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Is my baby thriving?

Is my baby thriving?

Babyhood is the time of fastest growth in a person’s life and, naturally, parents are often concerned to know whether their baby is thriving. This sheet describes various useful signs for checking whether a baby seems to be growing well, and what can be done if she is not, as well as providing information about weight gain and weight charts.

Weight gain in the first few weeks

Many babies, but not all, lose some weight in the first few days after birth, although the weight charts used in the UK (see box opposite) do not show this; generally, health professionals expect a baby to lose no more than 10% of her birthweight and regain the loss within 10-14 days after birth, but there is no clear evidence about what is the normal pattern.  The lines on a weight chart are called centiles. If, for example, a baby’s weight is on the ninth centile this means that 9% of babies in the samples used to create the charts had weights below this line whilst 91% had weights above it.  However, a baby’s weight may not follow any centile lines in the first few weeks but grow at a faster or slower rate1  before tending to follow a new centile (i.e. not the birth centile). Total weight gain is best worked out from the lowest weight reached, rather than the birthweight. Catch-up growth: Babies who are born quite a bit smaller than the average tend to grow rapidly in the months and years after birth. This is called catch-up growth and very low birthweight babies have often caught up by the time they are 8 years old, although to a lesser extent if they were small-for-dates when born.2 Catch-down growth: Some babies of higher than average birthweight grow very slowly initially, even though they are healthy and satisfied after feeds. Such babies have been particularly well-nourished by the placenta during pregnancy and show catch-down growth to reach the sizes expected from their parents’ sizes.1 

Weight monitoring

Weighing a baby regularly shows how a baby is growing over a period of time so that babies who seem to be growing too fast or too slowly can be identified. The weight chart needs to be interpreted3 for that particular baby, taking various factors into account. This is an opportunity for the health professional’s expertise to complement the mother’s knowledge of her own baby.  A baby who has been ill may not put on much weight during the period of illness. Usually, babies gain at least 450g (1lb) in a month during the first three months4 but babies can be very different and some seem naturally to gain weight more slowly than this. A baby whose parents are slim and of below average height is likely to put on weight more slowly than a baby whose parents are tall and well-built.5 If the other signs show that a baby appears to be thriving there is unlikely to be a problem. There is no evidence that rapid weight gain, such as half a kilogram or more a week, causes any problems in a breastfed baby. However, a formula-fed baby who puts on weight rapidly may be more likely to be overweight in childhood.6 

How do I know that my baby is thriving?

Weighing needs to be combined with looking at how the baby is overall, and weight changes interpreted carefully. A baby’s appearance and behaviour are useful guides to whether she is thriving. A thriving baby has good skin colour and muscle tone. She’s alert when awake, asks for feeds and is usually satisfied after them. A baby who seems lethargic yet is not ill probably needs more milk. The amount of weeing and pooing is also a useful sign (see the NCT information sheet What’s in a nappy? for more detailed information).7 A thriving baby usually produces at least six really wet nappies a day after the first week and two substantial poos a day. Although the poo is black and tarry (called meconium) after birth, it changes during the first few days and by day 5 or 6 is yellow and runny. Some breastfed babies after the first few weeks may only produce one very large poo every few days, or even less often. A baby who has dryish nappies and scanty poos is not taking in enough milk. Rarely, such a baby has a medical condition which makes it difficult for her body to absorb nutrients from the milk.  

What can I do if my baby is not getting enough breastmilk?

If the weight gain seems low and your baby is showing signs of not thriving, you are likely to feel very anxious but there are several actions that can help to increase the amount of breastmilk a baby is getting:
  • check that your baby is as well-latched on as possible so that she is feeding effectively; if you are not sure, contact a breastfeeding counsellor or other breastfeeding specialist;
  • offer both breasts at a feed, if you are not already doing so, and even the 1st and 2nd breasts again at a feed; this increases the volume of milk taken at a feed;
  • feed more frequently, making sure there are no long gaps between feeds;
  • express any surplus milk and offer it to the baby after breastfeeds, preferably using a cup or spoon rather than a bottle.

If these actions are not enough, you may be able to obtain some donor breastmilk from a Milk Bank. Food provides energy for the baby’s body to function – moving, thinking, digesting – with any spare energy used for growth. Sometimes, it is just not possible to provide a baby with all the breastmilk she needs at that time, and topping-up with formula can be used as a temporary measure.

However, if someone suggests that you use formula before you have tried the various actions listed above, be aware that giving formula introduces non-human protein to a baby, which may make her more likely to develop allergies later.8 Also, formula takes longer to digest so your baby may feed less often if she has formula regularly. But to increase the breastmilk supply she needs to breastfeed more often. So giving formula may reduce the breastmilk supply further. Also, a young baby who has been given bottles sometimes starts to have difficulty in latching on and needs coaxing to continue breastfeeding. Apart from these physical effects, you may feel less confident about breastfeeding if someone is suggesting topping-up with formula. You are welcome to talk to a breastfeeding counsellor about the situation and your feelings.

