Things to consider if your four-month-old baby coasts down the growth charts

This post was prompted by a woman who wrote that her four-month-old baby was gaining weight too slowly, and that she had decided to stop breastfeeding exclusively because of worries about her milk supply. I am hoping that this information will be helpful to mothers who google "four-month-old baby with slow weight gain" or "sliding down the growth charts 4 months" or "milk drying up four months." I don't provide as much hands-on breastfeeding support as I used to, so shoot me an email if you catch any errors, please.

The Principles:

1) Less in the breast means more in store. Hm, maybe I was trying too hard to make a catchy rhyme and wound up obscuring my point. Here is the fundamental law of milk supply:  the breast makes milk fastest when it's emptiest, slowest when it's fullest. To increase milk supply, empty your breasts more completely and more often. (If you want more detail, take a look at this article.)

2) Human children grow most appropriately when fed human milk. It's not surprising, if you think about it, that kids grow at different rates depending on their diets.  Breastfed children put on weight more rapidly in the first few months than formula-fed children (causing some jumpy doctors to expatiate about overfeeding and obesity epidemics), and more slowly from about 3-4 months through the end of the first year (causing many more doctors to dispense dated advice that leads straight to iatrogenic supply issues and premature weaning).  This does not mean a mother has a milk supply problem. It does not mean she needs to supplement with artificially modified cows' milk so that her child will grow like all the other babies receiving artificially modified cows' milk. In the absence of other symptoms, it for sure doesn't mean the baby needs a workup for various scary pathologies.

Growth charts, just in case you were unclear, do not proceed from the mouth of God. They reflect the way a group of children did grow, not the way yours should grow.  Growth charts from formula-fed populations do not reflect the species norm for growth patterns in infancy, but lots of doctors don't know this.  If your doctor's office is still using the CDC charts instead of the free downloadable WHO charts normed on breastfed infants, I suggest you bring your own.

3) Breasts come in all sizes. This is not news, you are thinking, but I'm talking about storage capacity and not cup size.  You can be an A cup with a large storage capacity, or a DD with a teeny tiny storage capacity.  Women with small storage capacities can make just as much milk for their babies, but they have to remove it more frequently.  In this culture, we're all about the large storage capacity.  Is he sleeping through the night? Are you able to leave him with someone else for a few hours and not worry that he (or you) will need to nurse? That's much easier for the woman who can store more milk.  Small storage capacity means you may be vulnerable to supply downturns when baby sleeps all night, or goes longer without nursing during the day. (Small storage capacity also has advantages, I feel compelled to say. Off the top of my head: longer average duration of amenorrhea, which is at least partially responsible for the diminished risk of ovarian cancer and premenopausal breast cancer seen in mothers who breastfeed; more frequent hits of the happy-making hormones prolactin and oxytocin; and perhaps more comfortable babies, who get frequent small snacklets instead of giant stomach-distending meals.)

The Practical:

1) Nurse that baby.  To make more milk, empty your breasts more thoroughly and more often. Throw out the schedules; streamline your life for a few days and focus on nursing whenever your baby seems remotely interested.  Before you nurse, use breast massage briefly to increase the volume and fat content¹ of the milk available during that feeding. While baby is nursing, use breast compression to assist with breast emptying, and to settle a baby who seems to want more milk pronto.  Even if they're not part of your usual routine, short-term babywearing and co-sleeping will increase the frequency of nursings, which is good for milk supply.

2) What's changed? Don't just think about what's going on with the baby -- what's going on with you? Are you taking medications? Hormonal birth control is a frequent culprit -- even progestin-only preparations can interfere with milk production in sensitive women. Stopping the hormones can often reverse the problem. (I was going to recommend LAM as an easy free effective alternative, but I don't know if there are concerns about relying on LAM after synthetic hormone use. Alicia? Anybody? Does a woman have to be more systematic about NFP in that case?) 

Cold medicine, particularly pseudoephedrine (the active ingredient in Sudafed), can also cause problems.  Some women hear that it's considered safe for the baby, but learn the hard way that it can cut a mother's milk supply by 24%.  Many times the milk supply will rebound, but if it doesn't, I highly recommend the resources at http://bfar.org. Much of the information there is helpful for any woman with supply concerns, not just those who've had surgery.

Has your baby recently started pulling away and looking around during nursing?  Some mothers interpret this as a complaint about the milk supply, but it's normal four-month-old behavior. Try reducing stimulation, perhaps by nursing in a sling or other baby carrier so that a) there's nothing to see except breast and sling fabric and b) if baby tries to turn around mid-nursing, he won't be able to take your nipple very far (ouch).  Has your baby seemed unhappy? Teething, an ear infection, a UTI -- any of those could lead to a miserable baby who's not nursing as effectively. Is there a chance you could be pregnant? Sometimes a reduction in milk supply is the first symptom for a nursing mother.

