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Lactation & Breastfeeding
Magazine of the European Lactation Consultants Alliance • www.elacta.eu • ISSN 1614-807x
COVER STORY COVER STORY COVER STORY
Neonatal weight A Growthchart Nutrition and Weight Development
changes – Seite 4 is but a Chart – Seite 12 of Premature Infants – Seite 19 2 • 2019 32nd Volume
Photo: Field exchange 48
2 EDITORIAL
EDITORIAL
Dear members,
dear colleagues,
IMPRINT
Company Information:
ELACTA European Lactation Consultants
Alliance
www.elacta.eu
Magazin: www.elacta-magazine.eu
Email: magazin@elacta.eu
ZVR-Nr.: 708420941
ELACTA president:
Karin Tiktak, IBCLC
president@elacta.eu
Editorial and project coordination:
Eva Bogensperger-Hezel, IBCLC
The summer and the holiday season are coming and with it the Email: magazin@elacta.eu
peace and quiet and the opportunity to read this interesting Team:
edition of Lactation & Breastfeeding. Andrea Hemmelmayr, IBCLC,
ELACTA illustrates its association work with reports of a meet- Elke Cramer, Ärztin, IBCLC,
Dr. phil. Zsuzsa Bauer,
ing with the BDL in Fulda, a visit to Daventry UK where we met Bärbel Waldura, IBCLC,
representatives of our member association LCGB, a visit to IPD Julia Glantschnig
in Slovakia and a meeting with DACLC members in Copenha- Gudrun von der Ohe, Ärztin, IBCLC
gen. And last but not least we had a successful event CERPs Translations:
International in beautiful Bled in Slovenia. Elizabeth Hormann, IBCLC,
Annika Cramer, Catherine Pilgram,
As IBCLCs, we are concerned with weight development in all Marion Kenny, Martina Hezel
its facets: in the first days of life, later on, in special situations
Advertising:marketing@elacta.eu
such as the care of premature babies and children with trisomy
21. We need many instruments and skills to support mothers Photos: © as mentioned on the photos;
Coverphoto: © iStock.com/didesign021
in their desire to breastfeed, even when they have problems: be Note: The stock photos used are symbol
it the correct use of baby scales, the decision which reference photos; the pictured models do not suffer
curves to use for the benefit of mother and child, and above from the symptoms possibly described in
the respective articles
all how to communicate hurdles and offers of help without dis-
couraging mothers. Layout: Christoph Rossmeissl
We don‘t need to tell any more: the interest should be aroused Published quaterly at the end of March,
in order to leaf through the pages and start reading. June, September and December
Deadline: 15 January, 15 April, 15 July,
Enjoy! 15 October
With its articles, Lactation and
Karin Tiktak The editorial team Breastfeeding wants to go beyond expert
information about breastfeeding and
President of ELACTA also stimulate discussion. Therefore, we
welcome your views. Please send Letters
to the Editor to the following email
address: magazin@elacta.eu
PLEASE NOTE:
The articles published in Lactation
and Breastfeeding do not necessarily
reflect the opinions of the editors or of
ELACTA. Rather, they are the author’s
own personal viewsThis PDF may not
be passed on to colleagues or other
people, published in the internet, or
reproduced in any form without the
explicit permission of the editorial team.
Violations will be prosecuted.
www.elacta.eu Lactation & Breastfeeding 2 • 2019
CONTENTS 3
Photo: © IPD
2 EDITORIAL
4 COVER STORY
Neonatal Weight Changes
A Growthchart Is But a Chart
Photo: © Marica Bettinelli
17 HANDOUT
Weight Development
19 COVER STORY
Nutrition and Weight Development of
Premature Infants
29 P R A C T I C A L K N O W H O W
Improving Weight Gain in Premature
Infants Through Lactoengineering
Weight Gain Problems – Two Clinical
Cases
Weight Development in Children With
Trisomy 21
Which Baby Scale?
40 SCIENCE
Does Breastfeeding Protect Children
Photo: © Andrea Hemmelmayr From Becoming Overweight?
42 E L A C TA N E W S
Call For Action to ELACTA Member
Associations
Members - Goodbye and welcome!
11th European Conference of ELACTA
Elacta Board is Looking For New
Boardmembers in 2020!
44 F R O M M E M B E R A S S O C I AT I O N S
Visit to the Slovakian Association of
Lactation Consultants
NVL- the Netherlands.
