There continues to be discussion of the amount of weight loss "allowed" for
bfg infants in early pp. I promised I would look up some ref. which would
support my contention that the current 10% is too high, and that it reflects
poor feed management rather than a physiologic process. Let me say in
advance that this does not mean I am suggesting automatic supplements.
Glucose water supplements, for example, have been shown in numerous studies
to negatively impact infant weight status. Glover and Sandilands,
(Supplementation of Breastfeeding Infants and Weight Loss in Hospital,JHL
6(4), 1990,) compared bfg babies supplemented and unsupplemented with glucose
water. The glucose water supplemented babies lost more weight and had longer
hospt. stays.
What I am suggesting is that as babies are observed to be losing towards
the 10% mark it is an indication that intervention should be begun to
investigate and remediate the problem. That may or may not involve
supplemental calories, but should definately involve hx taking, physical
assessment of breasts and baby, observation of baby at breast, refinement of
feed management plan and follow-up weight checks. With early discharge and
the release of many bfg infants before adequate feeding has been documented,
this puts an increased responsibility on the family pract. and pediatric
communities to advocate for early well-child checks (on Day 3) or for home
health care nurses who can get an accurate weight and make a referral to an
LC and a report to the doc if the weight loss is excessive. It also means we
need to keep the pressure on to normalize birth and to get babies roomed in
and kept at breast in the early pp.
I found the article I was hunting that discusses the issue of how feeding
practices influence weight loss. It is A. Avoa and P. Fischer, The Influence
of Perinatal Instruction About Breastfeeding on Neonatal Weight Loss.
Pediatrics 1990 86(2):313-15. These authors make the point that some weight
loss pp is normal. They cite an American pediatrics text as stating
breastfed babies lose 6.9% of their birth weight before beginning to gain.
Bottle fed American babies lose about 4.2%. In Lesotho, Kenya, breastfed
babies lose just 3% of birthweight. "In a recent study in Zaire during which
babies lost a mean of 7% of birthweight, the degree of loss was found to be
correlated directly with the age at which the child was first breastfed."
(pg.313.) The authors implemented educational interventions in a clinic in
Zaire for mothers immed after birth to encourage bfg, early colostral feeds,
freq. sucking. The results were compared with a control group who did not
receive the intervention. The 162 study children lost 3.8% of birth weight
before gaining. The controls lost 6.2%. Multivariate regression was used to
control for other factors. The intervention was highly significant for
decrease in weight loss.
Michel Odent wrote a short article which appeared in Mothering Winter 1989.
I wish it had been published in a journal, but he discusses his observation
that during a 2 1/2 yr period he attended 70 homebirths in which one out of
three infants didn't lose any weight at all. Typically, the infants
maintained their weight, or lost a small amount which was quickly recovered.
Odent questioned the long-standing assumptions of pp birth weight loss as
being normal. He theorizes one mechanism may be the variance in colostrum
intake if infants are unseparated and kept at breast, and if mother feels
safe in her surroundings and can release colostrum in sufficient amounts..
He suggests that the enormous protein concentation of colostrum holds a
"huge osmotic charge -- that is the capacity to hold water... [which may]
correlate with an increased capacity for water retention in the newborn
period." (pg.73.)
Another study describes similar affects of early and frequent breastfeeding:
Y.Yamauchi and I Yamanouchi, Breastfeeding Frequency During the First 24
Hours After Birth in Full-Term Neonates. Pediatrics, 1990, 86(2):171-75. The
authors studied the frequency of bfg., intake, weight loss, meconium passage
and bili levels . The frequency of bfg during the 1st 24 hours correlated
significantly with frequency of meconium passage, maximum weight loss, b-milk
intake on day 3, and weight loss from birth to time of discharge (Day 7).
These researchers label as iatrogenic many of the problems exper. by bfg
babies (like excessive weight loss). The frequent early feeders were
compared with less freq. feeders. Early freq. feeders had maximum weight
loss on Day 2 compared to Day 3, and the maximum weight loss was lower:
6.8%+/-1.7 loss in the 0-6 times/24 hr group compared to 5.8%+/-1.9 in the
7-11 times/24 hr group.
What this tells me is that 'normal' (i.e. hospt. managed, sched. feeds
following medicalized births) weight loss is probably about 6-7% of birth
weight. That's demonstrably (thanks to these studies) higher than it needs
to be. So to let things go all the way to 10% loss is really showing up a
baby in trouble. We probably ought to be ready to assist when babies go
above 8%. And by that I mean assist with skillful assessment and
case-specific remediation which preserves the empowerment of the mother while
it protects the status of the infant. Knowing or having some idea of what
'normal' may look like should help us better assess when we need to get busy
to support a lactation which is faltering.
Sorry this is so long.
Barbara Wilson-Clay, BSE, IBCLC
priv. pract. Austin. whose home birth babies fit the pattern Dr. Odent
observed, but who saw a home birth baby just last week down 10%. Which goes
to show you assess each nursing couple as individuals.
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