3) Pump it up. Pumping can be a quick and effective way to boost milk supply. Unfortunately, it is also kind of a drag. There is some great advice on the web about making pumping tolerable, so I will just stress two things. First, do not borrow your sister-in-law's old Pump In Style for short-term pumping. The PNS is a) an open-system pump, designed so that your SIL's milk may still be floating around in there no matter how carefully she cleaned it, and b) only guaranteed to last a year. Breast function is more robust than breast pump function, but so many mothers think that their limited response to a flagging breast pump means their milk supply is flagging. Rent a good pump for a week. Really. It's cheaper than formula and you'll thank me later.

My second piece of advice: power-pump. If there were a Nobel Prize for clinical breastfeeding support, it would go to the LCs who came up with power-pumping. Power-pumping eliminates the need for a big chunk of time in which to sit motionless in front of a breast pump (while your older children "redecorate" and perhaps give the dog a fetching new haircut) and simplifies the cleanup. Power-pumping takes advantage of the anti-microbial properties of human milk, which can be left at room temperature for ten hours and have FEWER bacteria at the end than at the beginning.² To power-pump, find a corner where you can leave your breast pump set up for a while (maybe 4 hours, if you're pumping for a healthy full-term baby).  Whenever you have a few minutes, sit down and pump -- a little bit here, a little bit half an hour later, a little bit forty-five minutes after that.  You can stop and rescue the cat from his impending coronation with a headpiece crafted from Play-Doh and cold spaghetti. You don't have to do all your pumping in one fell swoop, and you don't have to clean all the bits and pieces in between mini-sessions. Genius.

Oh, wait, I have a third suggestion and it is this: pump right after you nurse the baby. You'll get very little in the collection containers, but you'll send a powerful message to your body: More milk. Right away, please. Remember, the emptier the breast, the louder the call for more.

4) Think about your options. My intent in this post is not to dictate how long anyone ought to breastfeed, or breastfeed exclusively, or to tell anyone what remedies she ought to try.  Different mothers prioritize breastfeeding differently; different mothers have different hassle thresholds. One mother's weekend of extra cuddling and nursing and pumping is another mother's purgatory, and I am not attempting to shove the latter into the former's camp. But I find it absurd that the solution routinely proposed for slow weight gain in breastfed babies is the introduction of a potent allergen with a high potential renal solute load, a substance associated with increased risks of health problems both short- and long-term.  If a mother wants to keep breastfeeding her baby, there's usually a way to make it happen.

If your baby's growth is a concern, vigilance is appropriate; panic and one-size-fits-all action plans are not. You have choices in addition to formula supplementation. If your baby's weight is in the normal range, he is meeting developmental milestones, and he is reasonably happy, you might just watch and wait.  This week's weight could be a blip that will level out two weeks from now. Or it could be part of a trend that will be clearer in a month.  With a healthy baby you can take a little time to figure things out, as long as you stay alert for signs of trouble.  If you opt for milk-based supplementation, the World Health Organization recommends your own expressed milk as the first choice, pasteurized donor milk as the next option (I know -- good luck with that one in this part of the world), and finally formula. For a baby four months or older, you could also consider the introduction of nutrient-dense solids such as mashed avocado (not rice cereal, which supplies bulk with few calories).

Saying "I don't have enough milk" can be a self-fulfilling prophecy. "I didn't have enough milk for my first baby either" overlooks the reality that many women with a history of milk supply problems can do just fine nursing subsequent babies: milk production usually gets more efficient. Keep in mind that in many cases, a little bit of trouble-shooting coupled with a few days or a week of extra milk removal can turn things around, setting you up for months of harmonious nursing, if that's your goal. Get input about the problem from an experienced LC or volunteer breastfeeding counselor; get some temporary help with your other responsibilities. Other people can cook your dinner or bring you takeout, but only you can build your milk supply. Good luck!

¹Stutte PC, et al. (1988) The effects of breast massage on volume and fat content of human milk. Genesis, 10, 22-25.

²Barger, J. and Bull, P. (1987). A comparison of the bacterial composition of breast milk stored at room temperature and stored in the refrigerator. Intl J Childbirth Ed, 2, 29-30.

Comments

[Tall Kate]

Bravo. Just, bravo.

I wish I could wave a magic wand and make everyone able to grasp this . . .

[Michal Levy]

This is a great article, thanks for that!!
All we need is more encouragement and more knowledge about breastfeeding. Too often I see that women just give up because they don't have the right type os support and they lack the knowledge.

[Tracy]

Bravo. Clap, clap, clap. And very useful information for those who want to use it. :-D.

And I love this - "the introduction of a potent allergen with a high potential renal solute load". I want to be able to write like you...

I did e-mail you back but not sure you got it, btw, since I sent it from my other e-mail address.

