Uneasy about doctor's advice

[PerpetualStudent]

My DD is gaining weight very poorly. She's 11 weeks and has barely added a lb to her birth weight. (3.1kg to 3.5kg. She was born at 38 weeks and has had several colds, poor mite)
She is BF, on demand without any issues as far as I can see (DS had tongue tie so know what to look for there) has wet/dirty nappies etc, though green poos since latesr cold.
Have been in and out of GPs getting her weight monitored since 6 week check. Yesterday DP took her, as I am poorly with mastitis, and saw a different doctor.
His advice was to swap completely to formula for 5 days, barr BF enough to relieve the mastitis to 'check if the milk is the problem' With the assumption that I can switch to pumping, and presumably back to BF if this isn't the problem, without messing up my supply.

To me this feels like very wrong-headed advice? From what I understand a tiny %age of women have real supply issues, surely my DD needs to start getting tests for other issues?
Literally since her birth formula has been suggested to me by midwives, Drs, HV - it feels like for any issue BF is seen as the weak link to be eliminated before other action is taken.
Im not anti formula, DS was mix fed, but I feel like there could be a real problem here which is not being identified due to formula being treated as a magic bullet?

Has anyone else been advised to do this formula check/swap?

Just as a point of info: a baby who had this history would be seen by most paediatric departments within a day or so, simply because there is a very small chance this is more than a deficit of calories. It might depend on a clued up hcp recognising the importance rather than self referral but in some areas parents can refer themselves to a community paediatrician (equally qualified as a hospital one).

On another point - there is a great difficulty distinguishing true unfixable low supply from low supply related to the effect of the way bf gets messed up. It’s quite incorrect to say that 20 per cent of mothers have low supply as if it is something that just ‘happens’ to some ppl. We just don’t have evidence for that. And the review linked to does not say that.

Can I suggest la leche league. Either a local group or the helpline (which is 24/7) they can help you get a plan in place so you LO can gain weight whilst protecting your milk supply if you wish to carry on nursing or stopping safely if that's what you choose

Has her nose been stuff a lot? The green ooo would suggest that she either isn't feeding for long enough (for examination or because she has difficulty breathing) or that you are producing too much fore milk. Maybe try expressing into a bottle to see if that changes how she feeds? It will also enable you to monitor exactly how much she is feeding.

I’m surprised that none of the professionals has suggested expressing and bottle feeding rather than formula. It would show fairly quickly if there’s a milk transfer issue or something more serious with your milk/her ability to properly digest it.

No, expressing and feeding in a bottle is a bad idea.

Here's why:

• it's very time consuming. To maintain a supply it needs to be done at least eight times in 24 hrs inc at night

• it means extra labour for the bottle and teat cleaning

• it's far from guaranteed to produce much....some women feeding twins can hardly express a drop

• there is no way of knowing whether it shows up a milk transfer problem - how could it do that? You mean if the baby takes seven ounces from the bottle, this shows there is a milk transfer problem from the breast? How so? Babies feed differently all the time, and do not take equal volumes at every feed.

@tiktok I don't understand why some people are so reticent to admit that low supply exists and is not uncommon. Human biology varies greatly across all aspects, why would milk production be any different? Why do we insist on saying "it's just supply and demand" yet all the breastfeeding support websites have entire sections dedicated to treating low supply (fenugreek and round the clock pumping anyone??)

Whether the low supply "just happens" or is because things "get messed up" the result is the same; not enough milk. Insufficient milk production is the reason why wet nurses existed and why in many countries babies are routinely given prelactel supplementation. Before formula and if you didn't have access to wet nurses many babies died because their mothers didn't produce enough milk. It is common in the animal kingdom and in humans also.

The review I posted is one source, perhaps you're not impressed with how it is written, and we need better study in this area, that doesn't change the fact that not every mother will be able to produce enough to sustain their child.

