Newborn Weight Loss

I just want to scream when doctors say a baby has lost too much weight and instead of getting the mom a great lactation support system in place, they demand the use of formula! There are a lot of criteria to look at! The first is an amazing article about whether the mom had a lot of IV fluids in labor:

Newborn Weight Loss and IV Fluids in Labor
Monday, October 31, 2011 at 8:15PM
Nancy Mohrbacher in Useful Breastfeeding Research

Until now, weight loss during the first 3 to 4 days after birth has been considered one indicator of how early breastfeeding is going.  If on Day 4 a newborn’s weight loss is in the average range of 5% to 7%, this usually means breastfeeding is going well.   Nearly all babies lose some weight after birth, because after floating in amniotic fluid for 9 months, they are born waterlogged.  Normal weight loss comes from the shedding of this excess fluid as they adjust to life on the drier outside.

But when babies lose more than 7% of birth weight during these early days, does this automatically mean they are not getting enough milk?  No, according to a recent study.

A greater weight loss may be completely unrelated to breastfeeding and due instead to excess IV fluids mothers receive within the final 2 hours before delivery.  According to this study, these excess IV fluids inflate babies’ birth weight in utero and act as a diuretic after birth.  Babies whose mothers received more IV fluids before birth urinated more during their first 24 hours and as a result lost more weight.  Number of wet diapers during the first 24 hours predicted infant weight loss.  This was true whether the babies were born vaginally or by c-section.  Another study published earlier this year had similar findings.

This weight loss has nothing whatsoever to do with breastfeeding and milk intake.  In fact, the authors suggest that if clinicians want to use weight loss as a gauge of milk intake, they calculate baby’s weight loss not from birth weight, but from their weight at 24 hours.  According to their findings, this could neutralize the effect of the mother’s IV fluids on newborn weight loss.

This is one more reason weight loss alone should not be used to determine when newborns need formula supplements.   The Academy of Breastfeeding Medicine put this well in one of its protocols: “Weight loss in the range of 8-10% may be within normal limits….If all else is going well and the physical exam is normal, it is an indication for careful assessment and possible breastfeeding assistance.”

Article originally appeared on Breastfeeding Answers Made Simple (http://www.nancymohrbacher.com/).

See website for complete article licensing information.
The second is how supportive the pediatrician or neonatologist is to breastfeeding to begin with. I have a mom of twins battling the ability to fully nourish twins without supplementation going on right now. The doctor has a hidden agenda to begin with. She suggested that it was good for the dad to offer a bottle to his sons. Is that her decision? NO! It is the mom’s decision to feed her baby the way she chooses. The weight gain was not the doctor’s primary concern- iit was that she did not believe a mom could nurse twins exclusively. That is stinking thinking! And it has no place in evidence practiced medicine! This is a great article about how pediatric policy can make a difference in this!

Can a Change in Pediatric Office Policy Begin to Change the Culture of Infant Feeding?

Written by Jennie Bever Babendure, PhD, IBCLC

In the February issue of Breastfeeding Medicine, Ann M. Witt and her colleagues analyze the impact of integrating lactation consultants into a pediatric practice1.  Although providing referral to or in-office lactation services if requested is not a new idea, what makes this study unique is the systematic change made to schedule ALL breastfeeding newborns with a lactation consultant for their first pediatric office visit.

How did this work?  At the time of the study, the American Academy of Pediatrics (AAP) policy dictated that all healthy term breastfeeding infants be seen at the pediatric office within 3-5 days of hospital discharge2.  In 2009, the study practice changed their policy to routinely schedule these visits with an in-office IBCLC precepted by a physician.  IBCLC’s spent 45-60 minutes with the patient, then discussed the history and breastfeeding evaluation with an available physician who spent about 5 minutes in the room evaluating the patient and deciding on a treatment plan.   Follow up phone calls and in-person visits were scheduled, as well as a routine visit with the primary physician at 2 weeks of age.  More than 45% of patients had multiple visits with a practice IBCLC, and a limited survey indicated high maternal satisfaction with the new policy.  IBCLC’s were employed 4 hours a day 5 days a week in the practice to meet the need for these visits and follow up.  As the physician evaluated the patient at the 3-5 day visit, it was reimbursed as a general medical visit, which sufficiently covered IBCLC salaries.

