Hidden hunger is a common occurance in mothers with children having MAM or SAM which is often overlooked but by supporting these mothers with FBF you get better results rather than just leaving them without. I would encourage you to give FBF for pregnant and lactating mothers if you have access to it

Hello,since its a supplement,its not advisable to give FBF.Ask the mother if she has enough milk for the baby even if she is practicing proper lactation and make a follow up after every two weeks to see how the baby is progressing.

A baby who is falling down the percentiles on a weight chart is usually failing to get enough breastmilk during breastfeeding even if the mother is making enough.  But since poor breast drainage over time will lead to inadequate breastmilk production, this becomes a chicken-or-egg situation.  Feeding a mother more when her weight is already OK wont help the baby who is not breastfeeding effectively. Often a baby like this wants to breastfeed "all day" but what's really happening is that a weak baby is often just flutter-sucking for long times without ingesting an adequate quantity to thrive. To turn this around, it's often necessary to ensure that the mother breastfeeds 8-10 times in 24 hours, for short times, (she can use breast compression and switch-nursing to keep maximize the baby's intake with the least effort on his part) and then after breastfeeding have the mother manually express what the baby is _not_ taking, to use as a supplement. This milk can be stored to be cup-fed after the next breastfeed.  Over time, more efficient breast drainage leads to increased breastmilk production, and increased breastmilk intake for the baby leads to higher weight gain.  In my experience, a low weight gain baby may need to be helped to get enough milk in this way until he reaches the weight he should be for age on a weight chart.  This sounds time-consuming but the breastfeed-supplement-express routine can be over in an hour giving the mother an hour's break before she needs to start again. it does work!  It usually takes as long to "fix" this kind of breastfeeding problem as it took to occur.   

Thanks Rosemary for your response

Thanks Hellena for your response.

Thanks Pamela Morrison for your response.

Thanks Pamela Morrison for the response

I asked because in some instances when you supplement with FBF regardless of the mother's nutrition status you get better results the mother starts producing enough milk and the baby start gaining weight...... While in others just counselling, teaching on attachment and positioning, and proper follow up plan also works well.

So I was wondering which is the best recommended practise

It depends on various factors. You have counselled the mother on propper lactating practices . The question that I might ask you is. How is she in terms of household food security? Does she has enough food  to meet the requirements of breastfeeding mother? During breastfeeding, the mother needs to eat an extra food ( to meet the requirement for her and the infant  about 550 Kcal per day 

Secondly, based on your counselling what is her MAD at household level and is she financially able to buy 5 food groups + during lactation as well as ensuring diet that  is rich in proteins? 

If you have counselled her on proper lactation practices and she can be able to afford to eat extra meals with dietary diversity. I don't see the need for her to get any supplement. But if you see her she is at risk of getting malnourished with inadequate food security at household I will advise you can give her a supplement and with justification as to  why. you did that 

NB// Ensure the underlying causes of malnutrition are taken care of for both the mother and the infant.

@ ENUNU Henry Thanks for the response,, Quite a good number of lactating mothers I encounter are mostly food insecure and they rarely meet the 5 groups recommended since they come from humble backgrounds. So we mostly supplement with Advantage to just "boost" their calorie intake regardless of mother's nutrition status as long as the child is SAM or MAM as a part of management in addition to the named services like counselling. ( I wanted to confirm is this is correct)

Hi All,

There are at least two different topics going on in this thread, and--although related--we should probably keep them clear.

1) Giving a MOTHER (for her own consumption) fortified blended flour (or any of the fortified blended food commodities). Can you clarify for us though how you know that “the mother’s nutrition is fine;” i.e., are you talking about micronutrient profile or macronutrient status (like you’ve got her MUAC or BMI or weight/height? Though I can appreciate that if her dietary diversity is quite poor, fortified commodities may be attractive, I would agree that if the mother's weight is good, it's probably not a great idea to give her supplemental commodities that have the main purpose of providing calories. Maybe instead, better to consider small-quantity lipid nutrient supplements, micronutrient powders (if that is part of the national protocols), or multiple micronutrient supplements (sometimes called prenatal vitamins and they may ultimately come to replace iron-folate). Hopefully as multiple micronutrient supplements become the norm, that will be a good option for mothers who are already at a healthy weight. Those amongst us who work on micronutrients or food assistance can advise.

