slow weight gain

[cww]

Our DD is 5w1d - she was born at 9lbs 11oz but was 9lbs 3oz two days later.  She gained 10oz the first week, but has been averaging about 1 oz/wk for the last 4 weeks, and now the pediatrician says we have 1 week for her to gain 5-7 oz or they will start supplementing with formula.  I will absolutely refuse to do this, b/c I don't think it is warranted.  I've been seeing a lactation doc (and a few LCs) b/c of constant pain while nursing (ever since she was born), and the L doc says that I should either pump and bottle feed exclusively for 24 h to measure my supply or rent a scale from Medela and weigh her before and after feedings for 24h.  It seems to me that the pumping would tell us about my supply but not exactly what she is getting, and the weighing would tell us what she is getting but not whether or not my supply is low (maybe it is ok, but she is just not eating enough at certain times of day). 

I don't think there is an issue with my supply b/c the 6-7 times that I've pumped, I've always gotten somewhere between 4-7oz, and I've pumped at different times of day...  (Also, when going to the LCs or L doc, the weighing before/after that feed always registered about 4oz, although they were always in the early-to-mid-day - she has never been weighed later in the day or at night. 

If it seems from these numbers that the volume she is getting is ok, then she would get referred to be checked out more thoroughly. 

She is otherwise growing in head circumference, hitting milestones, alert, having plenty of wet and dirty diapers, etc., and she doesn't look skinny or malnourished - the pediatrician today said that she looked "fantastic."

What I'd really like is for one of these doctors to say that she may just be totally normal but a slow gainer, but I'm not hearing this from any of the doctors.  I just hate to get into such a spiral of diagnostic problems from a single measure of weight gain when there are no other indicators of a problem. :(

I was hoping there might be others here who had a similar experience who could either offer advice, or just tell me how things worked out with them?  (Or just plain old encouragement also welcome. :))

Thanks for reading my post!

[motherhendoula]

I reallly think looking at your baby is very telling...you describe her as happy and alert and having plenty of wet and poopy diapers.  Does your pediatrician know this?  You have made a very good argument for waiting  to try supplementing,  I would try and bring this argument to your ped next time and ask for a little more time. 

Its a tough situation, of course you wouldnt want to leave any stone unturned when it comes to your LO, but yes, it really sounds like the doc is jumping the gun on this one, and I thought i remembered .5 - 1 oz a week weight gain is perfectly reasonable.

Maybe this ped is expecting more from a 9 lb baby! 

[katelove]

One ounce a week is a little bit low (in Australia we say about 125g/week with is about 4.5 ounces) but if everything else is good then I wouldn't be *too* concerned. My personal view is that pumping and measuring or pre- and post-feed weights are of limited value. Pumping and measuring will only tell you how much you can pump and pumps are not as good as babies at removing milk from breasts. Theoretically weights should be more useful but the amounts are so small and the scales rarely accurate enough so it's not a great test.

The best way to tell if a babe is getting enough milk is if they have 6-8  good wet nappies in 24hrs, regular poos, settle well between feeds and are meeting milestones and gaining weight. It sounds like your LO is doing all those things, even if the weight gain is a bit slow. If all of those things stay true then I would probably be inclined to take a watch and wait approach. Do you need to keep going back to the paed? Do you feel your milk supply is good? You could maybe try a batch of lactation cookies to give it a little boost and see if that made a difference?

I assume you're feeding on demand? You could try offering the breast a bit more frequently for a few days and see if that makes any difference.

I have copied the Kellymom link for growth which has links to other pages if you scroll down.

http://www.kellymom.com/babyconcerns/growth/weight-gain.html

All the best

Kate

[mominme]

I am the mother of eight children and I had this issue with my seventh child.  She was 8lbs 6oz at birh. While she may have been a very slow weight gainer she was never sick. She continued to be a slow weight gainer most of her life.  I remember her wearing size 8 clothes forever.  She is now 18, 5'5  112lbs. I remember  my Ped  wanting me to bring her in for weekly wight checks.  I finally had to resort to my basic mothering knowledge and confirm, yes she was having plenty of wet diapers, alert and healthy. 

