The steady weight gain of a nursling is an important criteria for whether they are drinking enough. Whether a baby gains quickly or slowly, whether it is heavy or light is dependant upon its constitution, state of health and diet and babies grow and develop at different speeds.
Sometimes, babies who are doing very well with exclusive breastfeeding alone for the first few months start to appear to not gain as well after two to four months. This may be normal - the most commonly used growth charts predominantly show the development of formula fed (ff) babies. Exclusively breastfed (ebf) babies do not grow along the same growth curves as ff babies so to use the ff baby as the model for a bf baby is irrational and leads health care professionals to make errors in advising mothers about feeding and growth. Here is a link to the new WHO growth charts for ebf babies:Growth Charts for EBF babies announced by the WHO
Ebf babies in the first three months grow at the same speed as ff babies. At about the three month mark the ff babies begin to put weight on quicker. Put into figures this means that in the first month of life an ebf baby gains on average 34.5g per day, a ff baby 34.4g. In the fourth month the average weight gain of an ebf baby has dropped to 18.7g per day where as a ff baby gains on average 23g. This means that around the fourth month the ebf baby drinks less milk than the ff baby, but uses this milk more efficiently.Is my baby gaining enough and what is “normal” weight gain?
In the first week after birth babies loose up to 10% of their birth weight. This should have been regained within the first two weeks of life. Particularly at this early stage it makes sense to regularly check your baby’s weight. In the first four months a baby should gain at least 100g per week. According to the WHO average weight gain is in fact more like 500g per month. After these first four months it is absolutely fine if your baby is gaining at least 80g per week. A baby can also gain less one week, then compensate and gain more the next. As long as you are following your baby’s cues and it is being allowed to eat according to appetite, a baby’s weight gain cannot be forced into a standard pattern.
That is to say, if your baby is eating as much as he wants, you can’t force him to eat more!
After five or six months, a baby has normally doubled its birth weight, after twelve months it is 2 ˝ to three times heavier than at birth. In an American study growth curves of ff and ebf babies were compared. The results showed that ebf babies gain generally very quickly at first, then slower than ff babies. Between six and twelve months they are generally lighter than ff babies, but by 18 months have caught up again. Growth (height) and the growth of the head should be in rough proportion to weight gain. When a baby grows 2.5 cm per month, the head should grow roughly 1.2 cm per month.Slow Growers
are babies who are on the lowest edge of the growth charts, though still are steadily gaining weight, and who’s growth follows roughly a steady line. The height gains and head growth are also roughly in proportion, and they are meeting their developmental milestones roughly on target.
A slow growing but otherwise perfectly healthy baby :
• looks healthy and alert
• has good muscle tone
• good skin elasticity
• at least six to eight wet nappies per day
• light coloured urine
• has a creamy consistency to their poos (if infrequent then a decent quantity, and soft)
• a slow but steady weight gain
• Mother has a good let down
(possible failure to thrive)
• apathetic or crying a lot
• slack muscle tone
• bad skin elasticity (papery, dry skin that if pinched stays crinkly)
• few wet nappies
• dark, strong smelling urine
• rare poos and then very little and hard
• Mother has problems with milk let down
• very variable weight gain
(Ruth Lawrence: Breastfeeding – a guide for the medical profession, pg 367, Mosby)
The Early Days
If a baby has not met its birth weight by two weeks and it is lower than the third percentile on the growth charts there can be the suspicion of failure to thrive. Failure to thrive can develop slowly and creepingly or appear suddenly and acutely. As a preventative measure it is important in the first four weeks of life (better 6), until your milk supply has regulated itself to the demands of your baby, that you weigh your baby ONCE a week, in the morning before a feed and naked. If they have gained too little in one week, they will probably gain more the next, but you should keep an eye on the situation.
In some cases, an illness in the baby such as infection, high fever, diarrhoea, vomiting and lost a great deal of liquids may result in slower weight gain than is expected. Supplementing with formula does not cure the illness, and may rob the baby of the beneficial effects of exclusive breastfeeding. You can tell when a baby is getting milk and when he is not (see below). A very sleepy nursling must also be closely watched.
Often the reason for a baby not gaining sufficient weight has its roots in breastfeeding management. A baby who’s latch is not good cannot efficiently suck, and won’t get enough calorie rich hindmilk . If you feed by the clock and don’t allow your baby to finish one side, but remove him and give the other side after a certain amount of time. This can lead to a disturbance in the balance of fore and hind milk.Mistakes in breastfeeding management
• don’t interrupt a feed – let your baby lead and follow its cues, letting him drink as often and as long as he likes on each side.
• If the baby is too warmly dressed and the room is hot, he will suck more weakly and become sleepy. Undress him a bit, and wake by massaging the hand, face etc
• The length between feeds may be too great – follow your baby’s cues, not the clock. Should your baby sleep a long stretch in one go he may regulate this by needing the breast more often in the wake periods.