Visit Report of the 10th Spanish
Breastfeeding Congress
Photo: © Marica Bettinelli ELACTA visited Lactation Consultant
Great Britain (LCGB) on 26-27th April
2019
4 COVER STORY
Neonatal Weight Changes
Meaning, determinants and clinical implications. Author: Diane DiTomasso PhD, RN
Photo:© Adobe Stock/RioPatuca Images
T he World Health Organiza-
tion (WHO) recommends exclu-
sive breastfeeding for the first six
include poverty, difficulty in accessing
health services, social marginalization,
maternal obesity, lack of workplace
Neonatal Weight Changes
Newborn weight loss is a normal phenom-
enon after birth. [4] Newborns receive small
months of life to achieve optimal support, marketing of breast-milk sub- amounts of colostrum from the breast dur-
growth, development and health.[1] stitutes and early use of complementa- ing the first two days of life. After secreto-
Breastfeeding initiation rates across ry foods.[2] Increasing evidence has sug- ry activation of breast milk begins, usually
the globe are currently 95 %.[2] Despite gested that concern about infant weight on the third day, most breastfed newborns
high initiation rates, data from 123 changes may also be contributing to low will begin to gain weight steadily.[6] New-
countries has showed that exclusive breastfeeding duration.[4,5] This review borns usually regain all lost birth weight
breastfeeding duration falls far short of will summarize findings from current by 10 days, although some will take 2 to
WHO recommendations.[3] In the WHO literature regarding expected neonatal 3 weeks to meet that goal.[5,7] Monitoring
European Region, only 25 % of infants weight changes for full-term breast- newborn weight is considered by many to
are exclusively breastfed for the first fed infants. Determinants of neonatal be one of the most accurate measures to
6 months.[3] Many factors contribute weight changes and associated clinical assess newborn health and adequacy of
to low breastfeeding duration; these implications will also be reviewed. feeding.[5,6] In spite of this, there is little
www.elacta.eu Lactation & Breastfeeding 2 • 2019
COVER STORY 5
consensus regarding the expected amount tremic dehydration (blood sodium level versely, early breastfeeding initiation
of neonatal weight loss after birth.[6] Con- ≥ 145 mEq/L), complications of which can (within 1 hour) and skin-to-skin care with
ventionally, weight loss up to 7 % of birth include renal and liver failure, disseminat- mother after birth contribute to less neo-
weight has been accepted as normal.[8-12] ed intravascular coagulation, intracranial natal weight loss.[36] Also, insufficient milk
When infants lose more than 7 % of birth hemorrhage, seizure, and death.[18-20] supply can cause weight loss. This some-
weight, careful evaluation of breastfeeding times develops because of breastfeeding
adequacy is recommended.[8,10,13] Often- Determinants of Newborn Weight difficulties or separation of mother and
times when weight loss is > 7 % formula Changes newborn.[37] Less common causes of inade-
supplementation is provided to help the in- Many factors impact newborn weight and quate milk supply include mammary hypo-
fant gain weight.[4,5,14] More recent studies, the percentage of weight loss after birth plasia, hypothyroidism, polycystic ovarian
however, have showed that healthy, full- (Table 1). Across the globe, males have syndrome, prior breast surgery, retained
term newborns may routinely lose > 7 %. consistently been heavier and taller than placenta, excessive blood loss and Shee-
Mean neonatal weight loss may be 8 % or females at birth, during infancy, and child- han’s syndrome. [38] Ill or jaundiced infants
more and it is not uncommon for some hood.[21-23] Ethnicity, race and genetics all are also at risk for increased weight loss or
infants to experience 10 % loss of body play a role in size at birth, the central regu- slow gain.[38,39]
weight after birth.[4,5,15] lation of food intake, and growth.[24-27] Ne-
For a small percentage of newborns, onatal weight loss is often increased with Infant Weight Loss
too much weight loss (> 10 %) may indicate advanced maternal age and education, In 2016 a systematic review of studies fo-
a problem. Potential breastfeeding prob- obesity,[28,29] depression,[30-31] lack of breast- cused on infant weight loss was conducted
lems may include poor latch at the breast, feeding experience,[5] female gender, pre- to determine the mean weight loss (MWL)
inadequate number of feedings or low maturity, small (< 2,500 grams), and large for healthy, full-term, exclusively breastfed
breast milk supply, infant metabolic disor- (> 4000 grams) gestational size at birth.[4,32] infants after birth. A previous review and
ders, or other morbidities that cause poor Increased intravenous fluid given during 9 primary studies published between 2008
feeding.[16,17] Newborn weight loss of 10 % labor [33,34] and cesarean (CS) birth[7,35] can and 2015 were examined.[6] MWL for new-
or more may be associated with hyperna- increase the amount of weight lost. Con- borns ranged widely among studies from
3.79 % to 8.6 %. Maximum weight loss
usually occurred 2 to 4 days after birth.[6]
Close examination of the studies, however,
revealed significant methodological flaws
Table 1. Determinants of Weight Loss for Breastfed Infants
in the research used to determine MWL.
The majority of infants in many of the sam-
Infant Care Practices: ple groups were only weighed during birth
• Gender • Method of delivery (vaginal delivery or hospitalization; for most, this was for only
• Race/ethnicity cesarean section) 1 or 2 days.[11,35,38-41] This made determining
• Genetics • Antepartum IV fluid
• Gestational age • Early breastfeeding initiation
a true nadir weight impossible as most in-
• Gestational weight • Skin to skin contact fants likely continued to lose weight after
• Jaundice • Mother/infant separation data collection ceased. At times, research-
• Other illnesses ers did not clearly identify if infants were
breastfed or formula fed,[11,40] and, in many
Maternal Maternal/Infant:
of the studies, exclusively breastfed infants
• Maternal: • Insufficient milk supply were combined with mixed and/or formula
• Age • Pain with feeding fed infants for analysis.[11,35,38-40] Patterns of
• Education • Poor latch
• Basal metabolic rate • Ineffective suckling weight loss and gain are markedly different
• Parity between breast and formula fed infants. In-
• Prior breastfeeding experience fants that are breastfed typically lose more
• Prior breast surgery weight in the first week of life compared
• Depression
• Medical conditions to formula-fed newborns.[13,42] In order to
-- Retained placenta determine accurate health outcomes asso-
-- Excessive blood loss ciated with infant feeding, different types
-- Sheehan’s syndrome
of feedings must be explicitly described.[43]
-- Hypothyroidism
-- Mammary hypoplasia Finally, in several studies focused on new-
-- Polycystic ovarian syndrome born weight, infants that required
formula supplementation for excess ›
6 COVER STORY
› weight loss were excluded from sample Northern Kaiser Permanente hospitals in the study. Second, the median hospital stay
groups.[35,44,45] This likely resulted in an California. [35] Daily weights were extract- was 1.5 and 2.6 days after vaginal and CS
underestimate of weight loss for breast- ed from inpatient electronic records and delivery, respectively.[35] Hospital discharge
fed newborns.[6] In this systematic review, from outpatient visits in the first month likely occurred before the nadir of weight
Thulier concluded that, due to the meth- of life. Differences in weight loss by de- loss was reached for many newborns. Both
odological flaws in the literature, MWL for livery method (vaginal or CS) became ev- of these limitations may have resulted in
breastfeeding infants was uncertain and ident 6 hours after delivery and persisted an underestimate of weight loss for exclu-
likely higher than had ever been reported.[6] over time. [35] Median percentage weight sively breastfed newborns.