[HeatherB]

My 3 month old DD has also been a slow gainer, so I've been doing a fair amount of research on the subject. Kellymom.com is a fabulous resource and somewhere I've spent a lot of time in the last few weeks!

According to Kellymom, the average growth for a breastfed baby should be 5-7 ounces per week. My DD has been averaging around 3 ounces per week over her lifetime. While she has had one week (of the last 4) where she gained nothing, she has also gained 4-5 ounces for two weeks, and 2.7 or so in the fourth week. She's had all the positive signs that your DD has - plenty of output, on-target or above-target development, growing head circumference, growing in length, happy, alert, strong, etc.

A couple of things have come up as possibilities in our search for an answer. First was the possibility of a dairy allergy (soy would be another big one). My DD has had mucousy stools and occult (hidden) blood in them. From my reading, this is often from a dairy allergy but can also be from foremilk/hindmilk imbalance. If there is an allergy, it could cause malabsorption which, perhaps, would lead to poor weight gain.

Second, is poor transfer, perhaps related to a structural anomaly like tongue tie. We confirmed that my DD had a posterior tongue tie which could contribute to poor transfer as well as excess foremilk. I was having periodic pain while nursing, though not as much as is often found in cases of tongue tie.

In an effort to evaluate whether my DD was having problems on the front end - getting enough milk - or the back end - using it effectively - I opted to rent a Medela BabyWeigh scale. It is very precise (down to tenths of ounces) and easy to use, though using it at every feeding for more than a couple of days gets very tiring. We were able to determine that her total intake over 24 hours was on the low side of normal, though not substantially below normal. It was valuable information in helping to put the puzzle together.

I eventually decided to get her tongue clipped, to be sure that part of the puzzle was accounted for. We were finally able to do that this week and have seen improvements in her latch already. While only time will tell if it affects her overall weight gain, it has the potential to.

It's a difficult position to be in, to have a seemingly healthy child who isn't meeting certain expectations. Are the expectations wrong? Is there something more insidious going on? Is there something simple that could be remedied, or is it so complex that it may never be understood? I really feel like it's worth looking into all the possibilities, though. I have felt like I was casting a wide net, getting as many opinions and as much input as I could, assembling it together, and going on instinct and prayer to figure out the next step. I don't know that we're at the end of the road, yet, but I am confident that pursuing answers has been the right choice. Given the extremely low numbers for your DD, I'd rent the scale, do the weight checks, check for simple things like tongue tie or other latch issues, and get as many (trusted) opinions as you can. Like you, though, I'd refuse to supplement until there was a clear indication to do so (and I'd go with donor milk, if at all possible, when it came to that).

Please keep us posted!

[cww]

Thanks so much for your replies everyone.  I really, really appreciate the support!

The LCs and lactation docs did check her out for tongue tie, which she does not seem to have (although the LCs were uncertain as to whether or not she might have a mild case, the doc said that it is not a problem, based on my nipple shape after feeding).  However there could be something going on with how she gets milk from the breast b/c I've had pain the whole nursing relationship.  No one can pinpoint why, though, which is why we are currently treating for yeast (hoping that this is the root cause of the nursing pain) - but I'm not sure if yeast can affect how much she eats when she doesn't have any of the white patches in her mouth?  So maybe there is something else.