Your words; true unfixable low supply from low supply related to the effect of the way bf gets messed up. It’s quite incorrect to say that 20 per cent of mothers have low supply as if it is something that just ‘happens’ to some ppl.

It has been estimated by the Academy of Breastfeeding Medicine that 10-18% of U.S. EBF newborns experience “starvation jaundice” from insufficient feeding ( ABM Clinical Protocol)
One large Baby-Friendly hospital system in the US reported that 12-20% of babies born developed hyperbilirubinemia and that 10.1% of those newborns were admitted for phototherapy.

That’s over 10,000 babies in 3 years needing treatment due to insufficient feeding in one hospital system in the US.

The scientific literature has shown that by the time they meet criteria for phototherapy, markers of brain injury are already present in the blood.

So yes low supply exists; for whatever reason. And it causes medical complications to the baby.

Can we please stop pretending low milk supply is a figment of women's imaginations?!

I don't think that anybody is denying that problems with low supply exist, the more interesting question is why? and that is something that the studies I am aware of are unable to really answer.

No doubt there are some women who biologically are unable to produce sufficient milk, but many more have issues with poor supply because as a society and individually we are not very good at BFing: it may be the way nature intended all mammals to feed their offspring, but certainly in most Western countries we have lost the skills and the knowledge that goes with BFing. And it is very multifactorial: shocking number so people think that BFing is a bit 'icky', people are taken aback how difficult/time-consuming it can be, timely BFing support is lacking (both in terms of family support and official trained HCP) and there is sitll the perception that FF is 'scientific' and somehow superior.

Of course low supply is not a figment of any affected woman's imagination, but there is far more to it than just milk glands. The social component is huge.

And I am saying this as somebody who really struggled with BFing/supply issues.

it may be the way nature intended all mammals to feed their young.. in western society we have lost the skills..

Nature does not "intend" anything and nature is brutal.
The assumption that parenting in nature is perfect, and it is only humans who encounter difficulties in birth and lactation is a total fallacy. Many mammals also suffer lactation failures (total or partial) and associated infant mortality rates are high.

Anyone who thinks that parenting in "nature" is the ideal has failed to understand natural selection or hasn't watched enough nature programmes.

"Early neonatal mortality among mammals is appalling, ranging from 16.3% among the apes, our closest animal relatives, to 28.5% in small primates and slightly more among carnivores. "

Obviously, parenting in nature is very far from perfect. High deaths rates are the norm and the population grows because parents have future children to replace the ones that died. Birth is dangerous; early infancy is dangerous; indeed the entire first year is dangerous. The same is true for human birth and infancy, and it isn’t culture that’s to blame, it is nature itself.

*I would encourage you to read further here:
www.skepticalob.com/2017/11/mothering-like-an-animal.html

1stTime - I have never said and would never say that low supply does not exist. Ditto 'it's just supply and demand'. Ditto 'it's a figment of women's imagination'. I know no one who understands breastfeeding who says this.

There certainly is insufficient feeding. And babies do become compromised as a result. This is NOT the same as low supply. Babies in their early days who do not get sufficient breastmilk are not reflecting their mothers' low supply, necessarily. They do reflect poor maternity care, in particular a lack of observation of when BF is not going well and needs attention.

You are mixing up your terminology. You are accusing me and others of denying low supply. You are attributing an attitude to me I do not have. You are unable to assess the literature well....and yet you come onto a thread and make suggestions to a mother that she does not need to get specialist medical advice yet, because according to you, it would take weeks to see a paed - this with a baby who may well be in need of one. You got that wrong, too.

Not good. Not helpful. Not fair.

@tiktok genuine apologies if I am miss attributing things to you.