Interestingly, several studies conducted loss for infants born vaginally was 7.1 % In 2017, Thulier conducted a retrospec-
during the past several years indicate that at 48 hours of age. Median weight loss for tive analysis of data from 286 women and
weight loss > 7 % may be a normal phe- infants born via CS was 8.6 % at 72 hours their term, breastfeeding newborns in a
nomenon for breastfed infants[4,6,35] (Ta- after delivery. [35] The authors concluded tertiary care center in New England.[4] The
ble 2). In 2015, Flaherman and colleagues that the nomograms presented could be aims of the study were to determine MWL
completed a large retrospective study to used for early identification of newborns and to examine the effect of weight loss
introduce early weight loss nomograms for on a trajectory for greater weight loss.[35] > 7 % on exclusive breastfeeding (EB) rates.
breastfed newborns. [35] The sample includ- Two important limitations were noted. [4]
Full-term singleton breastfed newborns
ed 108,907 exclusively breastfed, singleton First, breastfed infants who were given delivered by CS were included. Data were
infants, born at > 36 weeks gestation at formula for weight loss were excluded from collected by chart review from birth through
Table 2: Newborn Weight Studies
Feeding
Study Sample/Setting Number of Weights Weight Loss Findings Limitations
Method
Flaherman 108,907 healthy EB (100 %) Daily weights 7.1 % median loss at 48 hours 72 % of infants had only 2
et al singleton, Days 1–4 (VD). weights recorded.
2015 > 36 weeks, 8.6 % median loss at 72 hours Excluded infants who received
(retrospective) VD (77 %) (CS) formula due to excess weight
CS (23 %) loss.
Paul et al 143,889 healthy EB (63 %) 5 (4–6) weights in 30 5.9 % median loss at 61 hours Feeding type was not assessed
2016 singleton, MF (33 %) days (VD). (VD). after birth.
(retrospective) > 36 weeks, FF (4 %) 6 (5–7) weights in 30 7.1 % median loss at 68 hours
VD (76 %) days (CS) (CS). Weights were not taken daily
CS (24 %) Increases in weight occurred until the nadir was reached.
at a rate of 1.2 % (VD) and 1.1 %
(CS) daily.
Thulier 286 healthy, EB (53 %) 3–4 days daily weights 7.9 % + 2.2 % MWL for all Excluded vaginally born infants.
2017 singleton, PB (25 %) infants.
(retrospective) > 37 - 42 weeks, MF (22 %) 58 % (n = 165) lost > 7 %.
CS (100 %)
DiTomasso & 151 healthy, EB (70 %) Daily weights x 14 days 7.68 % + 2.35 % MWL for all Limited diversity in the sample
Paiva 2017 singleton, PB (20 %) or more infants. group.
(prospective) > 37 – 42 weeks, MF (9 %) 56 % (n = 84) lost > 7 %.
CS (33 %) Increases in weight occurred at
VD (67 %) a rate of 1.1 % daily.
Flaherman 83,344 healthy, EB (100 %) 5 (4–6) weights for 4 % median weight loss at 23 82 % of the sample had only
et al 2017 singleton each infant in the first hours (VD). 2 weights recorded prior to
(retrospective) > 36 weeks, 30 days 7.1 % median weight loss at 44 hospital discharge.
VD (76 %) hours (CS). Excluded infants who received
CS (24 %) formula due to excess weight
loss.
Note. VD = vaginal delivery; CS = cesarean section; MWL = mean weight loss; EB = exclusive breastfeeding; PB = predominant breastfeeding; MF = mixed feeding, FF = formula
feeding.
