” The problem with this
recommendation is most pediatricians will only recommend it if the child is
gaining adequately. Some women have been told after the first several months
that they cannot provide enough milk for their child. In the second six months
infants weight gain slows down to two to four ounces per week and at this point
is perfectly fine to feed the infant cereal and other foods. Also about this
time period according to notes that I received from Intermountain Healthcare in
Layton, Utah, “the child should not be nursing at night and should be sleeping
through the night.” A mother who reads these notes might start to think that
her child does not need to be nursed and will initiate a plan to make this so. A
potential resulting problem with this is that the production of breast milk is
influenced by the amount of suckling stimulus. If the sucking stimulus is
diminished, breast milk production is reduced. The infant may then slow the
weight gain which will lead the mother to believe that she has dried up and
then she might wean altogether. As you can see conflicting advice from
pediatricians causes mothers to doubt their abilities to feed their child.
A stumbling block that can get in the way of achieving this goal is the
lack of knowledge about how frequently an infant should nurse. This question
causes mothers to question their supply and ultimately give up. What is normal
for one infant may not be normal for another. Keep in mind that a one to two day
old infants stomach is marble size and can hold 1/6 to 1 /4 an ounce. A three
day old infant’s stomach is ping pong ball size and can hold 3 /4 to 9/10 an
ounce. By day ten the stomach size is that of a large egg and can hold two to
three ounces. Finally at 21 years old a stomach can hold approximately two cups
or 16 ounces and is the size of a softball. There are also growth spurts that
happen at three and six weeks and three and six months and this will make the
baby want to nurse very frequently. Eventually babies get into a regular routine
and they become somewhat predictable.
Another issue that mothers face with infants is that they want to sleep and the babies keep them up at night nursing. First the fat content in milk is higher at night so pumping a bottle earlier and
having a partner feed them does not give them all the nutrition that they could
have had. According to Kelly Bonyata (2011), fat content depends on the degree of
emptyness of the breast (empty breast = high fat, full breast = low fat). The
average fat content of human milk is 1.2 grams/oz. Alsobreastfeeding is a supply and demand operation and not nursing for several hours will impact supply. To survive these times mothers should learn how to nurse in the side laying position and view these times as short moments thatwill quickly pass. The partners can always help with the diaper duty.
If a mother needs to pump because she is returning to work and finds that
she can’t pump much out, this is not an indication that she cannot provide
enough milk for her child. It is important to pump on a regular schedule as that
will get the body used to the pump and will initiate a better response. Also a
mother finds that if she pumps on one side while nursing on the other it also
stimulates a better response. Furthermore, a mother should never feel
intimidated by the amount that she pumps. According to Shaw, G., (2011) At its
best, a baby's suck is far more efficient at removing milk from the breast than
any pump, but some babies don't have the best latch. (pg.1)
Adequate nutrition for mothers can become an area of concern. With having
a new baby it is difficult to get to thinking about what to eat, let alone
making something to eat. Thinking ahead is definitely a huge help. For instance,
before the baby comes a mother can freeze some well balanced, protein rich meals
ahead and make it easier on herself. Also keeping fresh fruits, vegetable, and
calcium rich foods such as yogurt or cottage cheese around is a big help for
those time when you need a quick snack.
According to my plate as quoted by Brown, J.(2011), “lactating mothers
should eat 8 ounces of grains, 3 cups of vegetables, 2 cups of fruit, 3 cups of
milk/dairy and 6 ½ ounces of meat and beans per day.” (pg. 177). Each mom is
different and may require more or less calories depending on her own metabolism
and health. Keep in mind that lactating woman will burn an extra 500 calories
per day to support breast milk production. This is why it is important to think
about a mom’s diet. If the mom is not taking in the nutrients and energy needed
she will lose weight, and the impact on the quality and volume of her breast
milk will be a problem. Further, some women actually lose weight while nursing
and some women don’t. Yet again evaluating her dietary intake will determine if
there is a problem.
If it is determined that a child has food allergies and the mom needs to
avoid certain foods, for example, dairy products, it is vitally important that
she replace the missing nutrients richly provided by dairy products to not only
to achieve adequate maternal nutrient needs but also the nourishment needed to
ensure the supply of breast milk.
Summary
Lactation is a complex process and many things go in to establishing a
solid breastfeeding relationship. Getting through a successful first six weeks
of breastfeeding is critical to establishing a good feeding relationship. If there are any issues in this critical
time period this could make it near impossible to achieve successful
breastfeeding. Further, the establishment of a successful breastfeeding
experience can be impeded by well-meaning pediatricians who encourage
supplementing at the first possible sign of a problem.
Pediatricians go to school for a long time however, they are not thoroughly educated in infant nutrition and make a lot of misleading statements. This is very unfortunate because their lack of specific
knowledge about lactation is a huge problem to mothers who want to breastfeed
their children. According to Davis, L, (2013)
What do doctors learn about breast-feeding in
medical school? “We learned that it’s what’s best for baby,” said my own
pediatrician. “But that’s it.” They’re introduced to evidence that prolonged
breast-feeding reduces the possibilities of obesity, SIDS and allergies, but the
science of it, what’s happening at the anatomical level? Not so
much.“It’s an hour, or a half a day, and [students]
don’t remember anything,” says Dr. Todd Wolynn, a Pittsburgh pediatrician and
executive director of the Breastfeeding Center of Pittsburgh. There were years,
he says, when there was literally nothing said about breast-feeding at all.
Furthermore, according to Newton, Edward., (1992), “a quick review of the major general textbooks in obstetrics and pediatrics reveals minimal information concerning the anatomy and endocrinology,
and inadequate and sometimes incorrect information on management of breastfeeding mechanisms.”
Mothers can educate themselves about this process and may be able to resist the recommendations to supplement their children; however, constant concerns over weight gain are going to eventually
lead women to give up. The federal government and the American Academy of
Pediatricians recognizes that breastfeeding is important, which is good however,
they give no other guidance to pediatricians to help them understand lactation.
Neither is there a requirement to rectify the problem.
Conclusion
In conclusion, if a mother is going to breastfeed her child the most
important thing she can do is educate herself on the matter. There are many
books written on the subject. Some that I would recommend are: “The
Breastfeeding Book, Everything You Need to Know About Nursing Your Child from
Birth to Weaning” by William Sears M.D. and “The Womanly Art Of
Breastfeeding” by Ina Mae Gaskin. I suggest reading these books before the
baby is born. This will not only instill confidence but will let her know that
the pediatricians, although well meaning, may give some really poor advice at
times. Another thing she can do is to surround herself with supportive people.
This can be accomplished by seeking out a La Leche League group or if she
qualifies she can get support through the Women Infants and Children
program. There are also support groups online that she can go to for some good advice and support. As for the pediatricians they can also educate themselves about infant nutrition even if
they are not required to do so.
Lastly, this project has helped me to want to continue on in my chosen
field. There are so many mothers out there that have been given poor advice and
really need somebody in their corner who might be able to advocate for them at
this critical time. I want to be that person.
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