Weight Gain in the Newborn and Young Infant

on February 26, 2014 in Breastfeeding, Weight Gain in the Newborn and Young Infant

The healthy breastfed newborn infant is born with extra fluids on board at birth, and when he begins nursing receives small amounts of colostrum.  Colostrum is important in providing the baby with protective antibodies as well as sealing the gut from harmful pathogens.  Colostrum also stimulates the passing of the black meconium stools, helping to rid the body of biliruben, the substance that leads to jaundice.

These small amounts of early milk are helpful in other ways.  The breasts are soft and pliable making latch-on easier than when the breasts are full and sometimes more difficult to assist the baby deeply onto the breast.  This gives both mother and baby time to practice the techniques of a comfortable latch.

The ideal time for the first nursing, is in the first hours following birth.  Thereafter, most newborns fall into a deep sleep and may be more difficult to rouse.  When babies are successful at latching right after birth, they are more likely to continue feeding well, but may need to be wakened every couple of hours to nurse during the first couple of days.  When nursings are frequent, the baby is more likely to have minimal weight loss, mature milk production begins close to 72 hours post partum, and the risk of developing jaundice lessens.

Most all newborns lose weight following birth.  While some professionals believe a weight loss of up to 8% is normal, others are comfortable with a weight loss of up to 10%.  Loosing 10% or more of birth weight may be a red flag that the baby has lost too much weight, which can lead to dehydration, jaundice and poor feeding.

An excessive weight loss can occur because of several problems like infrequent nursings, a poor latch, or a delay in mature milk production due to long labors with the use of multiple bags of IV fluids. Excessive weight loss can also occur if the mother has had a previous breast surgery involving an incision around the areola, has very large nipples, (as large or larger than a quarter), or when the latch is ineffective due to flat or inverted nipples.  Some mothers may have insufficient glandular tissue (breasts that did not grow during pregnancy, that are widely spaced, and have a flat space in between their breasts of an inch or more). Retained placental fragments are another possible, although uncommon, cause. It is thought that the hormones secreted by even small placental parts still attached to the uterine wall can keep the milk from coming in. Suspect retained placental fragments if you experienced postpartum hemorrhage or if, since the birth, you’ve had some of these symptoms: cramping, heavy bleeding, passing of tissue, foul-smelling lochia, and fever.  Some infants are ineffective at the breast if they have oral abnormalities such as tongue-ties, excessively recessed lower jaws, or high palates. Or rarely, a baby may not gain weight if the baby is sick or has medical problem.

When this happens, many doctors will want to begin using supplemental formula to prevent dehydration and jaundice.  Offering formula after nursings may lead to problems for the breastfeeding relationship if the baby starts to prefer the fast flow of milk from a bottle and the lack of frequent feedings at the breast, which is common, as formula takes much longer to digest.  But some infants who are offered formula by bottle may still be willing to feed at the breast until milk production begins and the baby becomes more vigorous at the breast.

While a baby may require additional calories if they have lost an excessive amount of weight, they can be offered colostrum or breastmilk and any additional necessary formula after nursings or breastfeeding attempts in other ways.  Hand expressing colostrum or breastmilk and pumping after feedings is strongly recommended.  This milk can be fed to the baby by spoon or syringe.  Some lactation professionals suggest offering extra necessary milk by using a tiny tube placed along side the nipple leading down from a small bottle, referred to as a “supplementer”.

Expressing milk by hand may be more effective for some women than pumping; especially before mature milk production begins.  You can learn the technique of hand expression taught by Dr. Jane Morton at Stanford University by watching her video at http://newborns.stanford.edu/Breastfeeding/FifteenMinuteHelper.html Click on “Hand Expressing Milk” to watch her technique.

A baby who is 24 hours old only needs a teaspoon of milk at each feeding.  A 48-hour-old baby needs about ½ ounce of milk at each feeding and a 72-hour-old newborn needs about an ounce per feeding.  A four day old requires about 1-½ ounces per feeding.  On day five, the amount needed is more closely associated to his weight; a 7-pound baby requires about 2 ½ ounces per feed; an 8 or 9 pound baby needs closer to 3 ounces per feeding.