www.elacta.eu Lactation & Breastfeeding 2 • 2019
COVER STORY 7 days 3 or 4 of life.[4] MWL for all newborns In 2017, a prospective observational birth weight for all newborns in the study on day 3 was 7.9 % + 2.35 %. More than cohort design was conducted by DiTomas- ranged from 2.7 % to 13.4 % and MWL was half (58 %) of the newborns lost > 7 %. [4] In so & Paiva to determine MWL of new- 7.68 + 2.35 %. [5] The nadir usually occurred addition, newborns who lost < 7 % had lit- borns and to examine the effect of weight on day 3 when infants lost < 7 % and on tle change in EB, from 87 % to 80 % by day loss > 7 % on EB rates.[5] Participants in day 4 when infants lost > 7 %. More than 4. In contrast, EB rates in newborns who the study had given birth at a community half (56 %) of all the infants in the study lost > 7 % dropped markedly from 90 % to hospital in New England that had received lost > 7 %.[5] Infants born via CS lost more 53 % by day 4 of life (p < .001). [4] This ev- Baby-Friendly Hospital designation, in- weight and were more likely to lose > 7 % idence showed an alarming pattern of in- dicating that its policies promoted and compared to infants born vaginally (MWL creased formula supplementation among supported breastfeeding.[46] Mothers were 8.0 % + 2.3 % versus MWL 7.5 % + 2.1 %; newborns on and after day 3 of life when enrolled during hospitalization after birth p = .049). [5] From days 5–14, newborns weight loss was > 7 %. It was concluded that and were provided a digital scale to weigh gained a mean of 1.1 % body weight daily, weight loss > 7 % could be common among their newborns at home daily for 14 days. those who lost < 7 % gained 1.2 % daily, and full-term breastfed newborns. The greatest The sample included 151 mother–infant those who lost > 7 % gained 1.0 % daily. [5] limitation in this study was that only new- dyads; 135 of these dyads completed data By day 14, newborns who lost < 7 % had borns delivered by CS were included. Thus, collection for at least 14 days.[5] A total of an EB rate of 83 % compared to an EB rate results are not generalizable to newborns 101 infants were born vaginally (67 %) and of only 60 % for newborns who lost born vaginally.[4] 50 (33 %) were born via CS. The nadir of lost > 7 % (p < .01). The average time for › Advertising We support nursing mothers by offering a carefully selected collection of nursing bras. We invite hundreds of mums, who range in body type and breast size, to help us perfect our designs based on real-life around- the-clock use. In addition, we help expecting and new mothers on their way through pregnancy and lactation. With the advice from experts and other mothers on breastfeeding, healthy nutrition, fitness, health and mental well- being, we are happy to assist all mothers around the globe. For product and sales information: Caroline.Schnepp@f1-generation.com For marketing and PR: Celine.Assmann@f1-generation.com › www.bravadodesigns.com
8 COVER STORY
› newborns to resume birth weight was 10 visits in the first month. Results showed examine if it would discourage continued
days. By 2 weeks, 91 % of newborns had that 50 % of newborns were at or above breastfeeding.[55] When compared to two
surpassed birth weight.[5] The majority of birth weight at 9 and 10 days after vaginal local non-intervention groups, no negative
women who gave birth in this facility were and CS delivery, respectively. Among those effect on breastfeeding rates for the study
white, had private insurance, were married delivered vaginally, 86 % were back to birth population was found.[55] In another small
or partnered and had a college degree.[5] weight by 14. For the CS born infants, 76 % qualitative study (n = 8) of women’s expe-
This limited the representativeness of the were back to birth weight by 14 days.[7] riences using a pediatric scale in the home,
sample. The authors concluded that weight Increases in weight occurred at a rate of daily weight checks did not have negative
loss > 7 % is common and is an independent 1.2 % (vaginal) and 1.1 % (CS) per day.[7] effects.[56]
predictor of formula use. After the weight An important limitation was that feeding In 2017, a cross-sectional sub-study[57]
nadir was reached, most newborns in this type was not assessed after birth.[10] Six- within a larger prospective study[5] of
study gained weight at a similar pace, de- ty-three percent of the sample was exclu- newborn weight changes after birth was
spite differences in early weight loss.[5] sively breastfed at time of birth; however, conducted. The purpose of this study was
by day 30, many newborns were probably to examine women’s perspectives regard-
Infant Growth consuming some formula. ing use of a pediatric scale in the home to
The 2007 WHO growth charts for male Using the same cohort of 161,471 in- monitor daily weight changes in breastfed
and female infants are a predominant tool fants, Flaherman et al. also conducted a infants during the first two weeks after
used around the world to assess infant retrospective analysis to determine the birth.[57] A total of 69 women participated
growth.[47] In the study used to develop relationship between newborn weight loss and answered a 10-question, online survey
the WHO growth charts, a sub-sample of and breastfeeding outcomes.[14] Their sam- that measured helpfulness, impact on new-
882 breastfed infants were included and ple included 83,344 newborns who were born feeding, and confidence in breastfeed-
came from 6 economically stable countries exclusively breastfed at hospital discharge ing.[57] Results showed that using a pediat-
from around the globe. Four weights were after birth. A median of 5 (4–6), weights ric scale to monitor newborn weight was
collected on each newborn during the first for each infant was recorded in the first 30 very helpful (n = 49, 71 %). Mothers often
month and 2 weights were collected in the days. [14] Median weight loss for vaginally changed the frequency of infant feedings
second month of life.[48] Although the in- born infants was 4 % at 23 hours and 7.1 % based on weight (n = 27, 39 %), but only
fants in the WHO sample were breastfed at 44 hours for infants born via CS. For- 9 % of mothers (n = 6) changed the type of
for at least one year, enrollment criteria mula use was significantly higher among milk fed (breast milk or formula). Confi-
allowed for the inclusion of infants who infants with weight loss > the 50th percen- dence in breastfeeding increased in 90 % (n
were predominantly breastfed; formula tile.[14] This finding is consistent with find- = 62) of the participants. [57]
supplementation was therefore provided ings from Thulier (2017) and DiTomasso In the same online survey (N=69),[57]
to some infants in this sample. In a 2014 & Paiva (2018) showing decreased exclu- mothers were asked to provide comments
systematic review, researchers used the sive breastfeeding with increased weight about their thoughts and feelings regard-
WHO charts to compare mean heights, loss.[5,6] Other studies that are available ing use of the pediatric scale to monitor
weights and head circumferences from on infant growth have usually focused on infant weight.[58] Sixty-three women pro-
children in 55 countries.[49] They found that body composition, overweight, and met- vided comments and the majority of them
using the WHO charts put many children abolic disorders. In these studies, data (n = 51, 81 %) had positive responses.[58]