2) Breastfeeding, and how to ensure adequate milk production, for the CHILD's nutrition. On this I would most trust the lactation consultant who's advising on this thread; Pamela Morrison always gives brilliant advice. She's telling us (I believe) that the way to increase milk production is through ensuring the breasts are emptied, through frequent feeds, alternating between breasts (I used to hear "empty one first" but I think she's saying we can be flexible and give the other breast if the baby seems they're doing a lot of work for the milk they’re getting), emptying the breast manually if needed and storing that milk and feeding it to the baby later from a cup (not a bottle). 

But if a baby is already SAM/MAM, we should probably focus on addressing him/her being underweight as a primary concern, before worrying too much about the micronutrient content of the mother's milk. In addition to whether baby is getting enough to eat, it's critical to consider why else could the baby be SAM/MAM... I know original poster said there are no medical complications, but illness is an important cause/effect of SAM/MAM. With friends from FCDO and ENN, we developed a diagram (Figure 2 here: https://mqsunplus.path.org/wp-content/uploads/2021/10/MQSUNAssumption-Map-brief_wasting-prevention-case-study_26October2021.pdf) to show the different factors involved.

Side note: if anyone's interested in doing research on the complexities of wasting, we and FCDO supported an ENN-led group to try to come to consensus on what the most important research questions might be: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228151 .

@ Carrie Hubbell Melgarejo, Thanks for the response and the PDF.

Just to reply to the question you asked on how the mother was stated as being " fine'', it  was based on MUAC assessment being > 23cm, we still have a challenge in assessing for micronutrient status of mothers because of limited resources, what can be assessed mostly is the Iron status.

Thanks for the  various inputs from members,it would be good to first consult from your national protocol and how is your programming  as for Uganda we have integrated management of acute malnutrition where we have   4 components; inpatient therapeutic care(management of SAM with medical complications  and  anorexia),outpatient therapeutic care (management of SAM without complications and appetite presence),community nutrition(active case screening ,mobilisation  and linkages) and finally supplementary feeding care(only in emmergencies ,or GAM rate of >15  +aggravating factors usually in refugee settlements ,it can be targetted or blanket supplementary feeding ,in your case if its BSFC then you can go ahead and supplement the mother whose child I  guess in this case is on your OTC program, In some settings especially for refugee settlements WFP  implement  a project on prevention  of  stunting usually called MCHN i.e maternal  child health nutrition along side TSFP where mothers attending ANC(0-9months and 6months postpartum receive super cereal ++ or corn soya blend ++ irregardless of their nutrition status and attention is turned to the child immediately complementary feeding is commenced at 6months,so there is nothing totally wrong with supplementing a mothers diet but it shouldnt be on bases of increasing maternal breastmilk supply.

Thanks for the  various inputs from members,it would be good to first consult from your national protocol and how is your programming  as for Uganda we have integrated management of acute malnutrition where we have   4 components; inpatient therapeutic care(management of SAM with medical complications  and  anorexia),outpatient therapeutic care (management of SAM without complications and appetite presence),community nutrition(active case screening ,mobilisation  and linkages) and finally supplementary feeding care(only in emmergencies ,or GAM rate of >15  +aggravating factors usually in refugee settlements ,it can be targetted or blanket supplementary feeding ,in your case if its BSFC then you can go ahead and supplement the mother whose child I  guess in this case is on your OTC program, In some settings especially for refugee settlements WFP  implement  a project on prevention  of  stunting usually called MCHN i.e maternal  child health nutrition along side TSFP where mothers attending ANC(0-9months and 6months postpartum receive super cereal ++ or corn soya blend ++ irregardless of their nutrition status and attention is turned to the child immediately complementary feeding is commenced at 6months to 23months(first 1000days of life), so there is nothing totally wrong with supplementing a mothers diet but it shouldnt be on bases of increasing maternal breastmilk supply.

@Vukoni, Thanks for your input.

Hi, Thanks for the question 

• First assess the household and reason for SAM / MAM in a child 
• Don't forget to check the child for IDDM , and get the routine blood test done for the child. Even if there won't be complications but Juvenile Diabetes is also one of the leading cause for SAM/MAM. Advise mother also to run for Blood Routine. 