[Amie]

All my my babies started going downwards on the chart between four and six months, I never knew that was normal.

[Linda]

I like you so much. You have an amazing ability to be a breastfeeding supporter without turning women off (well, except for that one blogger) with a holier-than-thou attitude.

[Summer]

Not that I really need the information at the moment, but I'm fascinated by the bit about storage capacity. I'd never even thought about the issue of in-breast storage, but now that you've explained it, I can clearly see that I was a small-storage lactatress. (So based on my example, you could change that sentence to "you can be an H cup with a teeny tiny storage capacity." My nursing boobs were ridiculous.) This explains why my son nursed so very often and why I never managed to pump more than 4oz, no matter how long it had been since I'd last emptied the breast, and why it took me nearly 12 months to get my period back.

FWIW, I also liked the trick of pumping one breast while nursing on the other. (I was using an Isis hand pump.) I was already sitting down with my shirt hiked up, and I was able to get the milk out the most quickly if I was nursing on the other side.

[Lisa C.]

I, too, was fascinated by the storage capacity part. And oh I wish I'd known about power pumping when I was pumping! 5 minutes here or there would have been perfect rather than the 3 20-minute snooze fests I took in the beginning. Yawn.

[Maria]

Thank you, thank you so much. It never occurred to me to give up on breastfeeding, from difficulties getting started through clogged ducts, mastitis, family and social pressure to wean, and random scoldings from people in the natural food store. I really really appreciate the supportive attitude and good information you offer to women who were not as fortunate as I in fellow-lactating-mama friends and La Leche leaders and other breastfeeding advocates.

[amy]

I need to bookmark this post for if I ever have another baby. Thank you, CJ.

The power pumping idea is great. I wish I would have felt free to cut my pumping sessions off without fear of wreaking my supply. (I pumped exclusively as my daughter never made the transition to breast after a NICU stay.) The only bummer was that I had a huge supply, so it often took 30 minutes to empty the gals. Oof, I tells ya.

I heartily second the recommendation to rent a high quality pump. It *is* cheaper than formula and your breasts will thank you. A great pump is the only way I managed to keep at it as long as I did.

[Arwen]

Can I just say how much I love you?

[maggie]

Hey, I have a four month old and boobs that don't seem to be doing the work they were doing a few weeks ago... Thanks for the ideas (and assurances.)

[luolin]

Perfect timing. I was just perusing the CDC charts, even though I know breastfed babies don't follow the curve (and even though I don't know what my 3-month old weighs, since his appointments are at 2 and 4 months).

[hedra]

Great info! I'll also add that if you had high supply or oversupply AT ALL, the difference in the growth pattern can be super scary - huge growth to almost none... but that's also normal, and we're evolved to kind of 'grow ahead' when the milk runs high, and even out as the supply adjusts to normal. My first gained a pound a week in the first 3 months. Sudden plunge in gain around 6 months... And gained only 1 ounce a month in months 9-12. Normal, and fortunately, our doc said 'chart correction in the first 12 months in breastfed babies is normal, he's happy, he's developing fine, don't fret.' If my doc had looked worried, I'd have weaned in a heartbeat, because that much change just seemed ... WRONG.

[Colleen]

thank you SOOOO much for the info...it was just was I was looking for. I suspect that I have the low-storage models. Unfortunately I have to work outside the home and a colicky baby, so I don't quite have the opportunity to power-pump like I'd like to, but hopefully I will get the chance to try soon.

[AmyinMotown]

Completely and totally off topic, but did you used to have, uh, another blog? (being incredibly vague because I don't want to out you or something). If not, you remind me exactly of another very talented blogger I used to really enjoy reading. If so, yay and glad to have found you again :-).

[Papaya]

Thank you thank you. If only I had known all this when my baby was 4 months and our ped was telling me she wasn't gaining quickly enough and I should supplement. I didn't listen to him (and worked on increasing my milk supply instead) but I was worried for months that I was starving the little one even though my instinct was telling me she was doing fine. Now she's 16 months and eats like a horse (as well as still breastfeeding), still petite, but as our (new!) ped says, a very healthy happy baby.

[Monica]

This could not have come at a better time for me. My 3-month baby is tiny - barely on any chart - and I am feeling panicked despite knowing we have a good nursing relationship. This helps calm my nerves.

[Lilian]

YAY for a breastfeeding post from you!! I also didn't know about the storage capacity thing. My breasts are teeny tiny, smaller than an AA perhaps, but have good storage I guess, coupled with a very strong letdown reflex. That didn't stop my youngest from nursing every 2 hours around the clock until he was 5 months old -- he's ALWAYS hungry that boy, to this day.

I knew the charts used by pediatricians in this country were no good (OK, based on formula-fed babies), but I didn't know that the WHO had their own!! Good! thanks for the link and all.