How did this impact breastfeeding?  In 2007, all infants were seen in the office by 2 weeks of age unless jaundice or weight gain problems were identified in the hospital.  The practice employed an RN, IBCLC 3 days a week to provide phone support for breastfeeding problems as well as in-person consultations.   When researchers compared infant feeding method  in retrospective chart review between 2007 and 2009 patients, they found that non-formula feeding (breastfeeding) went up by 10-15% at all time points from 2-9 months, demonstrating a significant increase in breastfeeding intensity following the intervention.

When I first read this study, I was struck by the brilliant simplicity of this idea.  By integrating lactation consultants into the existing medical structure,mothers and babies got automatic breastfeeding help and follow-up, and physicians could follow AAP policy and monitor jaundice and weight gain as well have a large influence on the on-going health of their patients with minimal input of time or cost and no additional formal training.  As I continued to think about this study, I realized that this policy has a much broader impact.  By making this systematic change to their office policythey have changed the culture of infant feeding in their practice.  Routinely scheduling the first office visit with an IBCLC sends a strong message to patients.  It says:  “Your physicians know you want to breastfeed, and feel breastfeeding is so important to your child’s health that we will do everything we can to help you through the challenges.”

I can’t help but imagine the impact if all pediatric practices were to adopt this model.  Would these actions speak louder than our words?  Would they whisper or shout:Breastfeeding is a public health issue3, we’re here to help you make it happen.

1.  Witt AM SS, Mason MJ, Flocke SA., Source1 Department of Family Medicine CWRU, Cleveland, Ohio. Integrating routine lactation consultant support into a pediatric practice.Breastfeeding Medicine 2012;7(1):38-42.

2.  BREASTFEEDING SO. Breastfeeding and the Use of Human Milk. Pediatrics2005;115(2):496-506.

3.  BREASTFEEDING SO. Breastfeeding and the Use of Human Milk. Pediatrics2012;129(3):e827-e841.

Jennie Bever Babendure, PhD, IBCLC

I am a mother of 2 active boys and an Assistant Research Professor in the College of Nursing and Health Innovation at Arizona State University. As breastfeeding researcher, I am constantly scanning the literature for articles that guide my research and inform my clinical practice. One of my goals is to increase the evidence base of our profession as lactation consultants. I feel it is important for lactation professionals to be aware of and contribute to breastfeeding research, especially when so much of it is fascinating! As an ongoing contributor to Lactation Matters, it is my hope that you will find the articles I highlight as interesting and informative as I do, and that you will use them to guide you in the important work of lactation professionals and breastfeeding advocates.

And then there is the whole let’s look at the baby rather than the scale approach. I had a mom recently who brought me her baby who looked vigorous and healthy. He had plenty of wet diapers and was now having sporadic poopy diapers. The pediatrician wanted him weaned from the breasts and only fed formula for the week to determine if the mom had a nutritional imbalance in her milk or if the baby had a metabolic issue. She pumped and gave the baby formula and also breast milk and pacified the baby at the breasts. He gained beautifully. By the way the mom looked like she was also the picture of health. The pediatrician said she could go back to nursing the baby full time. It is a miracle that the latch did not become an issue with this type of interference.  But I love Dr. Jay Gordon’s approach:

Feb 23, 2010
Look at the Baby, Not the Scale

It sounds simple doesn’t it? Yet I have seen so many moms whose babies have looked healthy, nursed well, met developmental milestones one right after the other and have lost all confidence in breastfeeding due to someone telling them that their baby’s weight was not on the charts. This someone was looking at the scale and charts, rather than the baby.

