I've been given the very mixed blessing of being without e-mail or internet 
access from home for a few days and it isn't over yet.  I am not home at the 
moment so I can't resist a short post on the topic of how we frame the 
problem, and the solution, when a baby is not thriving.  
The overwhelming majority of babies I see in the early days after birth or at 
our clinic *for breastfeeding problems*, who are not taking in enough food to 
grow on, have trouble with getting milk out of the breast.  Sometimes this is a 
problem due to baby's anatomy or physiology and sometimes it is due to 
parents not following baby's hunger cues so baby does not get fed when it 
needs to.  Both of these things over time lead to reduction in supply which is 
generally quite reversible.  
Sometimes the mother is told that the baby is not taking in enough because 
the health services don't know how to tell a malnourished baby from a thriving 
one, as exemplified by the following case.
Recently I was consulted by a mother whose son was over 3 months old.  He 
wants to feed very frequently day and night, never more than a couple of 
hours between feeds though he does have several times a day when he sleeps 
for two hours.  Mostly he feeds in clusters and she would be hard put to say 
when one feed leaves off and the next begins.  She would not switch breasts 
even when he slept for fifteen of every twenty minutes at the breast, out of 
concern that he wouldn't get the high fat milk at the end of the feed, so he 
routinely spends an hour per side, only actively feeding for about a quarter of 
the time, when the MER occurs.
I didn't know his total weight gain when she phoned me, and we don't normally 
see babies this age because they are followed by PHNs in the community.  
This mother was  reluctant to supplement as she was being encouraged to do 
by the PHN, who was concerned about his growth, so she came back to us for 
another opinion.  
In walks a tall, solidly built woman with a *very* large baby who is sitting bolt 
upright in her arms, bright eyes taking in absolutely everything, locking gaze 
with any person in sight and making social overtures to smile and even giggle 
from the safe haven of mother's lap. He is very active, trying to pull himself 
upright, wiggle around, turns easily from front to back and can nearly do a sit-
up from the supine position.  We undress him for a weight check and I note 
that his feet hang off the edge of my changing table, which means he is over 
60 cm long, and indeed his record shows that at 3 mos he was 64 cm, or over 
25 inches.  He has gained nearly 3 kg since birth, which is over 6.5 lb, so his 
weight at the appointment was 6850 g, over 15 pounds!  The 'problem' is that 
while his head circumference and length were over the 85th percentiles 
according to the WHO Growth Standards, his weight was just around the 
50th.  His father is 1,92 m tall, over 6 feet.
The WHO curves are not in use in Norway yet but are reported to be on the 
way in, and high time.  The curves in use make long babies look 
undernourished whether or not they are, but on the WHO standards his 
weight-for-length was above the 15th percentile, not a matter for concern.  
But I'd think that anyone who simply LOOKS AT THE BABY could see that we 
don't need to worry about this one.  In this case the mother was being 
advised to give him breastmilk substitutes in addition to feeding him herself, to 
get his weight into the same percentile as his length.  She was also told that 
he was plenty old enough to be expected to wait at least three hours 
between feeds and there was no reason to put off trying to get him on more 
of a schedule.  Fortunately I was not the first person to gasp in disbelief at 
that astonishing piece of advice for how to ensure inadequate intake; the 
community midwife, in contrast to the PHN, had also cautioned against limiting 
feeds because he seems to need all the milk she can get into him.  I 
suggested the mother ask the PHN for suggestions on how to comfort the 
baby when he thought he needed to feed and the clock said he was 
mistaken.  I also allowed as how more frequent switches from side to side, 
when he falls asleep while waiting for the next MER, could lead to him getting 
sated in less than an hour, and I dare say it wouldn't affect his calorie intake 
negatively.

I think I need to start holding courses on how to use growth standards.  
We'll start with a review of the major health problems expected in the coming 
decade, and see how far up on the list 'excessive slimness' comes. Then we'll 
talk about the difference between being above average in health and above 
average in weight.   Or maybe I'll just start printing up bumper stickers that 
say 'if it ain't broke, don't fix it!'

Rachel Myr
Kristiansand, Norway 

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