Once again, keeping a subject line despite the thread actually being
more about what goes in than what goes out...

Heather and Pat, I think you would both speak to the mothers in these
situations very similarly.  When Pat talks about a baby being at risk,
it's based on knowing only that the baby isn't stooling as expected
and not back to birthweight. To determine whether intervention is
needed, you'd have to look at all the features Heather mentions:
trajectory, feeding patterns, and all the rest of it.

I think we have made a certain kind of progress when we recognize that
with the care most women are getting when they give birth and
immediately afterwards, it's to be expected that a baby may take more
than four or five days to get back to birth weight.  In other words,
we can't conclude that BF just isn't working for them and they should
not bother trying any more, far from it!  We can allow ourselves to
adopt an expectant attentive stance as long as the follow-up is there,
so a mother can be sure that the baby is getting enough nourishment
while it gets on track.  My experience matches that of Pat's and
Teresa's and I would argue that we should use babies who have optimal
experiences as the standard for physiologic normalcy (and where on
EARTH will we be able to gather data to guide us on this?).   We
should be doing whatever it takes to get the other babies back to
physiologic normalcy as soon as possible.  This, in my opinion, only
very rarely involves the use of breastmilk substitutes, and the times
when it does are the times when follow-up in the first week or two has
been inadequate so that a baby in Pat's 'at risk' category goes
unnoticed until it is really in big trouble.  A baby who is being
followed by someone competent and knowledgable about breastfeeding
while it lives through a greater than average initial weight loss and
a two week recovery, is not at risk and I'm sure Pat will agree with
me on that.

Apologies for my poor memory, but the study identifying babies 'at
risk' for greater than average weight loss used the same indicators we
use for effective feeding in the first couple of days.  It's no
coincidence that babies who aren't feeding well from the start, are
the ones who take longer to stop losing weight and start gaining
weight, they often gain more slowly once they start to gain unless
artificially supplemented, and they are often the ones not having
bowel movements as expected.  Frequent stools are not in themselves
proof that breastfeeding is going well, and lack of stools is not
proof that it isn't, but the correlation is strong enough that babies
who aren't having at least one juicy, fullish diaper every day by day
four or five, deserve some attention to find out whether this
'symptom' is due to a problem or if it's just a digestive
idiosyncracy.

About the WHO curves and the first two weeks - my understanding is
that this period is fraught with uncertainty stemming from the myriad
of variables impinging on babies right after birth and that is why
they don't give a standard curve to follow.  Most of us who work with
babies in the first week have a very similar perception about which
babies you can just relax and not worry about, and which ones we
should keep in our sights a bit longer, and my hunch - and I use that
word very purposefully -  is that the true physiologic norm is to be
gaining, not losing, by day 5.

Rachel Myr
Kristiansand, Norway

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