at risk for misdiagnosis of macrocephaly or are commonly collected at birth and then Four themes were identified by the partic-
microcephaly and concluded that the use again, many months or years later.[50-52] ipants. Collecting daily weights provided
of a single international standard for head valuable knowledge (n = 42, 67 %), elicit-
circumference was not justified.[49] Maternal Impact of Weight Checks ed feelings of reassurance (n = 20, 32 %)
Very few other studies have examined At times, researchers have argued that and increased confidence in breastfeeding
the growth of breastfed infants beyond weight checks should not be done in the (n = 9, 14 %). For some women, (n = 9, 14 %)
the first weeks of life.[6] In 2016, Paul et al. early days of life because it could under- collecting daily weights caused concern
sought to determine the distribution of mine maternal confidence in breastfeed- about neonatal weight.[58] Women were
weight loss and subsequent regain during ing.[53,54] Yet, few studies have examined more likely to have mixed or negative feel-
the first month after birth.[7] Using a cohort mothers’ perspectives on neonatal weight ings if they felt the newborn was not feed-
of 161,471 infants, their sample included checks or the impact that frequent weigh- ing or gaining weight well (6 of 9 partici-
singleton neonates delivered at ≥ 36 weeks’ ing may have on breastfeeding. In 2006, pants, 67 %).[58] The authors concluded that
gestation at Kaiser Permanente Northern researchers compared breastfeeding out- monitoring neonatal weight changes may
California Medical Centers between 2009 comes in a community in which frequent provide mothers with valuable knowledge,
and 2013.[7] Weights were extracted from neonatal weighing (3 weight checks in reassurance, and increased confidence in
inpatient electronic records and outpatient first 10 days of life) was implemented to breastfeeding. Monitoring infant weight
www.elacta.eu Lactation & Breastfeeding 2 • 2019
COVER STORY 9
may also alert mothers to early problems potential to shake a woman’s confidence in should not be routinely administered to
with feeding or growth.[58] Limitations in- her ability to breastfeed. Women who lack stable infants when weight loss is > 7 %. If
cluded maternal self-reporting and the lack confidence in breastfeeding are more likely weight loss approaches 10 %, infant feed-
of comparison groups. Participants may to discontinue breastfeeding and/or sup- ing must be closely evaluated by a knowl-
have had a more positive attitude toward plement breastfeeding with formula.[62,63] edgeable clinician.
breastfeeding and/or use of the pediatric When formula is introduced it becomes The problem of too much weight loss
scale compared to women who were not in very difficult for mothers to return to ex- and/or inadequate growth has the poten-
the sample group. clusive breastfeeding even if this was their tial to impact millions of newborns every
Other studies focused on the mater- intention. [64] The use of formula in the ear- year. The first month of life is the most
nal impact of infant weight checks have ly days of life is one of the primary causes critical time when newborn morbidity and
focused on test weighing. Test weighing of premature breastfeeding cessation.[65-67] mortality is highest and when newborns
is when the newborn is weighed before Formula use at this critical time decreas- are most in need of appropriate feeding and
and after breastfeeding to determine milk es the occurrence of breastfeeding, often- care. [73] The first six weeks of breastfeeding
intake. In a study of preterm newborns times leading to an inadequate breast milk are oftentimes the most challenging and,
(N = 31), researchers reported that test supply.[68] Formula supplementation can for women who stop breastfeeding, the
weighing was helpful for mothers and no also undermine a mother’s confidence in majority (74 %) do so within the first six
increased stress or lower achievement of her ability to provide enough breast milk, weeks.[74] Yet during this most crucial time,
breastfeeding goals resulted when com- resulting in continued use of the formu- limited data on newborn weight chang-
pared to mothers not performing test la.[69] This is an all too common occurrence, es are available to guide practice. Larger,
weighing.[59] Another small study of pre- contributing to low exclusive breastfeeding prospective cohort studies that rigorous-
term infants showed that use of the pedi- rates and loss of health benefits associated ly measure feeding practices and infant
atric scale to objectively measure milk with breastfeeding.[4,5] weights are needed. In the meantime, it is
supply helped to maintain and improve If needed, feeding recommendations critical that health care providers critique
maternal confidence in breastfeeding.[60] In should support continued breastfeeding and utilize the most current evidence
this study, mothers described primary con- and may include increasing the number available to help guide practice. ›
cerns as knowing how much milk infant of feedings, breast pumping to stimulate
is taking, infant gaining adequate weight, milk supply, and/or supplementing feed-
and getting enough milk.[60] ings with human milk.[70] Between provider
visits, it can be challenging for parents to
Clinical Implications know if the breastfeeding newborn is get-
It is critical that health care providers are ting enough milk. Parents are often taught
knowledgeable regarding expected neo- to keep track of soiled diapers and signs
natal weight changes and can provide ev- of newborn’s satiety after feedings.[71] If
idence-based feeding recommendations newborns are sleeping rather than feed-
for parents. Evidence from this review ing every 2 to 3 hours, or if they become
demonstrates that approximately half of lethargic, they may need to be assessed.[71]
full-term breastfed newborns lose more Yet, these methods are not fully objective
than 7 % of birthweight.[4,5,35] Mean weight and may not always be reliable indicators
loss for breastfed newborns appears to be of milk intake.[72] Some parents may bene-
8 % and some newborns lose up to 10 % fit from use of a pediatric scale in the home
of birthweight.[4,5,35] Formula supplemen- to monitor their newborn’s weight and
tation should therefore not be provided to communicate findings to the health care
stable infants with weight loss > 7 %. When provider.
weight loss approaches 10 %, infant feed-
ing must be closely evaluated by a knowl- Conclusion
edgeable clinician. Several important methodologic flaws were
Maternal self-efficacy and confidence in found in prior studies used to establish 7 %
breastfeeding have a positive influence on as a guide to practice. Expected physiologic Diane DiTomasso PhD, RN,
breastfeeding outcomes[61] and have result- weight loss for healthy newborns appears is an assistant professor in
the College of Nursing at the
ed in higher sustained breastfeeding rates to be higher than previously documented. University of Rhode Island
at two[62] and six months after birth.[63] Recent studies demonstrate that mean Throughout her nursing career she
has worked in the area of maternal
When a health care provider expresses con- weight loss for breastfed infants is 8 % child health with a specialty in
cern about newborn weight, this has the or more. Thus, formula supplementation lactation care.