UK weight charts

The weight charts currently used in the Child Health Record (your baby’s ‘Red book’) are called the UK1990 charts. The data for the charts was obtained from three sets of babies typical of the UK population. Some babies were breastfed, some formula fed and some had both. Charts like this, which are typical of a population, are called reference charts. It’s unlikely that a real baby would follow any of the curves exactly. In 2002, the data for the 120 breastfed babies used for the UK1990 charts was used to make another chart, called the Breast from Birth chart. This showed that breastfed babies tended to gain weight more rapidly than formula fed babies in the first three months or so but then gained weight more slowly. If the weights of a baby near the top or bottom of the charts are plotted on both the UK1990 and Breast from Birth charts, different health professionals may interpret the situation differently. This shows the uncertainty in using weight charts so it’s important to look at other signs of whether the baby is thriving as well. 

WHO growth charts

In 2006 the World Health Organisation (WHO) published new growth charts for children.9,10 The ones for babies were developed by weighing the same babies regularly from birth to two years. Their mothers were supported to breastfeed exclusively for at least four months. These charts show how babies grow under near ideal conditions so are called standard charts. The babies came from urban settings in six very different countries – Brazil, Ghana, India, Norway, Oman and the USA. However, the only significant difference found depended on their gender, so there are separate charts for boys and girls. Like the previous charts, the curves represent averages and not the growth of an individual baby. The WHO charts confirm that breastfed babies tend to grow more rapidly than formula fed babies for around the first three months but then they grow more slowly and, by the time they are a year old, breastfed babies are on average half a kilogram lighter than formula fed babies. The WHO charts are to be piloted in selected areas in the UK before they are used throughout the NHS, and health professionals will receive training in their use. 

Errors in weighing

Human error in reading the scale or converting from kilograms to pounds and ounces can occur and it is important that the scales are zeroed before use. Also, different scales may give different readings so it is better to use the same ones, and avoid spring-balance scales as they aren’t accurate. Babies are weighed naked because the weight of the clothes will vary.

The first weighing – when and how?

Normally, babies are weighed very soon after birth. However, babies who have uninterrupted skin-to-skin contact are more likely to latch themselves onto the breast and get breastfeeding started well. UNICEF recommends that the first weighing is done after the first breastfeed.11 It is standard practice in the UK for babies to be weighed on their backs but this can trigger their startle reflex. Weighing a baby on her front (prone position) can avoid this.12 You may have an opportunity to discuss this ideas with your midwife. 

NCT help available with breastfeedingThere are local breastfeeding counsellors in many areas and the NCT Breastfeeding Line is open every day from 8am – 10pm, tel 0870 444 8708. 

If you would like further copies of this information sheet please visit: http://www.nctsales.co.uk/prodshow.asp?id=1402&cat=69&scat=394&parent=69

References 

  1. Sachs M, Dykes F, Carter B. Weight monitoring of breastfed babies in the United Kingdom - interpreting, explaining and intervening. Maternal and Child Nutrition 2006;2(1):3-18.
  2. Hack M, Weissman B, Borawski-Clark E. Catch-up growth during childhood among very low-birth-weight children. Arch.Pediatr.Adolesc.Med 1996;150(11):1122-9.
  3. Sachs M, Dykes F, Carter B. Feeding by numbers: an ethnographic study of how breastfeeding women understand their babies' weight charts. Int Breastfeed.J 2006;1(1):29 Available from http://www.internationalbreastfeedingjournal.com/content/1/1/29
  4. Mohrbacher N, Stock J. The breastfeeding answer book. 3rd revised edition Shaumberg, Illinois: La Leche League International; 2003.
  5. Griffiths LJ, Dezateux C, Cole TJ. Differential parental weight and height contributions to offspring birthweight and weight gain in infancy. Int J Epidemiol. 2007;36(1):104-7.
  6. Scholtens S, Gehring U, Brunekreef B, et al. Breastfeeding, weight gain in infancy, and overweight at seven years of age: the Prevention and Incidence of Asthma and Mite Allergy birth cohort study. Am J Epidemiol. 2007;165(8):919-26.
  7. McNally, S., Napier, K., and Welford, H. What's in a nappy? London: National Childbirth Trust; 2005.
  8. Rothenbacher D, Weyermann M, Beermann C, et al. Breastfeeding, soluble CD14 concentration in breast milk and risk of atopic dermatitis and asthma in early childhood: birth cohort study. Clin Exp.Allergy 2005;35(8):1014-21.
  9. Neil H. Puzzled about weight charts? Join the queue. New Digest 2006;(36):17.
  10. World Health Organization. The WHO Child Growth Standards.  Available from: http://www.who.int/childgrowth/standards/en/
  11. UNICEF. Breast crawl video: initiation of breastfeeding by breast crawl. Available from: http://breastcrawl.org/video.htm
  12. Cox S. Helping parents make a post-birth plan. Lactation Consultants of Great Britain conference; 2007.