I thought I'd update briefly - we are now about 17 hours into an exclusively pumping/bottle feeding/measuring experiment, and the numbers are: 

total pumped so far:  23 oz

total eaten by LO so far (offered a bottle any time she was fussy, even if she just ate, and kept offering milk until she stopped drinking it, even if she finished a bottle):  25.25 oz

So even if I only get a few oz per pump over the rest of the pumps, I'm clearly making "enough" milk based on the average of about 24 oz per day, however, my pumping output is not quite keeping up with what we can get her to drink (can you get a baby to drink "too much" just by repeatedly offering more milk too often or in too large quantities?).  Before bed, she drank 7 oz in a period of 2-3 hours, and first thing this morning she drank 6 oz again, and then 4.25 oz three hours later (and might have drunk more, but I'm out of pumped milk!).  I thought 5 oz was about the max for all babies, and she is only 5 weeks (although she is on the taller side and had a larger weight at birth - both my husband and I are really, really tall). 

I also noticed that I got a ton of milk out at the first pump (6.75 oz), but less in subsequent pumpings (closer to 4 oz) and even less in the last two pumpings (2-3 oz).  This makes me wonder if I always get such a large pumping amount b/c she is not emptying the breast efficiently when she eats (but when I pump for 24h straight, there isn't this leftover milk at subsequent pumpings?).  Or is it possible that my breasts are responding less and less well to the pump as the 24h stretch wears on?  (I thought I usually got the most milk out in the am, but during this 24h period, that's when I got the least amount from my pumpings...)  I know that I've read that the pump isn't as good as a baby at removing milk, but I'm wondering if that is equally true for all pumpings, or true for our LO?

We'll see what happens, but I'm beginning to suspect two possibilities:

1)  Maybe she is getting an average amount of milk, but she actually needs more than average?  (She's always been really fussy before bed, and since I cluster feed her 2-3 times before bed, I never imagined that she might be hungry, but since last night she drank 7 oz in one long feed from the bottle, I'm beginning to wonder if my breasts just aren't keeping up with a peaking evening/night demand...)

2)  Maybe she is just not getting enough out at a feeding, even though my supply (based on pumping numbers) seems "fine?"

I will call the lactation doc and see what she thinks, but I was planning to add in some extra pumpings today (to try to make up the fact that she is eating more than I pumped over the last 6 hours!) and to try to rent a scale so that I could do the weighing thing over the next 24h to see how much she is eating at the breast. 

I was wondering if the weighing shows that she is eating less from the breast than the bottle if I should start pumping after every feeding and then trying to get her to take a bottle after the breast.  I don't know if what she has been eating from the bottle this 24 h is an accurate representation of how much she actually needs.  I'm hoping the lactation doc will have helpful ideas - I'll post when I hear from her, in case my experience is helpful to anyone else...

Thanks again for all the support and advice - I really appreciate it.  This is so stressful, b/c I feel so responsible for making sure she is getting enough to eat (and I can't help feeling that if she isn't getting enough to eat, that it is my fault for not taking care of her properly - I know that is silly, b/c we are learning, but I feel it nonetheless...).  And there is just something really horrible about the idea that your child might be starving! :(  It really helps to have helpful support and encouragement. :)

[PatioGardener]

I'd encourage you to check out the 'mild' tongue-tie and look into getting it clipped. If baby is tongue-tied and baby is not gaining and Mama is in pain, what is the doc thinking? Those are all read flags which (at least to me) scream "clip the tie!" A little tie can make a huge difference.

so sorry you are going through this, but i admire your strength! Hang in there!

[cww]

Hi everyone,
I just thought I'd update. With pumping after each feed and feeding her as much of that as she would eat, she gained 10 oz in one week, so that seems to be fine. Now we are just working on trying to get her to get it directly from the breast. I've been taking herbs to boost my supply and the lactation docs says that I could use an oxytocin nasal spray to get the flow to be faster at the beginning of feeds, which is supposed to help her feed better (but I didn't want to move to using drugs unless absolutely necessary) - anyone else have experience with this nasal spray?

I've dropped down to just pumping to 2 times per day (the doctor wanted me to pump every other feeding, but my nipples are just too sore to keep that up, and since she wasn't drinking everything I pumped before, and actually gained about twice what was necessary, I felt that this is likely to be enough for now - we'll see at the end of this week).