In the first 24 to 72 hours after birth babies tend to lose about 3-10% of their birth weight and then regain that weight over the next 2 to 3 weeks. If a mother receives lots of IV fluids during labor, the baby could be born “heavier” because of the increased water. The somewhat higher weight could be measured if a baby were weighed right before it peed for the first time. The difference of this extra fluid retention might only be a few ounces, but some parents are told to be concerned when, at their baby’s two week checkup, the baby is a few ounces under birth weight.

Another common problem at early checkups is a baby that is not gaining what the practitioner considers to be “normal weight gain.” There is not general agreement on normal weight gain and the range in texts are from 4 to 8 ounces a week. Some babies are genetically destined to be a lot smaller or larger than others. As I mentioned in the first paragraph: Easy concept, isn’t it?

If you have been told that weight gain is not acceptable, look hard at this list of questions:

  • Is your baby eager to nurse?
  • Is your baby peeing and pooping well?
  • Is your baby’s urine either clear or very pale yellow?
  • Are your baby’s eyes bright and alert?
  • Is your baby’s skin a healthy color and texture?
  • Is your baby moving its arms and legs vigorously?
  • Are baby’s nails growing?
  • Is your baby meeting developmental milestones?
  • Is your baby’s overall disposition happy and playful?
  • Yes, your baby sleeps a lot, but when your baby is awake does he have periods of being very alert?

If you have answered yes to the above questions, you may want to progress on to two important questions which the “charts” seem to ignore.

  • How tall is mom?
  • How tall is dad?

If someone were to ask you what weight a 33 year old man should be, you would laugh. The range of possibilities varies according to height, bone structure, ethnicity and many other factors. Yet babies are expected to fit onto charts distributed throughout the country with no regard to genetics, feeding choice or almost anything else.

There can be nursing problems that can cause slow weight gain; an inadequate “latch-on” is probably the only common breastfeeding problem in the first weeks. This is an easily remedied problem with the right help. In the best of circumstances, breastfeeding should be assessed within the first day or two after birth by a skilled lactation expert. Good hospitals have these LC’s and IBCLC’s on staff and, if not, please line up a consultation within the first 12 hours of life. Your pediatrician can help you with this. If not, call La Leche League and ask them whom they recommend in your area. This is a crucial step in becoming a parent and must not be skipped.

If there are nursing problems, the first answer should never be supplementation but must be to find the best advice and help available. Find quality help in person if possible and online if needed. There is nothing better than having an experienced breastfeeding expert watch you and your baby and give you the help and encouragement and support you need and deserve.
Too many mothers and babies lose the breastfeeding experience and the lifesaving and illness preventing benefits because we doctors are trained to look harder at the scale than we are at the baby.

A few notable examples:

  • Baby, birth weight: 9 lbs. 12 oz.
    Weight 36 hours after delivery: 9 lbs. 2 oz.

I have seen mothers encouraged to supplement because “they have no milk, the baby is hungry and losing weight.” The baby looks good and is nursing every 1 to 3 hours and mom’s nipples are not getting sore. There is no need to do anything but nurse often, switch breasts every 5 minutes or so and wait another day or two for the milk to come in. A thirsty baby nurses strongly and is in no danger. A baby given water or formula might not nurse so strongly and mom’s confidence (and milk supply) will suffer for it. This mom only needs the support of an expert who can be sure that she knows how to latch her baby on to the breast.

  • Same baby, two week checkup: 9 lbs. 6 oz

Forgetting that this represents a 4 oz. weight gain from the 36 hour weight, some docs might recommend supplementation. Again, watch breastfeeding and if everything is going well, don’t worry. A dry, jaundiced baby with darker yellow urine is a different case and needs more help with nursing. This baby still should not get formula. Make sure mom is drinking enough water, nursing often without a set schedule (every 1 to 3 hours) and make very sure that she gets help latching her baby on, especially if she has sore nipples.

