A 3-day-old boy is brought to the office for follow-up after hospital discharge. He was delivered vaginally at 40 weeks gestation to a 28-year-old primigravid mother. All maternal prenatal laboratory results were normal, and Group B Streptococcus culture was negative. Maternal history is significant for lactose intolerance, celiac disease, and shellfish and egg allergies. Birth weight was 3.5 kg (7.7 lb); discharge weight yesterday was 3.35 kg (7.4 lb) and weight today is 3.26 kg (7.2 lb), a 7% decrease from birth weight. Physical examination reveals a crying infant who is easily consoled when held. Cardiopulmonary examination is normal. The Moro reflex is symmetric and the infant has a strong suck. There is an erythema toxicum rash on the trunk. The remainder of the examination is normal. The mother tearfully says, "I would like to continue to breastfeed exclusively, but the baby is still losing weight. He wants to feed all the time, especially at night. My husband thinks we should give the baby formula. What do you think?" Which of the following is the best recommendation for this patient?

Question

A 3-day-old boy is brought to the office for follow-up after hospital discharge.  He was delivered vaginally at 40 weeks gestation to a 28-year-old primigravid mother.  All maternal prenatal laboratory results were normal, and Group B Streptococcus culture was negative.  Maternal history is significant for lactose intolerance, celiac disease, and shellfish and egg allergies.  Birth weight was 3.5 kg (7.7 lb); discharge weight yesterday was 3.35 kg (7.4 lb) and weight today is 3.26 kg (7.2 lb), a 7% decrease from birth weight.  Physical examination reveals a crying infant who is easily consoled when held.  Cardiopulmonary examination is normal.  The Moro reflex is symmetric and the infant has a strong suck.  There is an erythema toxicum rash on the trunk.  The remainder of the examination is normal.  The mother tearfully says, "I would like to continue to breastfeed exclusively, but the baby is still losing weight.  He wants to feed all the time, especially at night.  My husband thinks we should give the baby formula.  What do you think?"  Which of the following is the best recommendation for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1da_6b1b_8f63_a15679820887_MD0005_00 Breast milk is the gold standard of infant nutrition, and breastfeeding should be encouraged for all mothers. Maternal benefits include maternal-infant bonding and reduced risk of breast and ovarian cancers. Due to transfer of maternal antibodies through breast milk, newborn benefits include decreased rates and severity of infections, including otitis media, gastroenteritis, and respiratory illnesses. In the first few days after birth, breast milk is colostrum, an antibody-rich fluid that is low in volume. Due to physiologically low volume of oral intake and fluid shifts in the newborn period, up to 10% weight loss is expected in the first week. By day 5 of life, production of breast milk typically increases to meet the demands of hydration and nutrition, and the newborn's weight is expected to surpass birth weight by age 2 weeks. This mother, who wishes to breastfeed exclusively, should be encouraged to continue to breastfeed and have close follow-up to monitor weight; follow-up should be within 2-3 days, not 2 weeks (Choice B). (Choice C) Formula-fed infants often have longer intervals between feedings due to slower gastric emptying, as compared to breastfed infants who typically feed on-demand at 1- to 3-hour intervals. Increasing the length of intervals between feeds would decrease breast stimulation and, in turn, breast milk production. (Choice D) With the exception of low levels of vitamin D, breast milk contains all nutrients and minerals required for infant nutrition, even in the setting of a restricted maternal diet (eg, vegetarian, celiac disease, short-term fasting). (Choice E) A newborn stomach can hold less than an ounce of fluid, and the low-volume colostrum is usually sufficient for nutrition and hydration. In this infant without excessive jaundice or weight loss, breastfeeding should be encouraged without formula supplementation. Educational objective: Exclusive breastfeeding should be encouraged for all families due to both infant and maternal benefits. Up to 10% of weight loss is generally expected within the first week of life, and continued on-demand breastfeeding should be supported. References: Breastfeeding and the use of human milk. (http://www.ncbi.nlm.nih.gov/pubmed/22371471)

A 3-Day-Old Boy Is Brought to the Office for Follow-Up