1. SAM/ MAM Children without any complications are preferentially given community based management treatment which includes focus on time and active breast feeding as well as follow up of immunization schedules and WASH practices. 

2. Mothers Nutritional needs should also be assessed , also check for househols food security and mother should be taking her IFA supplements and Calcium supplements.

3. Focus on diet diversification and yes fortified foods add on the supplements. 

4. Mother might seem nutritionally okay but might have anaemia or other micronutrient deficiencies. 

5. fortnightly follow up of such cases is important. 

since i am not aware of your geographic location i would have given you a more concrete reply. 

@ Purnima Thakur, Thanks for the response.

Dear Anonymous

Thank you for the very important question you raised about management of these nutritionally at risk infants under 6 months and their mothers.  I'd like to highlight the MAMI Care Pathway Package which is a resource material that helps guide through assessment and care of the mother-infant pair, and is particularly suitable for outpatient management.  It supports implementation of intergrated management of childhood illnesses, has valuable resource materials to support breastfeeding counselling (eg counselling cards to address specific problems and concerns), and has core support topics on crying, sleep, maternal mental wellbeing, complementary feeding, and family and community support.  If you have further questions about applying it in your context, do not hesitate to contact us. If you could share what country you are based in, we may be able to connect you to other practitioners local to you through the MAMI Global Network.

Dear Purnima

Thank you very much for taking the time to respond to the question.  Can I ask regarding your assertion that juvenile diabetes is a leading cause of SAM and MAM in infants under 6 months of age? Could you share the evidence on which this is based? I have never seen this evidenced nor has it been my experience or others that I have spoken to who work with this age group.  Many thanks

@Marie McGrath Thanks for your response and the MAMI care pathway package.

My current location is Kenya. 

Dear Anonymous, many thanks for sharing.  I have connected you offline to expert support in Kenya. Best regards, Marie

As a nutritionist...first, breast milk is the product of the nutritional elements the mother takes in. The milk produced by the child’s mother may not contain the nutrients necessary for the child’s growth, especially proteins, meaning the mother’s diet may lack the amount of foods that contain proteins, especially as we as nutrition specialists recommend increasing it. 25 grams of protein above the mother’s need... We recommend that the mother eat a special meal that contains protein - eat at least one meal per day that includes a source of protein, salad

 Green grains, such as corn or rice, and cooked vegetables such as potatoes and carrots... Secondly, it may be related to the situation and other reasons that colleagues mentioned previously... And perhaps there may be an organic disease or a physiological defect, such as a defect in the metabolism process...

Thank you @Mohammed Asufu for your reply

In the scenario you described, if the mother is already adequately nourished and breastfeeding exclusively, it may not be necessary to provide her with a nutritional supplement such as fortified blended flour (e.g., Advantage). Breast milk is the optimal source of nutrition for infants under six months of age, and as long as the mother is practicing proper lactation practices, including maintaining a healthy diet, positioning, and attachment, the infant should receive all the nutrients they need from breast milk alone.

In conclusion, while fortified blended flour or other nutritional supplements may be appropriate for certain populations or situations with high food insecurity emergency ect. it is generally not advisable to provide them to breastfeeding mothers who are already adequately nourished and practicing exclusive breastfeeding. Instead, efforts should focus on supporting and promoting breastfeeding practices to ensure the optimal health and development of infants.

“A mother's capacity to produce milk of sufficient quantity and quality to support infant growth is resilient and is generally independent of maternal nutrient intake.” https://www.uptodate.com/contents/maternal-nutrition-during-lactation Malnourished mothers CAN breastfeed. Studies have found NO difference in the quality or quantity of breastmilk of malnourished mothers, compared to well-nourished mothers. The studies that do find significant difference are INDUSTRY studies that are highly bias and spread propaganda for their profiteering. In all but the most extreme cases, malnourished mothers can follow the same recommendations for breastfeeding as mothers who are not malnourished. Since mothers lose around 500 calories a day breastfeeding, mothers need additional support for nutritious local foods for their OWN health and well being, and malnutrition increases risks of dying in childbirth, so it’s best practice to support maternal nutrition, while also protecting, promoting and supporting breastfeeding. The practice of "First Do No Harm" is imperative. I am currently noticing so much pushing of infant formula and maternal formulas on poor malnourished mothers, which risks DOUBLE malnutrition - that of the child AND mother, contributing to TWO cases of malnourished people in the family instead of one. Pushing of formula on malnourished mothers also increases her risks of breast cancer, ovarian cancer, diabetes and much more, as well as many child illness, childhood cancers and risks child AND maternal mortality. It is vital that we reclaim and protect indigenous nutritious foods, because many of the malnourished mothers I'm seeing are actually consuming Western multinational ultra processed products, that are in fact contributing to their maternal malnutrition. New products coming on the market such as maternal formulas are being marketed to pregnant, and lactating mothers, so they fill up on these costly products instead of their traditional healthy foods. Industry are causing great harm not only to health, but food sovereignty and exploiting mothers, especially malnourished mothers.

