How often do we read some comment by the exclusively formula feeding mother who points to her healthy baby as an example of why there are no risks to formula feeding and to her friends baby who was breastfed who happens to be sick.  My parents used to use this argument on me all the time when I would calculate how much money they wasted on cigarettes and showed them pictures of cancerous lungs -- to try to stop their chain-smoking.  In the old days, my Dad who is now closing in on 90 might be used as an example of why cigarette smoking is not harmful.  Unfortunately, my mother started cigarettes at age 14 and never could quit even though she had a heart attack at age 52, ignored a mild stroke and then died of a massive stroke at age 62.  My Dad really is not as healthy has he should have been had he not smoked because he had thyroid cancer and has emphysema.  So when you look closer at the long term effects, what seemed like a reasonable argument in the 1960s has fallen apart later.

To use the argument that "because my baby is OK, your baby will be OK" is not only unprofessional, it employs what is known as confirmation bias.  We are shoring up what we want to believe with information that confirms our beliefs. Rather than doing what we should do which is question all of our assumptions all of the time and reflect upon alternate explanations.

As with any "indicator" of public health risk, clinicians have to look at the individual as an individual while comparing that person to the population based risk.  For instance, take cutoff values for hemoglobin.  There is a curve of normal.  Somewhere along the left-hand tail of that curve there are very few individuals who are healthy at a particular value of hemoglobin.  Some will be.  Most will not.  You can calculate the predictive value of hemoglobin for detecting "anemia".  The value of the cutoff value is typically chose to minimize the number of individuals who are really healthy who will get an unnecessary intervention and the number of individuals who are not healthy who might not get a needed intervention.  Yet there will always be some individuals above the cutoff who are not OK and those below the cutoff who are.

And always with any indicator, numerical or observational -- clinical judgement and additional information should be taken into consideration.  For instance, someone with a low hemoglobin value who recently donated blood might be considered differently from a woman who had heavy menstrual cycles and complained of being fatigued all the time.  And the interventions for that woman might differ from the interventions for an elderly male alcoholic.  And yes, there might be the very fit athletic woman who eats a really healthy diet and no matter what her hemoglobin remains below the cutoff.  She actually might not need to boost her hemoglobin levels at all.

I really enjoyed Virginia's posting of the VARIED ways her babies grew because she actually spent some time and thought into describing why her babies may have grown the way they did.  This is the thoughtful type of analysis we need to provide to mothers when their babies are not growing according to the "standards" of the WHO growth charts.  Indeed, these charts are unique in that the WHO actually had the courage to state that this is how healthy babies SHOULD grow (and really formula fed babies should grow that way too).  So when they don't grow according to those curves we should investigate thoroughly and not just dismiss the situation because "My baby grew that way and was OK".  

My baby did grow slowly and over the years, as I learn more I understand more why that might have been -- and even though he is highly athletic and managed to get into one of the top public high schools in the sciences in New York -- I don't dismiss his slow growth as normal.  I've accepted that he adapted and is doing well.

So the reasons why I think he grew slowly were:
a) My husband and I are incredibly short -- I am 5 ft and my husband is 5 ft 4 inches
b) I had a fibroanoma removed from one breast and without informed consent the surgeon did a hemiaroelar incision which hindered milk release on that side (my IBCLC was the only one who definitively told me that was the case and I was grateful that she had an answer for me about what the surgery had done)
c) I had a moment of delirium in the hospital when I saw the pulsing of his fontenelle with his heart beat and I thought he was dehydrated and told the nurses to give him sugar water (Why they didn't stop me from doing this delusion-driven, nonevidenced based intervention is beyond my conception) -- which probably led to his jaundice (never treated) which probably led to sleepier feedings and a lag in the establishment of my supply
d) He was delivered surgically because his head turned sideways (if there had been room for a sideways head he would have come out ear first) -- which led to:
i) edema from the IV fluids -- which may have delayed my supply
ii) lack of colonization with vaginal flora -- which may have caused him to become a regurgitating self-limiting feeder who ate 20 times a day and would never drink more than 2 ounces ever no matter how it was offered.
iii) exhaustion from climbing in and out of a hospital bed that was so high I had to jump down and jump up into bed having just had major abdominal surgery -- which led me to find it more challenging to muster the energy to get him out of his isolette

He grew worse when he received formula (which was never more than 4 ounces a day).  This I attribute to further trauma to his gut started by the surgical delivery.  I do not attribute this to his "not really needing more".  I think had I known what I know now and focused on healing his gut - he may have found feeding to be more comfortable and been able to drink a little more of my own milk.

Later when he was a toddler he had sleep apnea due to enlarged adenoids and tonsils.  When these were removed he gained 10 pounds in 3 months.  

I regret that I didn't know more at the time to provide him feeding that was "optimal", but I don't feel guilty about it because I breastfed him until he agreed to stop and I did the best I could with the information I had at the time. And I'm sure as I look back I will find out more that might explains why he grew as he did.

I would never equate my slow gaining baby with any of the slow gaining babies I see and use it to "reassure" a mother of a slow gaining baby.  I always try to look with a fresh eye at these babies and their mothers to determine whether an intervention is needed or not and to offer the interventions that are more likely to keep feeding as "normal" as possible.  Yes, I have met babies who really do grow at a half ounce a day and are fine --but they are a minority of the babies that I see that grow at a half ounce a day.  Therefore, I think it is entirely appropriate to follow them closely until both I and, more importantly the mother feel secure that we've ruled out any impediment to optimal feeding.

Sincerely,
Susan E Burger, MHS, PhD, IBCLC, RLC

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