I'm really hoping to get her to feed better so that I don't have to pump anymore at all, unless I'm prepping a bottle for when we might go out.

I'm also still working on the nipple pain - we've complete a course of two weeks of oral antifungals, but it is no better (but maybe at this point it is just pump trauma?).

Anyway - I just wanted to update. Thanks again for all your replies!

[PatioGardener]

That's great news that she's gaining!  The nipple pain could be vasospasms from trauma too . Please do look into tongue-tie, Mama. It could be at the root of the poor transfer and your painful nipples. You need someone to look who has experience with posterior tongue-ties though.

You're working so hard at this - congratulations for sticking with it!

[Asiago]

I have no advice and nothing to offer but encouragement. You are doing a GREAT job!!!

[cww]

Just a quick update - LO is now about 11 weeks and has been gaining at about 5 oz/we for the last 5 weeks, although we've been giving her an extra bottle of 2-4 oz of ebf every night before bed.  The pain is still a problem, though - we're still working on that with the doc - she did another home visit today and at this point at least, there is no tongue tie (although she still wants to nurse for hours at a time, so there is probably still something that is inhibiting her ability to eat efficiently - the doc thinks maybe reflux?).  So we are still looking for other solutions for the pain, but at least we can stop worrying too much about weight gain...   Thanks again for all the encouragement and advice!

[ShwarmaQueen]

Who is looking at her tongue? A pediatrician? Most wouldn't know tongue tie unless it were obvious. Posterior is tricky and not at all uncommon. Have you thought of working with an LC experienced in tt?

[cww]

Came here to do an update, and realized that I never updated a few months ago (too many posts going at once!).  It turns out that our daughter had a posterior tongue tie, which was corrected (by a pediatric dentist with a laser - he also corrected a lip tie, but I'm not sure that really affected BFing) when she was 3 mos old.  Immediately she went from 1-1.5 hr feeds that were very painful, to 10-20min feedings that were still a bit painful, but manageable.  We still have some pain with feeding all the time, but she gained a pound in the month after the procedure, and I just found out today that she gained a whole kg (2.2 lbs, or 2 lbs 3oz) in this last month (from 4-5mo old).  Before the procedure, she always gained 1 oz/wk unless we supplemented her with an extra bottle of EBF at night.  So while the tongue tie procedure didn't totally cure the pain, it became apparent pretty quickly that it did make a huge difference in her ability to BF.  This was after months of seeing two highly recommended LCs and a Dr who specializes in BFing.  I was very lucky, in that my supply never went down enough to be a problem in spite of her inability to transfer milk effectively, but someone else who took that long to find a solution probably would have ended up with low supply issues. 

Just wanted to update for anyone else hunting around in future with similar issues - even if good LCs and BF docs say there isn't a problem, I would recommend ruling out tongue tie with someone who is known to specialize in treating posterior TT if you are having pain, long feedings and/or weight gain issues like we were.  I wish we had found the problem months earlier - it would have saved us so much pain and stress. 

Thanks again to everyone who replied to my posts here - it's this forum that helped us to find a solution!

[CookAMH]

I'm dealing with something similar in my 11 week old (see my other post about low weight gain), but I have no nipple pain and DD is done nursing as soon as flow slows down.  But the gain is similar. Is there any reason to suspect tongue tie if there is no nipple pain?

In the last day or so she's started playing with her tongue and she sticks it out...can a tongue tied baby do that? I have also felt her tongue on my finger if the finger below her lip (i support my breast with my hand) is close to her bottom lip while she nurses. But I do occasionally hear clicks though her latch looks good.

[goodygumdrops]

Wow.  Good for you!!!  It's awesome that you were able to stick it out and get to the root of your issue.  With time, the pain may eventually lessen...it's likely your babe is used to nursing a certain way and it might take a bit of correcting to help deal teach her/him to not pinch your nipple. 

You deserve an award!!! 