  • Same baby, six month checkup: 15 lbs.

Lactation consultation had been successful in the early weeks thanks to mom having found a supportive, smart doctor and being determined to succeed at feeding her baby the best. This big baby (9 lbs. 12 oz. at birth, remember?) had weighed 13 pounds at her four month visit and now weighs 15 pounds. The doctor is paying attention and sees that Mom is 5′ 3″ and Dad is 5′ 9″ and slender. He looks at the charts second and the baby first and isn’t concerned about the baby dropping from a very high percentile at birth to a lower one and then to a lower one still.

I think I’ll conclude this scenario with this happy ending.

In summary, babies who are nursing, peeing clear urine and wetting diapers well in the first weeks of life are almost always all right. I cannot recall seeing a baby for whom slow weight gain in the first 2 to 6 weeks was the only sign of a problem.

Older babies, 2 to 12 months of age, grow at varying rates. Weight gain should not be used as a major criterion of good health. Developmental milestones and interaction with parents and others are more important. Do not be persuaded to supplement a baby who is doing well. Get help with breastfeeding and use other things besides weight to guide you.

I think parents should print this blog article out and take it with them to the hospital and to their pediatrician’s office. If weight gain becomes an issue- let’s look at the experts. Let’s look at folks who are practicing evidence based medicine instead of barking out neanderthal statements that are not based on evidence but instead often times their own ideas and prejudices.

And here is another article about this very thing  The significance of weight loss in the first few days after birth.

The numbers are staggering!

“The American Academy of Pediatrics recommends that healthy, term infants who have a weight loss of 7% from birth, should have their feeding assessed and that providers should “consider more frequent follow-up.”  Hopefully, we are looking at the feeding of any newborn, frequent follow up is standard of care where you are and the AAP’s suggestion is reinforcing best practices and not breaking new ground. If not, you have an opportunity to change the world.

That 7% value seems to be a standard trigger for increased attention to a baby’s feeding.  And unfortunately, 10% weight loss seems to be the trigger for supplementationBut excessive weight loss, typically defined as weight loss greater than or equal to 10% of birth weight,  is actually pretty common. Losing 10% of birth weight is common? Yes, and 7% is likely a normal, average weight loss.

In a study by Chantry et al, the authors found that 19% of exclusively breastfed infants experienced excessive weight loss in the first 3 days of life, but by day 7 most babies had regained that weight.  They also determined, in what we will see is a common theme, that intrapartum IV fluids were an independent risk factor for excessive weight loss. An independent risk factor is one that can cause the outcome regardless of other factors, so, in this study, intrapartum  IV fluid could cause newborn weight loss all by itself.”

and this…”

One way to assess adequate transfer of breastmilk is to monitor stool output.   Urine output is usually a good way to monitor fluid intake, but if our baby is going to be peeing off lots of fluid from birth interventions, urine output may be great.  In fact, the urine output might be awesome.  But, in the first few days after birth, the urine output maybe artificially good as the baby becomes less of a water balloon. So, what did not get messed up by delivery?  Poop.

Colostrum is full of oligosaccharides: prebiotic, non-digestible sugars that play a crucial role in the development of the neonatal immune system.  Since oligosaccharides are abundant in milk and are non-digestible, the more the baby gets, the more poop there is. The more milk the baby gets, the more stool output.  We can use stool output as a good marker of the adequacy of breastfeeding. We would like to see the baby clear all the meconium by 4-5 days of life (maybe a day later for babies born via C-section).

Weight can also be influenced by which scale we use, under what conditions the baby is weighed (dressed, naked?), and whether they have just eaten, peed or pooped (every ounce counts!) before we put them on the scale. We can also look at the trend in weight loss over time.  If a baby has lost 10% in 72 hours, what was the pattern of the weight loss?  If the baby experienced a normal fluid diuresis, the weight loss pattern may have been 8% in the first 36 hours and only 2 % since.”