Dear Margret, please share the studies supporting the observation  "Malnourished mothers CAN breastfeed. Studies have found NO difference in the quality or quantity of breastmilk of malnourished mothers, compared to well-nourished mothers." In my experience maternal malnutrition matters for lactation and are part of the risk  for intergenerational malnutrition.

Hi Michael,

As I said earlier, maternal nutrition matters. Being malnurished increases risk of death in childbirth, and breastfeeding increases the nutritional needs of mothers. Therefore, best practice is to support the mother in improving maternal nutrition, while supporting breastfeeding. If you scroll up to the earlier communications on this thread, you will find lots of great references from colleagues and I'll add some additional ones below. It’s important to be aware, that the problem with much of the current research on breastmilk composition (quality/quantity) is that the studies are being conducted by/for the formula companies. Often these studies do not even disclose conflicts of interest. And just to be clear, the burden of proof should not be on our mothers and their breastmilk, but on the artificial alternatives. I hope this is helpful.

Magdalena

Human Milk output among mothers previously treated for severe acute malnutrition in childhood in Democratic Republic of Congo.

“We found no significant difference in human milk output and body composition in mothers treated for SAM during childhood compared to community controls.”

https://bmcnutr.biomedcentral.com/articles/10.1186/s40795-021-00467-7

“Variations in the diet of the mother may result in changes in the fatty acid profile and levels of certain micronutrients, but they are not associated with the volume or quality of the milk produced. The milk of all mothers, even those that are malnourished, has an excellent nutritional and immunological quality. The mother's body always prioritises the needs of the baby, and consequently most nutrients, such as iron, zinc, folate, calcium and copper continue to be excreted in breast milk in adequate and constant amounts, at the expense of maternal stores. In the event of famines and disasters, and when there is risk of child malnutrition, the approach recommended by the WHO is to support breastfeeding, which guarantees the correct development of the baby, and to supplement the diet of the mother”.

https://www.sciencedirect.com/science/article/abs/pii/S2341287916300643

“A mother's capacity to produce milk of sufficient quantity and quality to support infant growth is resilient and is generally independent of maternal nutrient intake.” 

https://www.uptodate.com/contents/maternal-nutrition-during-lactation

Agreed! - My point was: a malnourished mother will not be able to optimally breastfeed her baby without a price. This holds true even when lactation provides nutrients to the baby at the costs of the mother, e.g. iron. Probably, I misunderstood the previous answer as suggesting presently malnourished mothers could breastfeed well. Maternal health is for the infant as important as its own health.   

Thank you@ Najma Ayub @ Magdalena Whoolery @ Michael Krawinkel for your inputs.

Thank you members for your inputs on this subject; quite impressive discussions and learning. I appreciate

In our setting we often get mothers who complain that they don't produce enough breast milk. As I understand the baby's weight is the ultimate judge if that is really the case, and I often do see the dropped centiles, even in well nourished mothers. 

A few questions

1)Is there any role for manual expression or electric pumping to try and "see" if there really is no milk?

2)Has anyone had any success in using galactogogues (?Metoclopramide?) or other  supplements to boost milk supply in well nourished mothers?

3)Is there a basic breastfeeding counselor course, aimed at the level of community healthcare workers / clinic nurses in low resource settings, that anyone can recommend?

Thank you in advance 

It is important to check if the breastfeeding is really going well, recognize a shallow latch or an infant not stimulatting enough or not having often enough access to the breast see answer of Pamela Morrison. Margaret presented alrady some evidence more can be found in the book Breastfeedîng for the medical profession by Lawrence. WHO advise to support breastfeeding an dfeed the mother if needed.