Dear all:

First, I'm surprised no one mentioned going to ILCA publications for guidance on weight 
gain. There is a very inexpensive little manual called "Clinical Guidelines for the 
Establishment of Exclusive Breastfeeding" that provides evidence-based values for weight 
gain and MANY OTHER indicators of intake.  This document suggests looking more closely 
when the gain after day 5 is less than 2/3 ounce per day -- suggest that regaining birth 
weight by 10 days is normal and regaining after day 14 is something to be watched.  

There is a term in epidemiology called "necessary, but not sufficient"  and I think this 
certainly applies to weight gain as an indicator.

You canNOT look at weight gain or loss in isolation from those other indicators because it 
becomes meaningless.  Weight gain itself is many steps away from intake.  It is not just 
the result of intake, but also of metabolism and energy expenditure.  I have often 
mentioned this case before, but I will repeat this one again --- my most frustrating case 
was a baby who had marvelous intake --- over 3 ounces from the breast, albeit slowly.  
She was also being force fed milk from the bottle (which was very hard for her  --- she 
struggled to breath) thanks to the pediatrician who did not believe in test weighing and 
told the mother she didn't have enough milk.  In fact, this mother later was able to pump 
36 ounces a day --- by merely pumping twice.  That's right twice.  And NO her supply did 
NOT crash.  She had enormous milk storage capacity.  

The baby had a problem with sodium regulation and was losing weight because of it 
despite an excellent intake.  By not delving into the details, and assuming this was a 
supply issue (and ignoring my report) the pediatrician delayed the diagnosis eventually 
made by the endocrinologist.  The key in this situation was the mother.  She KNEW 
something was fundamentally wrong with her daughter and she was right.  Only the 
endocrinologist fully listened to her.

Now, most of the time we do not have such unusual situations.  But we should ALWAYS 
look at the baby's behavior to inform how we interpret what the weight gain might mean.  

Quite frankly, I find that most (but NOT all) babies who take 3 weeks to regain birth 
weight have some underlying problem that needs resolution. So, I watch them closely and 
do probe more when they are slow to regain birth weight.  

My most recent prolonged experience watching a very slow gainer turned out well.  She 
has developed beautifully, but she did have a posterior tongue tie.  Once she perked up 
and the tongue was released she gained at a slightly faster rate but never did go through 
catch up growth.  While I do believe that her tongue restriction slowed her early growth, I 
also think HER healthy rate of gain was slower than average.  I watched her BEHAVIOR 
closely the whole time.  She had wonderful periods of quiet alert and interaction and she 
was never fussy and never really lethargic.  

And YES, absolutely I see many babies gain quite nicely for the first couple of weeks and 
then falter miserably.  I actually worry a bit more when I see an average or high rate of 
gain followed by a plateau.  In this instance, the behavior again can be very informative 
in finding out what is going on.  

With breast surgery, if it did impinge milk release or production slightly, you can 
sometimes start seeing faltering later on when the infant has maxed out mom's capacity.  
Remember, babies still do increase the total amount they ingest over the course of the 
first five to six weeks.  In the first two weeks  they need slightly less.  If there is a slight 
mismatch in the baby's needs and mom's supply it can definitely start showing up in after 
the first couple of weeks as a slight deficit that remains throughout with the baby slightly 
edgy and not quite satisfied for the duration. Then you see a sharp jump up when solids 
are introduced as opposed to the steady rate of gain or sometimes drop in gain when 
solids are shoveled into the baby too quickly.  Other times the whole situation crashes if 
the baby gets too fatigued with the constant struggle to get enough.  This situation can 
quickly go downhill.  These are the babies that show up in my clinic at six weeks and still 
hovering around birth weight because they originally did well and then no one checked 
the baby in between.  Both mom and baby are exhausted by round the clock feedings that 
never quite satisfy the baby.

What is striking in the post to me was the focus on the numbers.  I would want to know 
at least as much about the baby's and mom's behaviors.  There is not enough information 
in the post to give me a clue about this particular situation and none of the NUMBERS tell 
me what I would want to know.  I can only speculate about a whole bunch of different 
scenarios that may be entirely wrong.

Best,  Susan Burger

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