Hi Tricia,
I will share some thoughts on this topic. My understanding is that
extrauterine growth should ideally match intrauterine growth, and (unless
something has changed) that ideal is 1 oz per day or 30 grams. I believe
some physicians would be happy with a steady gain of 15 or 18 g per day. I
wouldn't say that the doctor or nurses are concerned with "rapid" weight
gain, but rather "optimal" weight gain.
It seems the infant you write about gained 3 oz in 5 days, therefore about
18 g per day. The infant's weight loss was right at 5%, again accepted as a
fairly typical weight loss for a bf baby doing well (5 to 6%). I believe
these numbers are evidence-based but sorry I don't have that research. I
believe the best place to find such research would be Academy of BF
Medicine protocols, and lactnet member Nancy Wight's (San Diego if I'm not
mistaken and neonatologist) Toolkit. I am just going to talk about the
situation in general.
The infant was not in an ideal intrauterine milieu and not in an ideal
extrauterine environment (nicu/withdrawal), although I hope the mother was
able to do kangaroo care. By virtue of being 36 wks, such infants often are
less-than-ideal feeders, and infants going through withdrawal often don't
sleep or settle well, can spend a lot of time crying, and often spit up.
These things would contribute to lack of excellent weight gain.
However, formula is no better at putting weight on an infant, and
breastmilk is ideal for growth (putting on weight) while at the same time
contributing to maturity through growth factors, and of course if one
doesn't get an infection, one will grow better too. The *volume* of intake
is what is going to put the weight on that infant (taking aside the
withdrawal issues mentioned above which would apply to breast or formula
fed infants). I am not sure if baby was directly bf at breast, or was
receiving any/all expressed milk. That would be a key issue, in my opinion,
to find out what baby's actual intake was and optimize that.
In my experience, our local docs look for a weight of about 4 lbs 8 oz to
send the baby home *provided all other things are going well* for example,
temperature control, steady gain, bonding, stable home environment, no
withdrawal s/s, no withdrawal meds needed, etc. Sometimes the baby can go
home at a lower weight if all else if going well, typically the baby would
be over 4 lbs anyway to be able to meet those milestones.
Now, one has to ask, and I have asked this many times (you can check the
archives for the debates): Is it better to gain 18 g per day solely on
breastmilk feeds, or is it better to gain 30 g per day using formula
supplementation because there is no more breastmilk to give? I would vote
for the fully breastfed scenario and attempt to increase baby's
intake/mom's production. Now, is it better to gain 10 g per day solely on
breastmilk, or is it better to gain more on formula. Now this is not to say
that the breastmilk is deficient in any way, but that the mother's
production (*volume*) is maxed out. Of course if human donor milk is
available that would be how I would make up the volume difference.
Laurie Wheeler RN MN IBCLC
Mississippi USA
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