Dear Elizabeth

Greetings!  Nice to see you on LACTNET, and what an interesting 
question!   I don't have any references for you (nothing backed up by 
research), just some general personal experiences, gleaned over my 13 
years as an LC in Harare, and this will probably ramble on a bit.

You will remember your visit to Zimbabwe with Helen Armstrong way 
back in 1989, where you came in as the experts for the large 
conference of policy-makers and key Ministry of Health people, 
convened jointly with UNICEF and LLLI to kick-start 
breastfeeding?  Well, it succeeded beyond your wildest 
imaginings!  Breastfeeding just took off.  By the time I started 
visiting new mothers in the hospitals (early 1991) we had the 
situation where all the nurseries had been closed, there was 24 hour 
rooming in, and no formula was available for healthy newborns - in 
fact they had to be admitted into the special NICUs to get it, and 
then only on medical advice, for the shortest possible time, until 
the mother could express enough milk for all the baby's needs 
(usually partly on Day 1-3, completely by about Day 3)  So there was 
no formula, and the paediatricians wouldn't discharge any baby who 
wasn't breastfeeding well, so as a private practice LC I would get 
called in a lot.  It was normal practice to weigh babies at birth, 
and again just before they went home at 3 days.   I was also referred 
a lot of babies later (after the paediatricians' 10 day or 6 week 
check-ups) for low weight gain or failure to thrive.  I loved these 
cases, very challenging, but so fulfilling when they came right.

As a general rule I found that the large babies did lose more actual 
weight in the first 3 days, but this didn't usually work out as a 
larger percentage of total weight, even if the mother had had an 
epidural.  I'd red-flag any baby for follow-up at home if the weight 
loss exceeded 7%, but the paediatricians were happy (as long as the 
baby was otherwise well, and breastfeeding competently now) if the 
loss didn't exceed 10%.   I found that the larger the baby, the more 
vigorous and "demanding" he would be, which might be a problem for 
the mother until her milk came in well - again by about Day 3 
(first-time mom) or somewhat earlier for a second or subsequent 
baby.  If the percentage of weight loss was giving some cause for 
concern, then we would go on urine and stool output, and look at the 
condition of the baby too.  For example, a 3 day old baby who had 
lost a full 10% but who seemed demanding and vigorous and was 
producing light yellow urine and, say 2 stools in 24 hours, 
breastfeeding well, and the mother's milk was in well would be of 
little concern.  On the other hand, a baby who had lost only 8%, but 
was producing brick-dust urine, getting jaundiced, and sleeping a lot 
would need an intervention, and would usually not be discharged home 
- I'd usually encourage the mother to express (~120 ml/kg/day) and 
spoonfeed the baby, even if he was asleep, until things normalized.

Again, generally speaking, after hospital discharge I found quite 
often (though not absolutely consistently) that the large babies who 
were doing well would often gain at the same rate as the smaller 
babies - about 30g per day - so that, as a percentage of the total 
weight on the growth chart it would seem that the larger babies 
gained more slowly than the smaller babies, although they were, in 
fact, gaining the same amount of weight, and doing fine.  However, I 
have to say that a large baby who gained only an average of 20g per 
day would often be extremely unhappy about it, and the mother might 
seek help sooner because friends and relations would tell her she 
didn't have enough milk for such a large baby.  In 99% of cases she 
did, of course, but just needed to find a way to get more of it into 
the baby (improve positioning, alternate massage during breastfeeding 
to increase milk intake, switch-feed, drop the schedules, trust the 
baby ...)  I found that the "reserves" of a larger baby were higher 
than a smaller baby, ie he could usually stand a borderline 
under-supply for slightly longer than a small baby before eventually 
receiving so little intake that he would start to go into the classic 
pattern of failure-to-thrive where they want to feed all day (but the 
baby doesn't have the energy to actually milk the breast effectively, 
further compromising the mother's supply) and sleep all night, 
accompanied by very low urine/stool output and very low gain (or 
actual loss).