10 COVER STORY
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World Health Organization, 2018: Early › The American Academy of Pediatrics,
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Exclusive Breastfeeding. www.who.int/ and Fetal Medicine, & March of Dimes Genomics, 2011; 2(3): pp.169-179.
elena/titles/early_breastfeeding/en/. Birth Defects Foundation: Guidelines for
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P, Obregon AM, Weisstaub G, Burrows
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Receptor Gene Variants in Chilean
unicef.org/publications/files/UNICEF_ Kuzniewicz MK, Li S, Walsh E, Paul, IM: families: Association with Childhood
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Preusting I, Brumey J, Odibo L, Spatz
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A Growthchart
Is But a Chart
How the interpretation of and communication about growth is as important as the choice of chart
used for monitoring growth in babies. Author: Myrte van Lonkhuijsen
Photo: © Adobe Stock/Jason
M onitoring and interpreting weight
loss and growth is an important
part of a lactation consultant’s work.
other healthcare providers recognise that
problems such as sore nipples lead to pre-
mature weaning if the baby does not grow
Postpartum weight loss
Monitoring neonatal weight loss is at
least as important in breastfeeding man-
And communicating about growth is well, or the mother pumps insufficient agement as monitoring growth. Human
crucial to supporting breastfeeding suc- quantities. Perseverance is much higher if babies go through a physiological phase
cess. babies show adequate growth, even when of weight loss in the first days of life. And
One of the main reasons why mothers stop mothers experience severe problems with it is in these first days that supplementa-
breastfeeding in the first six months of life breastfeeding. ry feeding and premature weaning occur
is insufficient growth in the baby, perceived Yet defining ‘normal growth’ is not easy. (too) frequently. So we need to consider
insufficient growth, or even just fear of in- And is normal growth good enough, or do and communicate not only what normal
sufficient growth. This not only applies to we and parents need to strive for optimal? growth is, but also what can be considered
parents but also to healthcare professionals It is important to monitor growth care- normal and healthy weight loss.
who are less well trained in breastfeeding fully so that problems may be detected ear- Until 30 years ago (at least in the Neth-
management as for lack of other options ly, and adequate measures can be taken to erlands) weight loss of up to 10 % or even
there is a tendency to suggest supplemen- avoid premature weaning. There are multi- 12 % was seen as normal, and it was said
tal feedings or even weaning in the case of ple growth curves and norms that offer ei- that babies could go without milk for up
(perceived) insufficient growth. ther descriptive or prescriptive growth in- to three days postpartum. We saw a lot of
This effect may be even greater than dications. How we use these curves makes failure to thrive and insufficient milk syn-
we think. Most lactation consultants and all the difference. drome in those days.
www.elacta.eu Lactation & Breastfeeding 2 • 2019COVER STORY 13
Then 10 % weight loss came to be seen Both these tools are descriptive, meaning Dutch chart offer a visual representation
as the threshold for at risk babies, and 5 % that they indicate normally occurring pat- for expecting parents of what weight loss
loss was normal. And at 7 %, a proactive terns of weight loss without offering an will look like in the first days of life, and
review of feeding practice was needed in interpretation of the quality of feeding how normal it is.
order to avoid 10 % loss. These norms were practices. As such, these charts can be used as
based on clinical reasoning and best prac- The Dutch instrument was developed a visual explanation of why scheduled
tice, not so much on scientific observations with the specific aim of limiting the use feeds are not in the baby’s best interest.
and reasoning. of supplementary feeding to those situa- In Figure 2, two weight patterns are plot-
At present there are at least two tools tions when there is a medical indication. ted on the Dutch chart. Both babies lose
for specifically monitoring weight loss and For this purpose, the data of a large sam- a moderate amount of weight. The baby
re-growth in the first days postpartum: ple of breastfed babies was analysed to see following the green line showed little in-
› The NEWT tool, developed in the USA[1]. at which percentage babies were admitted terest in feeding in the first 24 hours but
The use of NEWT is included in the with clinically relevant dehydration or hy- is allowed unlimited access to the breast,
Academy of Breastfeeding Medicine pernatremia or a high risk thereof. This and regains the lost weight easily. The oth-
Clinical Protocol #3: Supplementary resulted in the Reference chart of relative er baby (red line) was fed on schedule and
Feedings in the Healthy Term Breastfed weight Change for the first 10 days of life cannot recuperate the weight loss, leading
Neonate, Revised 2017. In this protocol, for breastfed babies (Fig. 1.) to stagnation of growth.
