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Wednesday, December 4, 2013
Newborn and Infant Care
I have a 6 week old healthy infant who is formula fed. After starting formula at two weeks, he had very loose green stools and gas and fussiness. He was started on lactose free formula. He has been on this formula for 3 weeks. His stools remain green and though they are a little firmer are still loose and not the consistency of peanut butter. He is still gassy and he also has painful flatulence, thrusting out his legs and is fidgety most of the time. He only stools once every two or three days. He spits up at some feeds but then not at others. He sometimes sounds congested after a feed and I have sometimes noticed a clear runny nose. His pediatrician said it was up to me if I wanted to try a different formula but I hate to switch him if it is not needed. He also eats quite frequently taking 3-4 oz every 2-3 hours. He weighted 7lb 6oz at birth and was 10lb 2oz at four weeks. He just seems so different from most formula fed babies. Is there any advice you can give? We are moving from overseas and will not see a pediatrician until the first week of July.
Feeding problems are certainly distressing to both parents and infants. Unfortunately, there are no tried and true solutions that fit all children. It usually takes trial and error as well as luck to find the best answer for any particular baby. Let's explore some of the issues you have raised.
Let me start by looking at your child's pattern of weight gain and formula intake. Formula-fed babies typically lose about 5-7% of their birthweight initially after birth and then by two weeks have regained it and then add 1/2 to 1 ounce of weight per day in the first 2 months of life. Since birth, if your baby did not lose any weight and only gained weight, the most he should have gain ideally in 28 days is 28 ounces or 1 pound and 12 ounces. Your baby gained 2 pounds and 12 ounces, over 50% more than average without allowing for any weight loss at all. So his growth is better than average. There is no evidence of a problem with weight gain because of the baby's inability to digest his formula, absorb it, and use it for growth.
Babies on average should take 2-3 ounces of formula per pound of body weight per day. So your baby should have taken no less than 14 ounces of formula per day but no more than 21-22 ounces per day as a young baby. Babies also do not need more than 32 ounces of formula per day maximum at any age. Your baby is taking between 24 and 32 ounces of formula per day already at 6 weeks of age. So the amount he is taking is not only adequate, it is more than he really needs. This would account for his above average weight gain and contributes to spitting up, gas and loose stools. This is not uncommon in young babies as mothers learn to read their babies' signals and establish good feeding and growth patterns.
Carefully tune in to your baby's signs of true hunger: rooting behavior, hands to mouth, sucking on his hands, tucking his hands under his chin and making sucking movements. Only feed him when you see true hunger signals. Also stop the feeding when he indicates that he is getting full by slowing or stopping his sucking and drifting off to sleep. As he gets older, he will likely become more restless rather than drifting off to sleep. When he slows or stops feeding, burp him, and offer the bottle again. If he turns his head away, looks away or down, or starts wiggling, he is saying he does not want more. The best thing to do is to stop feeding him.
Babies often need more sucking time in addition to their time feeding. We call sucking on a pacifier "non-nutritive" sucking. They are not doing to relieve hunger, they are doing it to soothe themselves. Babies do this while inside their mothers and continue to use sucking as a comfort method after birth. Some babies need this more than do others. Once a baby has had a good feeding and indicated fullness, it is a good idea to offer a pacifier rather than more food to avoid overfeeding.
Babies also cry and fuss for a variety of reasons, not just hunger. They cry to be held, they cry to be changed, they cry because of pain or feeling ill, and even boredom. It is always a challenge to learn the meaning of your baby's cries but over time, mothers pick up on the different nuances of their babies' cries. I highly recommend Penelope Leach's book "Your Baby and Child: Birth to Five Years" as an excellent resource in coping with the changing baby and the fussy baby.
In regard to changing formulas, there is only a 50% chance that a change will help. Any change often results in tummy upset for a few days, so a full week trial of any new formula is needed before you can decide whether things are better or not. Of course if the new formula results in a lot of crying or bloody stools, you need to stop it immediately. If you want to try a change, try a soy formula. They are all very similar, so there is no special one to recommend. Another option would be the protein hydolysate formulas which smell awful, taste awful, and are quite expensive, but they are a lifesaver for the babies who need them. These formulas avoid all allergenic substances. From the information that you have shared, I do not think your baby needs them but it is worth discussing with your current pediatrician. You might also want to ask him to check the baby's stool for occult (hidden) blood and excessive carbohydrate content to make sure there is no irritation in the GI tract. Just bring a small stool sample with you in a ziplock baggie.
Green stools are often the result of iron in the formula. Infant formulas should be iron-fortified. The American Academy of Pediatrics in the 2004 edition of the Pediatric Nutrition Handbook recommends that all infants receiving formula only receive fully iron-fortified formula. Green stools also occur when parents feed babies green vegetables. Stool frequency and color also vary widely among babies and change as the baby's GI tract matures in function. What is important is that the stools are easily passed and neither too watery nor hard. Fatty, greasy, white, mucousy, bloody or explosive stools are also not normal. Frequency is not an issue if the stools are not watery or hard and rocklike. All other stools are a variation of normal.
So to sum up, I suggest the following steps:
a) Have one last visit with your current pediatrician before you move. Discuss the merits of a formula change and bring a stool sample for testing for occult blood and carbohydrate content.
b) Feed only when you see clear hunger cues as listed above and stop when you see fullness cues. Burp well once during the feeding and at the end of the feeding with the baby seated on your lap and supporting the baby under the chin. Lean the baby forward and backward if necessary to aid burping.
c) Offer a pacifier if your baby needs to suck for comfort. Have several, matching the shape to that of your bottle nipples to aid acceptance. Clean them daily with hot, soapy water or in the dishwasher. Never use your mouth to clean a pacifier.
d) Purchase a good infant care book such as Penelope Leach's listed above and read along as your baby grows and changes for lots of helpful baby- and mom-friendly advice.
e) If your baby is not already on a schedule for eating, sleeping, bathing, and playing, then develop one that works for you. Having a predictable rhythm to the day's happenings helps babies become more settled. This is especially important now because you are heading into the period of maximum crying and the emergence of colic in about 25% of all babies. Schedules really help fussiness. Other aids to reduce fussiness include being carried around in a Snuggli (well-padded shoulder straps are a must), daily infant massage prior to the fussy period, and motion such as car and stroller rides, and swings. Trying to maintain a schedule even while moving will help fussiness.
I hope these suggestions help and good luck on your move.
Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University