With low weight gain babies, I found that the baby's weight chart was 
one of the best tools in the box.  I would work out the baby's 
expected gain (using a loss of 10% of birthweight on Day 3) and plot 
it in blue on the chart.  I'd then plot the actual weights in red so 
that the mother could see what had happened.  The weights would often 
tell a story and you could often see - with hindsight - when a 
problem had begun (in the first 3 days?  When the family went on 
holiday at 3 weeks?  When the mother-in-law came to stay at 5 
weeks?)    Often where there was FTT the baby would need formula 
supplements while the mother worked to increase her own breastmilk 
supply.  The red line would jump up the chart as the baby did a 
catch-up and started to perk up.  But I found a very consistent and 
at first unexpected outcome - that you couldn't expect a baby to 
breastfeed effectively enough to drain the breasts really well until 
the red line had caught up with the blue line on the chart - if the 
mother stopped supplementing with EBM (1st choice) or ABM (2nd 
choice) too soon and tried to rely solely on breastfeeding, the 
weight would start to dip again.  Thus I'd always suggest that the 
mother express after breastfeeding to make sure that the breasts were 
really well drained, and continue with the supplements, until this 
happened.  It sometimes took as long as 6 weeks.  By that time, she 
usually was producing enough milk (180ml/kg/day) to have gradually 
phased out all the formula.  Seems that a baby has to have sufficient 
nutrition in order to continue to thrive ....

Two cases of large babies who did NOT gain well particularly stick in my mind.

One was a big 4.something kilo baby boy born to a really dedicated 
German mother who I saw in the hospital because the baby was so 
unsettled.  He was kept in until Day 6 by which time his loud 
protesting cry had dwindled to a kind of mewing, really pitiful, and 
very worrying, and he'd lost 16% of his birthweight.  I knew that he 
was getting almost nothing (expressing the breasts produced glistens 
of milk) and had requested formula for him from about Day 4, but the 
paediatrician was reluctant to go with it, kept checking him and 
saying he was OK.  Eventually the mother went home, and on my advice, 
started formula by cup straight away, and kept putting him to the 
breast before every feed.  I was able to follow up at home for about 
3 weeks. That milk just never came in, and the mother was 
devastated.  We tried everything (expressing, breastfeeding, 
sulpiride) with no change.  Eventually she accepted that she would 
have to formula-feed.  It was awful.  She was one of the 3 mothers I 
worked with (in just over 3000 clients) who, where no other reason 
could be found (no retained placenta, nor hormonal things) just 
failed to lactate at all.

The second was a 4.2 kg baby girl, referred for low weight gain at 
about 6 weeks.   The baby seemed well, and the paediatrician was 
happy with her condition, was happy for her not to be supplemented, 
but she just wasn't gaining enough.  The mother was very diligent 
about feeding often, and made strenuous efforts to increase her 
breastmilk supply by expressing after feeding and topping up with EBM 
etc.  but the baby just continued to gain very slowly.  She turned 
out to be a very petite little girl, very bright and perfect, and 
eventually the paediatrician just concluded that she'd been born 
quite big and just grew into her weight!   When the mom had a second 
baby she wanted to avoid a similar situation happening again and I 
saw her from the beginning.  This time it was a boy, also a big baby 
- I think about 3.9 - and he just took off, right from the beginning, 
gaining really well.  I have a photo (still in the boxes somewhere) 
of the older sister, now about 3, with this massive baby lying on her 
lap, and she's lifting her little shirt and trying to breastfeed her 
baby brother!  So cute, but you can see in the photo that the baby, 
about 4 months, is almost as big as his sister, aged about 3.  Since 
I didn't see the mom with the first baby until about 6 weeks, I 
always suspected that her very early lactation might have been badly 
mismanaged, perhaps she got badly engorged and some of the lobes of 
milk-producing cells just shut down - but after the event, it was 
impossible to find out.

Hope this helps a little.  A fascinating question.  I'll look on 
LACTNET for other replies.

Once again, this reminds me of the inspiration you were to me nearly 
20 years ago!  I can never thank you enough!

Pamela

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