[Marissamom]

Originally Posted by CookAMH 

I'm dealing with something similar in my 11 week old (see my other post about low weight gain), but I have no nipple pain and DD is done nursing as soon as flow slows down.  But the gain is similar. Is there any reason to suspect tongue tie if there is no nipple pain?

In the last day or so she's started playing with her tongue and she sticks it out...can a tongue tied baby do that? I have also felt her tongue on my finger if the finger below her lip (i support my breast with my hand) is close to her bottom lip while she nurses. But I do occasionally hear clicks though her latch looks good.

I have two children, and both have posterior tongue ties. with one I had a ton of nipple pain, with this one I almost never do (only when he gets distracted and chomps down or lets the nipple slide into the corner of his mouth). both can stick out their tongues. and both have had clicking. 

[cww]

CookAMH, I'm not sure what an expert would say, but if I were in your shoes, I would probably at least try to see someone who specializes in tongue tie to rule it in or out - someone who really knows what they are doing should be able to tell right away if there is a problem or not. Especially since if that is a problem, it could have caused your supply to drop, which one would want to try to correct asap, hopefully before it became permanent. With our daughter, she was able to stick her tongue out a bit, but she couldn't lift it to the roof of her mouth, and once the procedure was done, you could see that she could really stick her tongue out much farther - in fact, now when she nurses, she kind of leads with her tongue, as though she is going to lick the nipple. I had also looked to see if her tongue was coming over her lower gums when she nursed by pulling her lower lip back, and it was. Also, everyone thought her latch "looked fine," so I'm not sure how helpful that is as a measure of proper BFing?

Here's what the BF doc had us do when we had the weight gain problem (to try to determine if the issue is that she isn't getting enough milk, or whether it's an issue with her "using" the milk efficiently (a more serious problem). She had us track how much she ate in 24 hours - there are a couple of ways to do this, each which can be more or less accurate. She had us pump for 24 hours and bottle feed so that we could see how much I could get in a pumping. The problem with this I think is that some people may have a supply that is just fine, but may just not be able to pump very well, and so it may look like they have low supply when really they just don't produce as much pumping as when the baby is feeding well. However, if you do this and get a decent amount of milk out, that suggests that your supply isn't the problem. For me, this wasn't an issue, b/c I got about 30 oz in 24 hours, so for us, the shorter term solution was just to pump extra after feedings (esp in the am when there was usually extra milk left over, since she didn't feed for as long during night nursings), and then to just give her bottle feedings of the extra milk. The dr wanted us to pump after every feeding, and then bottle feed that, and then if weight gain was good after that to go to every other feeding, and gradually reduce until we found out how much she needed to maintain "good" weight gain. This was a huge pain in the butt (I started to feel like I was trapped at home, b/c with pumping so often, I couldn't go anywhere, plus her feedings were always 1-1.5h long, so I was basically always BFing or pumping), so after she gained 10oz in a single week of this (without me pumping at night after that first 24h test period), I felt she would be fine if I just gave her one extra bottle of 2-4oz milk (taken from 1-2 am pumpings) at bedtime, and she was - she gained 5 oz/wk regularly with this routine.

The other option was to rent a Medela BF scale (see the Medela website and they can show you where to go to rent one in your area) and to weigh her before and after each feeding to see if she gains - we also tried this, but the scale we rented was clearly broken (b/c several times it showed that she lost weight during a feeding, or that she gained less than we fed her, even by a whole oz, when we gave her a bottle of precisely measured EBF - and no, we weren't changing her diaper or removing clothing in between feedings...), so we didn't get much info from this. However, if you get a working scale, this method should give you an accurate estimate of what she is eating in a 24 h period (but if that is low, it won't tell you if it is b/c your supply is low or if it is b/c she is just not removing milk efficiently.