• Allow your nursling to feed during the night – most babies won’t sleep longer than four hours in one go for at least the first six weeks.
• If you are concerned about your baby’s weight gain, don’t allow it to use a pacifier / dummy. The dummy prevents your baby from sucking on your breast, it pacifies the baby thus extending the length of time before he’ll cue for a feed.
• Don’t supplement with liquids or baby formula, much rather feed more often which stimulates your milk supply, or pump an hour after a feed and use this to top up feeds.
• When introducing solids milk should still be prioritised up to 12 months. Solid food is almost always lower in calories and fat. A mother who does not continue to prioritise milk feeds may find her baby's weight increase lessen and her supply diminish e.g. if she offers solids soon before breastfeeds.
Problems with the baby
• The baby is falling asleep whilst drinking. Wake the baby up by massaging, stroking the face or changing a nappy.
• If you have the feeling that the baby drinks only a few sips before falling asleep again, or just nibbles, you should remove it from the breast and change sides other side or change the feeding position.
• If the baby is really drinking correctly it won’t demand feeds so often as it is getting enough calories. If it is asking for a feed every hour you should check the latch and so on to find out why it isn’t sucking correctly.
• If your baby is unsatisfied after a feed and does need extra food, it is best to use a feeding device at the breast such as a Supplemental Nursing System (from Medela for example) in order to stimulate supply and help baby learn to breastfeed better.
If he is not getting milk well, it is unlikely the baby has an illness, and more likely the mother’s milk supply is down. The most common cause of unusually slow weight gain after the first few weeks or months is that the mother’s milk supply has decreased.Why would your milk supply decrease?
• You have gone on the birth control pill. If you have, stop the pill. There are other ways of preventing a pregnancy besides hormones.
• You are pregnant.
• You have been trying to stretch out the feedings, or "train" the baby to sleep through the night. If this is the case, feed the baby when he is hungry or sucking his hand.
• You are using bottles more than occasionally. Even when the milk supply is well established frequent bottles teach the baby a poor latch at a time when the baby expects rapid flow, even if you are giving the baby only breast milk in the bottle. With slow flow, the baby may pull away from the breast, decreasing time at the breast even more, and decreasing breast milk even more.
• some babies even without exposure to bottles may still become frustrated at the breast if the flow is slow. There are things that can be done to help in this situation so do seek advice.
• An emotional "shock" can, occasionally, decrease the milk supply.
• Sometimes an illness, particularly when associated with fever can decrease the milk supply. So can mastitis. Luckily, illness in the mother does not usually decrease milk supply.
• You are on a calorie-controlled diet (e.g. less than 2000-2500 calories a day) or drinking insufficiently.
• You are doing too much. You don't have to be a super mother. Let the housework go.
• Sleep when your baby sleeps. Let the baby nurse while you sleep.
• Some medications may decrease milk supply--some antihistamines (e.g. Bendryl), pseudephedrine (e.g. Sudafed).
• You are feeding one side only each feeding, so that he gets the high fat “hindmilk”. Remember, if the baby is not drinking, he’s not getting any milk and if he’s not getting any milk, he’s not getting hindmilk. “Finish” one side and if he wants more, offer the other.
• A combination of some of the above.
One way of dealing with a reduced milk supply is by taking a galactologue - herbal or otherwise. See the following link for more details on low supply in general : "I'm worried I may have a low milk supply"
and galactologues in particular: http://www.kellymom.com/herbal/milksupply/herbal_galactagogue.html
How do you know the baby actually drinks at the breast?
When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide-->pause-->close mouth). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This pause that is visible at the baby's chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more the baby got. Once you know about the pause you can cut through so much of the nonsense breastfeeding mothers are being told, such as: Feed the baby twenty minutes on each side. A baby who does this type of sucking (with the pause) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn't drink) for 20 hours will come off the breast hungry.
There are some very useful videos at http://www.breastfeedinginc.ca/content.php?pagename=videos
. The videos show how to latch a baby on, how to know a baby is getting milk, how to use compression.
Remember – you don’t have to do this by yourself! If you suspect latch issues or an issue with breastfeeding management contact a helpline or an LC
( "In real life" help, Useful websites, helplines
). Find support through our boards or ask your health professional.
We live in societies that place a vast emphasis on measurement and standardisation. Percentiles (even when calculated using bf babies) are guidelines only. Someone has to be on the 2nd percentile and it doesn't mean that baby is any less healthy or well-developed than their friend on the 90th. There are lots of ways to judge whether a baby is developing successfully and weight is only one part of that.
Catherine Watson Genna, BS, IBCLC for Medela
Handout #25: Slow Weight Gain After the First Few Months. January 2005
Written by Jack Newman, MD, FRCPC. © 2005
Das Ravensburger Stillbuch – Brigitte Benkert
Here are links to two threads which came up on the subject of low weight gain:Three Month MarkProblems with breastfeeding - baby not putting on weight...