I felt that you saying "It’s quite incorrect to say that 20 per cent of mothers have low supply as if it is something that just ‘happens’ to some ppl" was you saying that low supply does not just happen and it is just a perception of women. There is a lot of talk both in literature and in places such as these forums that it is simply "perceived insufficient milk" (PIM) and it results from BF mothers comparing their babies to FF babies, and that they dont have insufficient milk. (I am also fully aware that low supply is not necessarily the cause of insufficient feeding; it's just something that is very often dismissed when BF mothers bring up a worry about supply)

The information given to women often underplays or totally ignores the possibility of feeding issues, and pushes the over simplified supply/demand line. Even in my own antenatal breastfeeding class run by a IBCLC when one of the pregnant ladies said she was worried about not being able to BF because her mum couldn't the response was (to paraphrase) "everyone can BF and everyone produces enough " ... the same IBCLC who subsequently counselled me to pump 10 times per day to increase my supply.

Regarding this specific case; my advice was certainly coloured by personal experience and the experience of friends who felt that giving a small amount of formula was some kind of personal failing and they were failing or indeed harming their child by giving formula as the "breast is best" and exclusive breastfeeding message is pushed so hard on women (with YES a massive lack of support and follow up)

I hope the OP gets to see a peads doctor asap, but as the GP hasn't yet done a referral and the OP was asking if she was being obstructive by not giving formula on doctors advice, I was giving the advice to give the formula and if there's no improvement then seek the referral. From what she has said the GP seems reluctant to refer until a simple calorie defecit it ruled out. Unfortunately for all of the above the NHS is stretched and perhaps she would not have got a same day or next day referall and formula was not going to do any harm in the mean time.

I hope you understand where I am coming from?

Yes, of course.
Nature is not kind and not brutal either - it just is.

We are very lucky to live in a time and a place where we are able to feed our offspring safely on artificial milks and that we have a choice.

I just really don't like the implication that a. the 'choice' is a free one and b. that low supply issues in the main are biological or structural.

1st: of course I accept your apology :)

But I was quite clear, and what I said was not confusing! I said " It’s quite incorrect to say that 20 per cent of mothers have low supply as if it is something that just ‘happens’ to some ppl"

This has only one meaning . It doesn't mean that no one has low supply. It means that it is not true to say that 20 per cent have it unavoidably. And it isn't!

BF is a complex mix of social, cultural, physiological and psychological factors. Low supply reflects this - but in some cases it does appear that no matter what, the mum finds it hard/not possible to make enough, for apparently solely physical reasons.

You're reading the wrong literature and listening to the wrong people if you think it is common to dismiss this. Anyone who understands BF knows the truth.

You say you're paraphrasing when you report what your antenatal person told you. I wonder what she said? If she really gave you and the others the idea that there are no problems ever with breastmilk supply, then what's the point of BF support? Something like half of all mothers have concerns about this.

@tiktok I can't recall exaclty what she said in response to my friends concern. But she asked for what specifically her mother had struggled with, but she didn't know what the specifics of the struggle where. Her response was basicslly everyone can do it and don't worry.

I'm back from the GPs!

Firstly just to say been really enjoying the debate, just too busy feeding to chuck in myself. Personally I veer towards the sociological aspect being the biggest factor in women loosing confidence in breastfeeding, here's my conversation with the GP this morning and you may agree!

So, we weigh her and she's gained 270g in 5 days. So that's an initial relief. Without any other checks (female - relevant below) GP breezily says:

GP: Well, I would just continue with the formula
Me: OK, it's just I'm keen not to give up on breastfeeding, doesn't breastmilk have more calories ounce for ounce than formula? [FYI, I spent last night googling NICE guidelines, LLL info and BF journal papers, it does)
GP: Ohh, I don't know, does it? I bottlefed both of mine anyway, my 4 year old is massive now. I know these midwives say breast is best, but, I mean, formula has all the vitamins they need added straight into it, you need to give extra vitamin D if you're breastfeeding.

This is the message I have got again and again from every HCP I've seen since her birth: we will 'let' you BF if all is well, but at the first sign of any issue will heavily recommend formula, as this is 'proper' milk, which we know has everything babies need. AND THEREFORE WE DONT NEED TO CHECK IF ANYTHING ELSE IS WRONG.

