Sometimes, babies who were doing very well and gaining weight very well with exclusive breastfeeding start to gain more slowly and even not at all after two to four months. Exclusively breastfed babies do tend to gain more slowly after three or four months compared to artificially (formula) fed babies but this is normal. The more rapid weight gain of the artificially fed baby is not the standard. Breastfeeding is the normal, natural, physiologic way of feeding infants and young children. Using the artificially fed baby as the model of normal is not rational and leads us to make errors in advising mothers about feeding and growth.
In some cases, however, an illness in the baby may result in slower than expected weight gain. Supplementing with formula does not cure the illness and may rob the baby of the beneficial effects of exclusive breastfeeding.
You can tell when a baby is getting milk and when he is not (see below and the video clips at the website nbci.ca). If the baby is sucking at the breast and not getting milk, well, this explains why he is not gaining weight and it is most likely the mother’s milk supply is down. The mother’s milk having decreased is the most common reason that the baby fusses and pulls at the breast and/or no longer gains weight well enough.
This reason (number 11) requires more explanation. In the first few weeks, babies tend to fall asleep at the breast when the flow of milk slows down. This slowing of the flow occurs earlier in the feeding if the baby is not latched on well. A baby who has a less-than-good latch but whose mother has an abundant supply can gain well, but he really depends on the milk ejection (letdown) reflex in order to get milk. The baby will suck and sleep and suck, without getting large quantities once the initial rapid flow diminishes but if the mother has more milk ejection reflexes, he will drink some more, even half asleep. Once the baby is older, however, some may pull away from the breast when the flow slows down, often within minutes of starting the feeding (Actually some do this from very early on, some never do this, and some do a combination of sleeping and pulling away from the breast depending probably on how hungry they are or their mood). This is more likely to occur when babies have received bottles from early on, but can also occur even without the baby’s having received bottles. When this pulling occurs, most mothers will probably put the baby over to the other side but then the same thing happens. The baby may still be hungry and may refuse to take the breast again, preferring to suck his hand. He won’t get those extra milk ejection reflexes (letdown reflexes) that he would have gotten if he had stayed longer at the breast. So, the baby drinks less and the supply also decreases because he drinks less and the flow slows even earlier in the feeding (because there is less milk) and a vicious circle has started. It doesn’t always happen this way and many babies may gain weight well even if they do spend only a short period of time on the breast. They may still pull off the breast and suck their hands because they want more sucking (which is pleasurable for them) but if their weight gain is good, there is no need for concern. Still, it’s nice to have a baby breastfeed without pulling at the breast.
The way to prevent this all is to get a good latch from the beginning. Many mothers are told the latch is perfect when, in fact, it is far from perfect. The latch can still be improved even in the older baby, but it’s not always easy. But sometimes it is. See the Protocol to Manage Breastmilk Intake and the video clips at the website nbci.ca.
Often, domperidone will increase the milk supply significantly and we use it often. However, you should not use it if you are pregnant. In the first place it won’t work if you are pregnant and although there is no evidence that it is worrisome to use during pregnancy, the absence of studies showing concern does not mean it is safe during pregnancy.
When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide – pause – close mouth type of suck). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This pause that is visible at the baby’s chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more the baby got. Once you know about the pause you can cut through so much of the nonsense breastfeeding mothers are being told. Such as: Feed the baby twenty minutes on each side. A baby who does this type of sucking (with the pause) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn’t drink) for 20 hours will come off the breast hungry. See the video clips at the website nbci.ca which show when a baby is getting milk (or not) and also how to latch a baby on and how to use compression.
The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.
This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!
©IBC, updated July 2009
Questions or concerns? Email Dr. Jack Newman (read the page carefully, and answer the listed questions).
Make an appointment at the Newman Breastfeeding Clinic.