[Angela]

Thanks so much for this, I only wish I'd thought to look for it sooner - like when he was 4 months old and we were having problems but my PED and LC assured me that by looking at him even though my LO wasn't gaining he was still ok.
Now he's 6 months old and we're still struggling and having to resort to supplementing. I plan on trying some of your ideas, especially the power pumping - what a great idea! (I really hate having to clean all those little parts only to turn around and clean them again an hour later!)
Again thanks so very much! :D

[Amber]

I can not thank you enough for this great information. I have been worrying myself sick about not giving my 3 1/2 month old baby enough when I nurse him, he wants to eat more often than other nursing babies I know and when I pump I don't get more than maybe 2 oz at a time if I am lucky. The storage info was great and I really appreciate your ideas on the power pumping I will give that a try. This is my third baby and I wish I would have known about this information with my second child, I was going through this same issue at the same age with my second and just gave up on nursing because I thought I was losing my milk supply and it seemed like I had no support from anyone to help me fix the problem. Now I know its normal and understand the supply and demand thing more. Wish me luck. Again thanks a bunch.

[Sam]

Thank you so much for this. Google led me right to you - and I plan to power pump in a day or so - a little here, a little there, absolutely. I didn't realize I could leave the milk out for up to ten hours. (My husband remembers our lactation consultant saying five hours, but whatever - it's just good to know I can leave the bottle and come back to it!) Tonight I had to come home early from teaching my class, my child didn't have enough pumped milk to get through another hour! Talk about feeling like mother of the year...my supply has been low and I'm taking fenugreek, drinking more water - and Googling. Thank God for Google, and for you, for all this good information!

[Corie]

My baby is 18 weeks, my milk supply has gone down - baby is still hungry after feedings. I started to pump again after feedings (nothing coming out of breasts) I have not given up, however, I know my son is still hungry after I nurse. I have seen a lactation specialist, I am doing what I have been told, nothing seems to work. I started 4 oz of formula at night to help sustain his hunger. He wakes ever 3 hours at night to feed. Am I doing something wrong? I tried rice cereal, he spits most of it out. Not sure what to do at this point. I would like to continue nursing my son!!! I don't like the idea of formula

[Dawn]

Right on. I'd read Moxie and I'd read this months ago - sure enough today at the 9 month check up, he's coasted down to 25th again and the doc is using the chart with the big ole Emfami1 logo on it. I come home, check the WHO chart - he's in the 50th. Thanks :)

[Jaclyn]

Hi! I greatly appreciate what you have written. It is ironic because my son was born on the day this was published! He is a very slow gainer and it was at our 4 month appointment that we discovered he had only gained 8oz in 2 months. Our pediatrician was concerned, but willing to let us work it out until he comes back for his 6 month check-up. I have no plans on introducing formula to him, as I know my milk is best. :) I plan on bringing a copy of this article to show her! Thank you for the time, effort, and research you have put into this piece. Blessings!

[Heather]

Thanks for the info. My son dropped from the 75th percentile at 2 months to the 50th percentile at 4 months. I started really doubting myself and considered if I should supplement, but I'm going to tough it out and try to increase my milk supply.

Thanks again!

[clr]

THANK YOU SO MUCH. Finding this post could not have come at a better time. I spent most of this week sobbing after my son nearly 4 month old had slipped on the percentile chart and his doctor was downright alarmist at his last visit. I had no idea that this was normal at all.

[trina]

I am pumping while my 5 month old twins are asleep as I read this. Thank you for this info. They were 3 weeks early (term for twins, but technically 4 month olds gestationally) and I have been concerned about my supply the last 2 weeks. This makes me feel really good with how things are going and what I can do to get back on track and continue to exclusively breastfeed my babies.

[Crystal, Singapore]

Wow - what useful information. My son just turned 4 months and your post has answered a lot of the questions that have been flooding my mind. THANKS!

[Andrea]

Thank you so much for your post! I am linking to your blog from mine.

[Leila]

This is very useful information and you have the intensive study to back it up.

In my experience (not a ton of study -- 7 breastfed babies), this weight-gain slowdown is part of a big picture.

Children normally slow one kind of growth while another speeds up. With babies it's drastic sometimes, but as you gain experience with older children you realize it happens all the time. A 16 year-old thins out because he is at the threshold of a new part of his life.

A four-month old baby is vaulting into a whole new world for him (boring and uneventful as it may seem to mom!). He gets distracted at feeding (as you mention) and his mind is exploding with all he has to learn.

Mom has been wanting to get back to things -- and this is worse the more children she has - -but she should try to take this stage as a challenge to adjust to his feeding needs and enjoy seeing him take everything (not just milk!) in.

Patience! I wish everyone would learn to be patient :)

[Moby Wrap]

I like you so much. You have an amazing ability to be a breastfeeding supporter without turning women off (well, except for that one blogger) with a holier-than-thou attitude.

[Sara]

Thanks!