Anemia of Prematurity - Portal Neonatal

Warning signs of ineffective breastfeeding
What are the warning signs of ineffective breastfeeding in the infant? For example, if milk production is
inadequate secondary to poor latch-on or infrequent breastfeeding, the infant may become dehydrated
with a concurrent increase in his or her sodium level. Prolonged hyperbilirubinemia may accompany
the dehydration. Dehydration occurs over days to weeks, depending on the milk supply and the
frequency of breastfeeding. In rare cases, the sodium concentration may be as high as 180 mmol/L.
Nothing may be inherently wrong with the mother's milk, but if it is not adequately removed from her
breasts, either by suckling or by pumping, the milk becomes weaning milk with a higher sodium
concentration.
The main reason that the sodium level increases in the infant, however, is volume contraction
secondary to dehydration and insufficient water in the milk. Human milk is 87% water, but its
composition changes if an insufficient amount of milk is removed from the breast. The treatment of an
infant with hypernatremic dehydration is to replace the free water losses slowly, because an abrupt
decrease in the sodium level can trigger seizures secondary to cerebral edema and the rapid flux of
sodium concentrations. This treatment involves giving the infant intravenous fluid with decremental
concentrations of sodium to achieve a normal serum sodium level.
Another warning sign of ineffective breastfeeding is failure to thrive in the breastfeeding infant, which
also results from an insufficient milk supply. An infant can have both hypernatremic dehydration and
failure to thrive. These disorders occur along a spectrum depending on whether the milk produced is
adequate to maintain the infant's hydration state but insufficient to allow adequate growth. The primary
care provider must assess the growth of the breastfeeding infant over time. Neonates typically regain
their birth weight by 2 weeks of age, and their weight should increase by 50% at age 6-8 weeks. At 4-5
months of age, the baby's weight should be double his or her birth weight. Also, the infant's head
circumference and length should be assessed. The monitoring of subcutaneous fat deposition also
aids the clinician in assessing the adequacy of growth. An infant's growth should follow the growth
curve.
Failure to thrive in an infant should not be attributed to breastfeeding without an exploration of other
differential diagnoses. The mother whose infant is failing to thrive should be encouraged to breastfeed
with close assistance and, possibly, short-term supplementation. Daily visits for weight checks and
overall health assessments are often necessary. In rare cases, hospitalization may be indicated.
ASSESSMENT OF THE NEONATE Section 7 of 11
General principles
The assessment of the breastfed infant includes an evaluation of its voiding and elimination patterns;
feeding routines; jaundice; and, most importantly, weight. In addition, the mother should be examined
for pain or irritation of her breast and nipples and for signs and symptoms of undue stress or fatigue.
Healthy breastfed neonates should not lose more than 10% of their birth weight, and they should
regain birth weight by the time they are aged 10-14 days. Newborns should have a minimum average
weight gain of 20 g/d between ages 14 and 42 days. The average weight gain during this time is 34
g/d for girls and 40 g/d for boys. In addition, breastfed neonates tend to gain weight faster than
formula-fed neonates for the first 2-3 months, and the rate begins to slow at 6-12 months. Breastfed
infants also tend to have leaner bodies than those of formula-fed infants.
In the first 48 hours after birth, the neonate may void as infrequently as a couple times a day. Once
the mother's milk supply is established, the baby voids after most feedings, usually 6-8 times a day.