If a baby is not feeding well at the time of discharge, the mother should make arrangements to get a “clinical grade” breast pump; that is a rental pump with a double collection kit, rather than a “Personal Use” pump that may be less effective at draining the breast.  She should also be set up with follow-up appointments with lactation professional. Most insurance companies pay for this help. If a mother is not given the name of someone, she can find the names of local lactation professionals at ILCA.org.  Just scroll down to “Find a Lactation Consultant” and follow the instructions. If a mother receives WIC benefits, there may be a lactation consultant on staff who can help.

When a baby has only lost several ounces following birth, they should continue to do well so long as mature milk production begins close to 72 hours post partum.  There after the signs that a baby is getting plenty of milk include having frequent stools and that the stools are yellow by the 5th day post partum.

After the 5th day post partum, babies should be gaining about an ounce per day and achieving birth weight some time between 10-14 days of life.  While a few doctors are satisfied with a 2 week old not regaining their birth weight, this should be investigated.  Gaining nothing or gaining only a half-ounce a day in the early weeks, means the baby is not getting a sufficient amount of milk. It has nothing to do with not getting enough of the fatty milk; it has to do with not getting enough to eat.  Gaining an ounce a day is normal and healthy until a baby is older, until around 3 to 4 months of age.

I see many mothers who give on-line advise and even a few doctors, to accept inadequate weight gain.  If you have a young infant, less than three to four months old that is gaining slowly, this has nothing to do with a baby’s genetic size. Others may reassure mothers that so long as a baby is peeing and stooling daily, all is well.  I have seen babies who are two pounds below birth weight and they are often still making urine and are stooling, but this has no relation to whether they are getting sufficient amounts of milk.

Reaching out to mother-to mother breastfeeding sites can in some instances do more harm than good.  Know that most breastfed infants gain rapidly in the early months and then begin to slow down their weight gain sometime after three to four months of age, typically revealing their genetic size.
If on the other hand, a baby gains slowly in the early months of nursing, plot out the baby’s weights on the World Health Breastfeeding (WHO) Charts.  You can find these charts on http://www.cdc.gov/growthcharts/clinical_charts.htm Scroll down to “Set 2: Clinical charts with 3rd and 97th percentiles” for either boys or girls and using the colored charts you can follow your baby’s growth pattern.  There you can see how gaining a half ounce a day or less, will show the drop off of the weight percentiles. Babies who are not gaining weight as expected, should be evaluated by a lactation consultant who can find possible reasons why the baby is not gaining weigh as expected.

Even if a newborn regained their birth weight by two weeks of age, some may fail to gain weight later on. Babies after the first several weeks may not give early feeding clues like newborns do, rooting and fussing, and the number of number of feedings may be stretched out too much and fall below seven times a day.  Some babies may also begin sleeping long stretches at night. When the number of feedings falls below seven in a 24-hour period, milk production can slow down too much.  When babies begin finger sucking or begin relying too much on pacifiers when they are hungry, this can happen.  After the first several weeks, crying may be a late hunger cue, so putting a pacifier away and watching for finger sucking can help identify when the baby is hungry and needs to be fed.

Babies with reflux may pull on and off the breast or may cry at the breast and not drink enough milk at feedings.  Reflux may be caused by sensitivities or allergies to certain foods in a mother’s diet.

Some mothers with certain conditions such as hypothyroidism or mothers, who get sick with a bad cold, or vomiting and diarrhea, leading to dehydration, can cause the milk supply to quickly decrease.

Mothers who are employed outside of the home may lower their milk supply when using a poor grade electric pump, and may be using a flange size that is too small, or mothers who are not pumping often enough during their workday.  A mother who has returned to work or school may have difficulty getting in seven breast empyings, if they are not nursing or pumping often enough.

Visiting a lactation consultant who can take a thorough history, will be able to determine how much milk a baby is transferring at the breast and what measures can be taken to increase the amount of milk that the baby requires.  There are many ways to increase milk production and milk transfer.  Increasing the number of feeds, pumping after some or all of the nursings and the use of herbal remedies or even medications can be very helpful in turning the baby’s weight in the right direction.