Until just a couple of years ago, it was uncommon for mothers to be
discharged from maternity units here before the baby was at least 96 hours
old.  They would be weighed at birth, and then again on day 3, and daily
from then until discharge.  They weren't weighed between birth and about 72
hours.  If we found a baby who was more than 10 per cent below birth weight
we would try to increase frequency of feeds over the next 24 hours, assuming
that baby was suckling effectively.  If baby was still losing weight after
that 24 hours, we would start supplementing, but generally not before.  It
was most trying for the mothers because a baby with a large weight loss will
often seem insatiable for a couple of days until lactogenesis II starts and
they can guzzle down to replace their losses.

This has changed since we have fewer beds now in relation to the birth
census, and mothers are going home a lot sooner.  We still weigh them at
birth and at discharge but that is often at 48-60 hours.  We see much
greater discrepancies between birth weight and discharge weight now than we
did before, even though we are now weighing babies at birth after they have
been skin to skin with mother for up to several hours, and many of them have
passed meconium before being weighed the first time.    

In the first 48 hours a baby who is feeding well may still be taking in very
small amounts of colostrum, and passing large amounts of meconium, so the
net loss is startlingly large, often close to 10 per cent.  We have them
back in clinic again within a couple of days to do the PKU, which isn't done
here before 60 hours.  It is extremely rare for a baby to be more than 5 per
cent below birth weight by the time they come back.

If we weren't sure of seeing them again within such a short time I bet I'd
be more nervous about them.  As it is, in the rare cases where the baby has
continued to lose weight until day 5, we do a breastfeeding observation then
and there, and schedule a new weight check within a day or so, either at our
clinic or at the baby's well child center.  It works fine and keeps
breastfeeding, if not within, then at least close to, the realm of normal.

I realize that it is in part the existence of a functioning network for
follow up, both hospital- and community based, that makes this approach
possible.  It also requires more thought now on the part of the staff
interpreting the discharge weights, and I must admit that a good number of
them are very uneasy when they see a baby with an eight or nine per cent
loss on day 2.  I try to keep everyone aware that there is a reason we
always waited until day 3 to do a naked weight before - we don't want to
know how much they've lost in the first 48 hours because all it does is make
us nervous and the mothers are easily infected with our anxiety.  What they
need is confidence and trust in the process.

A final caveat: looking at weight loss in the early days is important, IMO,
but it does not replace looking at the baby.  If the baby is happy, vital,
awake, alert, seeming more content after a feed than before, waking
spontaneously to feed and having its needs met when showing signs of
readiness to feed, then I am less worried about the weight.  If the baby is
unhappy, or not waking spontaneously, or not feeding well when awake, then
the weight doesn't reassure me even if it is supposedly normal.

Rachel Myr
Kristiansand, Norway

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