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Case Study: Dylan, Milk refusal

Dylan, aged six months

Problem: Milk refusal

Cause: Introducing certain foods too early

Dylan was born three weeks early by emergency Caesarean. Although his mother, Myra, was very ill after the birth, she was determined exclusively to breast-feed Dylan. She breast- fed on demand for the first eight weeks of his life. It was nearly three weeks before he regained his birth weight and, when he was six weeks old, his weekly weight gain was very low, averaging no more than 110g (4oz) a week. He was very unsettled and crying for much of the time that he was not on the breast. Myra was becoming more and more depressed and exhausted by the endless feeding and trying to cope with a very fretful baby and two other children, and it was at this stage that she was advised to top up after each feed with formula milk.

By nine weeks Dylan was getting virtually all his feeds from the bottle. Myra had breast-fed her other two children for four months and was bitterly disappointed that she was not managing to do the same for Dylan. She contacted me for advice on how best to increase her milk supply so that Dylan would be getting most of his milk from the breast instead of the bottle. I suggested that she follow my plan for a low milk supply for one week (see The New Contented Little Baby Book).

As Myra's milk supply was so low, I advised that she would have to top up with formula after the 10.30am feed, instead of expressed milk as the plan suggests. Within one week her milk supply had increased so much that Dylan was taking the breast at all the daytime feeds, with a top - up of expressed milk after the 10.30am and 6.15pm feeds, and only one formula feed a day at 11pm. By the end of the 12th week Dylan was sleeping through to 7am from his last feed. He continued to feed well from the breast and gained 240g (8oz) in weight each week until he was four months old. At this stage his mother gradually began to introduce more formula milk, and by five months Dylan was on four full formula-feeds a day, and a small amount of solids at 11am and 5pm. He was also sleeping well from 7pm to around 6.30am every night.

Things continued to go well for a further five weeks. Myra was advised to begin weaning Dylan at about five months of age, and she introduced small amounts of first-stage weaning foods, plus some other fruits. However, one night Dylan suddenly woke up at 2am. Myra tried to settle him with a cuddle and some cool, boiled water but he could not be consoled. Myra was concerned that he might genuinely be hungry as he had only taken 150ml (5oz) at the 6pm feed, so she decided to offer him a small 120ml (4oz) feed. Dylan drank this quickly but still refused to settle back to sleep until he was given a further 120ml (4oz) of formula. He then settled back to sleep very quickly and had to be woken at 7am.

During the following week Dylan became more and more difficult over his day-time milk feeds, and a pattern soon emerged of him taking only 120-150ml (4-5oz) at each daytime feed, and only 90-120ml (3-4oz) at 6.15pm, before waking up desperately hungry between 2am and 3am. When his mother contacted me for further advice she assured me that she was still following my routines and guidelines to the letter.

The daily records she sent me showed that, until things had started to go wrong, the structure and timing of milk feeds and solids were correct. However, I noticed that she had decided to introduce certain fibrous foods earlier than I recommend. Banana, which I advise introducing at six months, was added to his breakfast cereal at five months. Dylan loved banana, and this prompted his mother to offer it to him regularly at lunchtime along with mashed avocado, another food that I believe is hard to digest. In addition to the large amounts of banana and avocado that Dylan was being given, when meat was introduced at six months it had resulted in him cutting back too quickly on his milk intake. The quantity of foods that I believe take longer to digest had been introduced and increased too quickly. As a result, he had to wake in the night to make up for the milk he still needed and was no longer getting during the day. It was clear from the feeding charts that Dylan, who then weighed 6.6kg (15lb), had cut back too dramatically on his milk intake during the day because his solids had been increased too rapidly (especially at breakfast). Myra, desperate to increase the amount of milk he was taking, decided to mix more formula into his breakfast cereal, which resulted in him having eight teaspoonfuls of breakfast cereal plus mashed banana at breakfast.

I advised Myra to cut back the breakfast cereal to four teaspoonfuls, with one or two cubes of pear or peach purée instead of banana. Lunch generally consisted of six tablespoonfuls of a savoury casserole followed by rice and fruit, and was also contributing to Dylan's decreasing appetite for milk. I suggested that Myra replace the rice and fruit with fruit and yoghurt. At teatime Dylan was given another savoury dish, again usually made up of fish or chicken, mixed with rice and formula milk to help boost his milk intake. I advised her to replace the meat dish with some carbohydrates, such as pasta or a baked potato with vegetables.

Within a week Dylan had increased his three daytime milk feeds to 210-240ml (7-8oz) a feed. Although he continued to wake up during the night for a further 10 days, I convinced his mother that it was now being caused by habit rather than a genuine need for milk, and she followed my suggestion of settling him back to sleep with some cool, boiled water. At the end of two weeks Dylan was eating three well-balanced meals a day and drinking 690ml (23oz) of formula from the bottle and taking a further 120ml (4oz) of formula in his cereals.

I believe that the types of foods Dylan was first weaned on were the cause of his rapid decrease of milk. Being given too much banana and avocado, and mixing sweet potato with baby rice, during the early stages of weaning causes babies under six months to cut back too quickly on their daytime milk. In Dylan's case the problem was made even worse by the fact that he weighed only 6.6kg (15lb) and that he was being given meat twice a day as well as hard-to-digest foods. It is a common mistake to introduce too much of the wrong types of food too early or at the wrong time and thus create a problem of milk underfeeding. It is the main reason for babies under six months cutting back too quickly on their daytime milk, which results in a genuine need to feed in the night.

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