She did go on to concede I could carry on 'topping up' with BF if I wanted to, and agreed to refer me to a paediatrician, who we should apparently see sometime in January.

Seeing her weight go up with the formula, I can't in all conscience stop giving it, but will be very much topping up BFs with it, rather than vice versa, and will seek out some properly qualified BF support to look at ways I can increase my supply and sort any (apparently invisible?) transfer issues - as it's clear she is able to put on the weight.

Student, glad your baby is doing well.

Breastmilk and formula have more or less the same calories (but breastmilk varies, because of its variable fat content during the feeding), but this does not matter....the point is that the baby has to get at them. If the bfs are restricted in some way, limited, or less effective because of some anomaly (e.g. Tongue tie, baby weak, preterm, or battling an underlying condition) then the baby will not gain as he should. Not because of breastmilk's calories or abundance/lack of them.

Chronic low supply can result from any of the above. This is much commoner than physiological low supply where no matter what happens, the mother struggles to make enough.

It's definitely worth getting to the bottom of why your baby has not gained normally on BF - seems no reason to cease BF from what you say here, but continuing alongside formula makes sense until you resolve it.

Hope things go well.

If I were you I would see formula as the primary source of nutrition for my child but would continue to offer the breast first. However if BF became a struggle or the baby refused the breast, I would just stop.
Your child has really really struggled to gain weight. Now it’s going better thanks to formula. That is not to be sneezed at.

I'm glad she's gained some weight - that's good

I'd keep doing what you're doing while also very actively persuing trying to figure out why her gain so far has been so slow.

Just for the record: doctors get exactly zero training on infant feeding.
I'm not defending it, just stating a fact.

@perpetualstudent
Have you tried pumping in place of formula? I haven’t read the whole thread (missed the part out where the thread was derailed so might have missed out some info). I know it’s time consuming but it would keep your supply up?

You can hire a double electric from medela and they have next day delivery. Think it’s £48 or so a month. After about 3 weeks I exclusively pumped for my twins (well the odd bottle of forumula probably 5 or so a week). I also bought a single electric one which I took out with me (used it when I was a passenger in the car etc). Worked for me but realise it’s a big commitment.

Just for the record Please don’t think I’m saying don’t use formula (I genuinely think as long as baby is fed and actually there is too much pressure to breast feed). I just wanted to present an alternative as you seem keen to remain breast feeding.

If you are wishing to continue with breastfeeding whilst topping up with formula, may I suggest a supplementary nursing system? You can put the formula (or expressed milk) in the bottle part and still feed directly at the breast, which ensures that your breast still gets the relevant stimulation to produce milk. There is one here on amazon:
Medela 009.0005 Système de Nutrition Supplémentaire Jaune https://www.amazon.co.uk/dp/B00JZF8LHK/ref=cmswwrcppapi_epQjAbTXFWAEJ

If you haven't already then please seek advice from a lactation consultant or breastfeeding counsellor (whilst waiting for your paediatric referral). They can assess for tongue tie restriction and also any malformation of the palate which could hinder milk transfer.

@perpetualstudent so glad to hear baby is doing well! And very interesting the discussion with the GP, it does not surprise me GPs don't get feeding training.

Sounds like you've got a plan that will work for you and baby, and that's what matters.

Sorry if derailed the post there for a bit, was not my intention. It was just to highlight that the push for "exclusive breastfeeding" (by the WHO/NHS and others) is very difficult for a lot of women to achieve (for reasons discussed e.g. tongue tie, low supply, weak baby etc etc) and it often results in women feeling like failures when they need to use formula to supplement. I have only this week seen people calling formula "poison" on a post about breastfeeding and it upsets me massively that people believe that (it was on instagram not here)

Anyway... best of luck with everything