clinicians are encouraged to use NEWT This chart shows clearly that the as- Last but not least, these curves can be
to determine the weight loss range for sumption that 7 % weight loss in the first used to explain to both healthcare profes-
a newborn when considering the need days of life is an indication of lactation sionals and parents that weight loss in the
for supplementary feedings. This tool is failure or insufficient feeding is not neces- first days of life is not the same as lactation
available online: www.newbornweight. sarily warranted, as is also discussed in the failure. At present, breastfeeding is seen
org/. article by DiTomasso. as ‘insufficient’ in the first days of life, re-
› The Reference chart for relative weight Using this chart may have more advan- sulting in weight loss. The normal frantic
loss in the first 10 days postpartum tages than just preventing unneeded sup- feeding most babies show in the second
developed in the Netherlands. The tool plemental feeds. These applications have night and third day of life is interpreted as
is available for parents in the form of not yet been clinically tested but show an indication that baby suffered the days
an app that offers not just this tool, but promise in actual practice: before. With just as much confidence, we
also the normal standardised Dutch These tools can be used in antenatal can alter the narrative: the baby is
growth charts[2]. preparation because both NEWT and the ready to drink more after the days of ›
NAME: DATE OF BIRTH: BIRTH WEIGHT: NAME: DATE OF BIRTH: BIRTH WEIGHT:
3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10
Date Weight % 24 % Date Weight % 24 %
AGE IN DAYS AGE IN DAYS
22 22
Relative weight change = Relative weight change =
P P
100% * (weight ! birth weight) / birth weight 20 100% * (weight ! birth weight) / birth weight 20
99.4 99.4
+2
+2.5
.5
18
+2
+2.5
.5
18
16 16
98 98
+2
+2 +2
+2
14 14
12 12
10 10
84 84
+1
+1 +1
+1
8 8
0 1 2 0 1 2
RELATIVE WEIGHT CHANGE RELATIVE WEIGHT CHANGE
% 6 6 % 6 6
BREAST!FED INFANTS BREAST!FED INFANTS
4 50
4 4 50
4
0 0
2 2 2 2
0 ! 0 0 ! 0
16 16
!2 !1
!1 !2 !2 !1
!1 !2
!4 !4 !4 !4
!6 2 !6 !6 2 !6
!2
!2 !2
!2
!8 0.6 !8 !8 0.6 !8
!2
!2.5
.5 !2
!2.5
.5
!10 !10 !10 !10
!12 !12 !12 !12
!14 !14 !14 !14
!16 !16 !16 !16
!18 !18 !18 !18
AGE IN DAYS tno.nl/rwc © 08!2013 TNO AGE IN DAYS tno.nl/rwc © 08!2013 TNO
!20 !20 !20 !20
0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
NOTES: NOTES:
Fig. 1: Referenzkurve der relativen Gewichtsentwicklung Fig. 2: Gewichtsverlauf von zwei Kindern. Grün: nach Bedarf
in den ersten 10 Tagen, Source www.tno.nl/media/2544/ gestillt; rot: nach der Uhr gestillt.
grafiekborstgevoedekinderenmettoelichting.pdf14 COVER STORY
25
20
15
weight loss in %
10
› rest for which he or she was prepared, and 5
now needs unlimited access to the breast in
order to regain the lost weight. Seen thus, 0
the increase in feeding frequency on these
-5
days is a positive natural healthy response
of the baby leading to regrowth. -10
A case history: -15
Mrs A delivers a healthy baby girl at 39+5 0 2 4 6 8 10 12 14
weeks gestation at 0:17 hrs, weighing 3490 Age in days
grams.
For the first two days, breastfeeding goes
very well: very mild soreness, good stooling
and wet diapers, a baby that wakes by herself.
Mother is told she and her baby are ‘naturals’
at breastfeeding.
Then in the morning after the second night, It could have been different: Descriptive versus prescriptive
the baby has a low temperature (36.3°C) and The curve on the chart could have been used growth charts
is restless both at the breast and after feeding. to reassure the parents on day two that the After the first days of life, normal growth
At this point the mother is told by the mid- weight loss was well within the normal range is expected
wife that “breastfeeding is not going as well as and that this indicated how well breastfeeding Most nationally used growth charts
we thought’’. Baby is given supplemental feed- was going. This message would have support- are descriptive and based on predom-
ings, and the mother starts exclusively pump- ed the parents’ confidence both in breastfeed- inantly formula/bottle fed infants, as
ing as parents and healthcare providers feel ing and in the healthcare providers. And the they were developed by collecting data
they need to make sure they know how much healthcare professionals would have kept their on growth within the population at
baby drinks. Mother pumps a maximum of 10 own confidence in their clinical skills and in times when breastfeeding rates were or
ml per session at the end of that day, which is breastfeeding per se. are low. (See the article by DiTomasso.)
seen as proof that breastfeeding was after all With unlimited skin-to-skin contact, the There used to be (and often still is) insuf-
not going so well. baby would have warmed up soon. Her nor- ficient recognition that growth patterns
Based on the chart it is clear that there mal growth would in all likelihood have con- for breastfed and formula fed infants are
was no medical urgency, and this intervention tinued if she were offered unlimited access to different, and this has repercussions for
is damaging for several reasons: the breast. future health.
› The weight loss does not warrant supple- Or, if all had gone as described above on Descriptive charts are widely used and
mental feeding. days two and three, but this curve had been may lead to inadvertent mismanagement
› The low temperature is not unusual after used on day four, it would have been clear the of breastfeeding. Breastfed babies may be
a night spent mostly in the crib except for baby was getting too much supplemental feed- (and often are) seen as overfed in the first
feeding. ing. She is clearly growing faster than needed, two months of life, and this can mean that
› The most damaging effect is the resulting indicating too much food. mothers are told they need to feed less
lack of trust. As the mother voiced it: “ap- The slower gain after day seven could have frequently . When growth appears to fal-
parently even experienced professionals been interpreted as ‘the baby following her ter after four months, the mother may be
could not see my baby was not getting own curve’, and this could have led to a reduc- told to work to increase her milk supply or
enough from my breasts, so how could I tion in supplemental feedings. start supplementary feeding.
ever feed in confidence?’. This positive labelling, supported by clear
› The healthcare professionals concerned also evidence-based and visual information, would Prescriptive growth charts: the WHO
lost their professional confidence: how could have given parents and baby a much better charts
they have been so wrong? start. The WHO curves for breastfed children
are unique not only because they describe
On day four, the mother starts to breastfeed growth based on predominant breastfeed-
again, combined with 30 ml of formula (as she ing, but also because they are prescriptive.
