Dear all:
Haven't been following any thread, but growth charts are like weighing scales. Growth charts and
pre and post feedng weight checks are only useful when you look at the entire picture in context.
I've decided it is just like the current push in Manhattan to test our children every six weeks ---
with NO REFERENCE to how the educational system will be improved or respond to this absurdly
frequent testing system. You must have an in-depth investigation any time a red flag is raised to
really determine whether or not an interventions is necessary and if so, what really is the
appropriate intervention. Without an appropriate response, measurement is just an exercise in
futility.
The new growth charts probably have a much more narrow range for reasons that Kathy Dettwyler
had previously posted long ago. Those babies who were growing exceptionally slowly were
excluded and (if I remember correctly) she mentioned that the babies were mostly from Davis - a
US population that is close to the Norway Lactopia as possible but also probably heavily sleep
trained. This may not be your nurse whenever crowd. So the higher gains that one might see in a
nurse whenever population may not have been included in these charts.
This means that the extremes have been eliminated and so there may be overdiagnosis of "failure
to thrive" as well as "obesity" if one merely looks at percentiles in the infancy period.
As with using a weighing scale properly for evaluating intake from a baby ---- that is looking at
how quickly the baby feed, evaluating how the particular feeding fits within the usual feedings for
the baby --- evaluating health factors that may influence maternal supply - and I'm sure I could
add about 20 additional items to investigate at least ---- one cannot look simply at the
percentile. In fact, this is what Marie Ruel isolated as the major flaw in health care systems in
developing countries that stagnated at growth monitoring without the crucial piece --- growth
promotion! The whole goal of having a monitoring system is to link it to further investigation and
appropriate action. WIthout that, it becomes a useless exercise in measurement alone.
One must evaluate the whole picture when a baby is not gaining along a particular trajectory.
Birth weight is pretty useless because many babies go through "catch up" or "slow down" growth
and I think Magda Sachs said this more eloquenty a week or so ago. What you are looking for is
plateaus and dips. These should be investigated. If a baby is healthy, thriving, and active with no
particular factors that would suggest a problem then you merely watch to make sure the baby is
developing properly. If the baby is lethargic, not meeting developmental milestones or showing a
myriad of other signs of not doing well -- that is when interventions may be necessary.
Weights can be a great tool, but NEVER in isolation from the entire picture.
My son gained very slowly --- despite being born at 8 lb 9 oz. He has small parents --- I'm five
feet and my husband is five feet four inches. He was always exceedingly active. Nevertheless, I
am sure part of his slow gain was due to reflux that caused him to limit his feedings. When I had
to go back to work and pumped he really would never take more than 2 oz at a time. Later in life
he developed sleep apnea from enlarged tonsils. This was really a period of very slow growth.
Once his tonsils were removed at age four (which I was very reluctant to do until he really showed
he did not breath well) he gained 10 pounds in 3 months because he simply found it easier to eat
without his enormous tonsils blocking his food. So, his later slow weight gain was a clue to a
problem that took a while to discover. During the entire time he never showed apathy or lethargy
but he certainly felt better and ate better once the problem was solved. I'm sure some day
someone will figure out why certain children have such an overgrowth of tissue that the tonsils
become obstructive, making such highly invasive surgical interventions unnecessary.
I would always investigate iron and zinc intake amont infants that are beyond 6 months of age and
plateauing or dropping in weight gain. Kay Dewey did a great presentation on iron and zinc needs
beyond six months - and the need for these nutrents is substantial. Some infants are quite fine
and others are not. Zinc is important for immunity and appetite. Iron is important for cognitive
development and about 25% of infants who are not eating an additional food source of iron
between 6-9 months will develop anemia. Cognitive development is depressed even before
anemia occurs. The tests for anemia are highly unreliable and, at least in Manhattan, done
improperly. Nurses I have observed routinely squeeze the finger which causes excess interstitual
fluid to enter the samplke throwing off the assessment of anemia. Other tests are highly invasive
requiring venous samples. Not exactly something I would suggest on a routine basis for infants.
Although the new weight charts show a different trajectory, the utility of the new charts will still
only be as good as the diagnostic skills of the user!
Best regards,
Susan E. Burger, MHS, PhD, IBCLC
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