Another thing we also did before the tongue tie was diagnosed was to use herbs to up my supply. My supply was actually fine, but in our case, the dr said that the increased supply would increase flow rate, which should help her to get more milk - whether that helped or not, I don't know, but Fenugreek, for example, did in fact increase my supply (although it took several days to gradually kick in, and several days to gradually go down when I tried stopping a few months ago). You could also just try that (e.g. supply boosting herbs), if you haven't already, to see if it helps with weight gain (and that might save you the trouble of pumping for 24h?).

Good luck with everything - I hope you find a solution soon!

goodygumdrops, thanks for the encouragement. :) I'm glad we stuck it out (and would love for the pain to go away completely eventually - she definitely still tries to feed by pinching down on the nipple...)

[CookAMH]

Thank you for that, it's encouraging in many ways. I went to a drop-in clinic today with an experienced LC and she at first didn't observe/feel tongue tie, but upon examining her further, felt it was a *little tight* and noticed her tongue didn't rise very far when crying and looked asymmetrical when crying. She is only getting about 2-2.5 oz per feeding, and I am having a really hard time nursing her more often - many times she just will NOT take it and cry and refuse.

I have started taking fenugreek and some extra pumping to ensure a good supply (esp after an incomplete feed), even though she's not eating all of it.

I have an appt with a great bf Dr. to look at the tongue tie and possibly get it treated (if there is one, I will have it clipped). That is not for a week and a half since I'm going out of town, so I have considered supplementing with pumped milk until this is hopefully resolved and she has more thorough feedings. My concern is her preferring the bottle, but she needs to eat. For example, I fed her at 5pm today and she went down around 6 for a nap, I woke her at 8 to nurse and she would.not.nurse. She eventually got quite worked up about it but would suck mad on the pacifier. I *know* she'd take a bottle if I offered one but I honestly didn't know what to do at the time b/c I fear her preferring the bottle. So, she was sleepy enough that I put her back down and I plan to wake her up in about 20 min to try again. I also want to get one more feeding for her today anyway, before I go to bed in about two hours.

__

So she woke up as I was typing that (9:30) and she refused to nurse again, it had been 4.5 hours since she last ate by that point. DH suggested pumping for letdown then put her on - that worked for less than a minute then she had it. So, I pumped and DH is giving her the bottle. Not a lot (maybe 2oz), because I want her to nurse in a couple hours.

re the bottle - I have considered what you did - giving some bottle each day to bring her to the gain she should have. I know she'll gain that way. But I don't want that to make the issue worse, but missed feedings, by the time I get her to nurse after she refuses at times, amounts to fewer feedings by the end of the day.  How do you discern, obviously they need to eat, but maybe if the bottle wasn't an option she'd learn to take the breast better? We did that one weekend and she gained 4 oz from Friday to Monday, so like you, it isn't an issue of having enough but not being able to use it.

She just doesn't nurse past 3-4 min usually, even if there is more milk. It makes me wonder if she tires from a tighter tongue, and I wish it wasn't a week and a half until she can be seen for it.  I'd consider staying in town for the doc returning next week, but DH is out of town and I really want to be at my parents with help with the kids while he's gone. Maybe she could see someone while I'm there.

Edited by CookAMH - 6/23/11 at 10:17pm

[cww]

CookAMH, I'm so sorry that you're having such trouble getting her to drink at the breast. I would feel really frustrated in that situation. We didn't really seem to have problems with her preferring the bottle, but I know it can really vary from baby to baby. With us, she would stay on the breast for really long feedings and that was a sign that she wasn't getting milk well, but I know that really short feeds can also be a sign of tongue tie also. I do know that the first bottle we tried was just the Medela with the slow flow nipple since that is what came with the breast pump - our daughter drank up 4 oz in about 5 mins with that nipple, so I immediately bought some Platex drop-in bottles with slow flow nipples (they'd been recommended by several LCs but I had resisted b/c I didn't like throwing away a bunch of plastic liners), and this definitely slowed down the flow much more to come closer to what they get with the breast, so she would take more like 20-30 min to finish a bottle. So maybe it would help some to switch bottle/nipple type?