pumps about 20 ml by then). Then around day These curves indicate optimal growth, and
nine, another problem occurs: the weight loss the children and families on which these
levels off again, leading to the conclusion that curves were based were selected and sup-
her milk production really is insufficient. ported in achieving optimal growth and
development[3].
www.elacta.eu Lactation & Breastfeeding 2 • 2019COVER STORY 15
Based on these curves we can conclude even to the point of fighting the breast. His Discussion
that optimal growth of the world’s babies mother is exhausted. It is important to keep in mind which chart
is strikingly similar. In spite of local dif- After a difficult birth ending in an is used when and for what purpose. A de-
ferences in average adult size, babies show emergency C-section, Jonathan lost 9 % scriptive chart should be used in a different
remarkably consistent growth patterns in of his birthweight and she had badly dam- way than a prescriptive chart.
the first years of life. This results in growth aged nipples, so she pumped for a week. The original aim of the chart indicates
curves that indicate optimal physical devel- Then at the age of two weeks, when Jona- the interpretation. For example, the Dutch
opment in terms of weight gain and, to a than was back at the breast comfortably, he chart for the first 10 days of life does not
lesser degree, length. They therefore set a contracted HRSV and had to be admitted offer information on breastfeeding man-
benchmark for optimal growth for all ba- to hospital for a week. The mother pumped agement: we do not know if lower weight
bies. on the days when he was too sick to drink loss and faster regaining of weight is linked
effectively, and then Jonathan came back to specific breastfeeding management. The
There are, however, a few caveats to the breast to the relief of both moth- aim was to indicate the risk of dehydra-
The WHO charts do not include East Asian er and son. Growth was 150-200 grams a tion. More research is needed to determine
families and their babies. This may be an week; he was feeding 6-9 times in 24 hours, whether or not lower weight loss is related
important oversight considering the fact slept 2-5 hours between feeds and started to better management.
that 22 % of humans at present are of Asi- to smile at five weeks. Prescriptive charts such as the WHO
atic origin. Then the mother was told about the charts monitor optimal growth. However,
It is important to consider the dropout WHO curves and saw that her son was we need to consider that there is a risk of
percentage and the reasons for dropout clearly not growing optimally. She decided perceived breastfeeding failure in the first
in the cohort that formed the basis of the to give 9-10 feeds a day, but most of the two months of life when these curves are
WHO curves. The dropout percentage was time Jonathan seemed uninterested in used. This may lead to unnecessary inter-
high enough to be a relevant reservation: of drinking after one and a half to two hours. ventions or even premature weaning un-
the 1743 children that started, about 50 % So she started cluster pumping. Jonathan less parents and healthcare professionals
did not comply fully with the Multicentre grew a satisfying 400 grams the week after. can adequately support optimal breast-
Growth Reference Study’s infant-feeding Then the reflux started, and breastfeeding feeding.
and no-smoking criteria and were exclud- became a fight. Mother is at the point of Clinical observation is a vital part
ed[4]. Since we know that low weight gain is giving up, as she now hears that this may of using curves. There is more to a baby
a major reason to start supplemental feed- indicate an allergy and that she should go than a number on the scale. This includes
ing, babies with lower than average weight on a dairy-egg-soy-free diet. observing the physical state of the baby
gain would be at a higher risk of receiving This is when aiming for ‘optimal’ may (monsieur Michelin or skinny?), the de-
supplemental feeds and therefore dropping be aiming too high. This baby did not velopmental stage, the interaction be-
out of the study. have an optimal start, and was clinically tween parents and baby and the breast-
Healthcare professionals and lactation thriving after overcoming both the breast- feeding management.
consultants now see mothers who are feeding issues in the first week, and the Special consideration is needed when
worried about breastfeeding problems in viral infection from which he was still re- applying any curve to babies that do not
apparently thriving babies because their covering when the WHO curve was first fit into the main category of ‘healthy’. This
children do not follow the WHO curves in used. This was not an optimal start, and not only includes LGW (low gestation-
the first weeks of life. This can and should therefore optimal growth was not to be al weight) and premature babies but also
be an opportunity for early detection of expected. those ‘in the spectrum of LGW and prema-
breastfeeding problems and counselling The mother’s efforts to enforce more turity’ (With ‘in the spectrum of’ I mean
about adequate management, provided frequent and more abundant feedings were the tiny fat babies or the long skinny ones
the parents have access to a social network not a response to her baby’s behaviour (he that are not officially LGW or macrosomic
and/or healthcare professionals who can was visibly doing well) but originated in but show some or all of the relevant clini-
offer proper assistance. worries about a higher standard than was cal aspects.) as well as those who are born
Without such support, the parents apparently needed. macrosomic or in the spectrum, a category
may be advised to supplement ‘in order to When pumping was stopped and Jona- which is becoming more and more relevant
maintain proper growth’[13]. than’s cues were followed, his reflux symp- with the increasing number of women with
toms were reduced to normal spits from any type of diabetic disease or precursors
A case study time to time. He fed on average 7-8 times to diabetes. Prescriptive curves especially
The mother of 7-week-old Jonathan in 24 hours and kept growing adequately may place the standard for growth out of
is worried that her third son might have on the normal curve. At five months, he reach of these babies, again possibly lead-
reflux. He spits up more and more often was still a slim baby but thriving and fully ing to unnecessary stress and early
and is increasingly visibly bothered by it, breastfed. supplementation or weaning. ›You can also read