I do know that some LCs that I saw were less worried about this issue - they encouraged me (even at 2 days postpartum, when I was having so much pain) to feel free to pump and feed, because they seemed confident that they could then help us get back on the breast again. Have you talked about this issue with a good LC to see if they have advice? I know that there is a lot out there written for helping babies get back on the breast from the bottle.

We did have some minor trouble getting her to nurse sometimes, where she would just sit there hungry with the nipple in her mouth and scream - fun!, but it wasn't too terrible and I didn't bring it up with LCs or anything - we just dealt with it on our own. Our techniques were to take a break from nursing if she got worked up and to do something that calmed her down - with our daughter that was bouncing on the birthing ball or going for a walk, for example - and then we would try putting her on the breast again. I also had some luck by doing the following: instead of just putting the nipple in her mouth, I would kind of tease her with it by brushing it against her cheek, to try to get that rooting reflex so that she would turn her heat towards it and latch onto the nipple on her own. If I could get her to latch on, I would then bounce her to try try to keep her calm while she was nursing so that she would stay latched on. For her, it seemed that if we could just get her going, then keep her relaxed as soon as she latched, then she would nurse. There was one week there though where she would scream at the nipple every time I put her on the breast. When we had problems, these techniques did gradually over a period of several days make her more likely to nurse right away. I know there are other options that involve using a homemade or storebought supplemental nurser, but we never tried one of these (but I bet someone else on here could provide advice if you wanted to try something like that).

If you just started the fenugreek, it may take 3 or more days to kick in fully, so maybe that will help soon? I'm not sure how recently you started it. (I was told to take 3 pills 3x per day - pills that are about 600mg each.)

I totally understand about your wanting to see the doctor right away - when I was finally convinced that our daughter was probably tongue-tied, we had to wait a week to see the doctor, both to wait for insurance precertification, and b/c my husband's family was visiting (and we had to drive a full day to get to the doctor). It drove me nuts waiting when we had been suffering for so long and finally it looked like there might be a solution in sight!

One thing I might try in your situation (I'd probably only do it during daytime), if you can get it to work, is to always offer her the breast first, get her to drink as long as she can, and then give her a bottle of whatever you pumped after the last feeding while you pump after that feeding. Maybe this would work to keep her on the breast (since she always gets the breast before the bottle and never just gets a bottle feed), but still get enough milk into her while you guys figure out how to get her to eat more efficiently?

I really hope you get some improvement soon - this can be really frustrating and really feel like it is taking away our quality time with the new baby!  Whatever happens, do keep updating us if you feel like it. 

[CookAMH]

Thanks again for the comments. I'm glad to see that I have been already trying some of the things you said you did to help your LO nurse. Thankfully, she nursed this morning at 6:30, 8:30, 11:30, 1:30 and 5 (after her long nap) just fine with little or no fussing, and she even went back and forth to both breasts which she rarely does. So, she takes in more milk that way, and that little bit over several feedings (if she keeps that up) will result in more weight gain. We did side lying each time I fed her and that seemed to help. She cried tonight though after nursing a couple minutes around 7:30, so when we put her to bed a little after 8, my DH gave her about 2oz from a bottle. I may need to wake her part way through her long nap though to get another feeding in most days. I do love that she takes such a great nap though but she could use the extra feeding.

I did figure out last night before going to bed that a lot of her refusal was b/c dairy - I had been off it for weeks but had been trialing kefir this week, little bits each day.  I didn't realize it at first but it seems clear now - fussing at the breast, gas, some reflux and congestion. So, I didn't have any today and hopefully will continue to see improvement.

Thank you for mentioning a different nipple. I had been using the medela slow flow but didn't realize there was another one slower, and I think I will get the other kind you mentioned. Though I prefer to use glass bottles, but that may not work.

Sorry for hijacking your thread but I'm glad for the help!