Newborn Weight Loss and IV Fluids in Labor

Until now, weight loss during the first 3 to 4 days after birth has been considered one indicator of how early breastfeeding is going.  If on Day 4 a newborn’s weight loss is in the average range of 5% to 7%, this usually means breastfeeding is going well.   Nearly all babies lose some weight after birth, because after floating in amniotic fluid for 9 months, they are born waterlogged.  Normal weight loss comes from the shedding of this excess fluid as they adjust to life on the drier outside. 

But when babies lose more than 7% of birth weight during these early days, does this automatically mean they are not getting enough milk?  No, according to a recent study. 

A greater weight loss may be completely unrelated to breastfeeding and due instead to excess IV fluids mothers receive within the final 2 hours before delivery.  According to this study, these excess IV fluids inflate babies’ birth weight in utero and act as a diuretic after birth.  Babies whose mothers received more IV fluids before birth urinated more during their first 24 hours and as a result lost more weight.  Number of wet diapers during the first 24 hours predicted infant weight loss.  This was true whether the babies were born vaginally or by c-section.  Another study published earlier this year had similar findings.

This weight loss has nothing whatsoever to do with breastfeeding and milk intake.  In fact, the authors suggest that if clinicians want to use weight loss as a gauge of milk intake, they calculate baby’s weight loss not from birth weight, but from their weight at 24 hours.  According to their findings, this could neutralize the effect of the mother’s IV fluids on newborn weight loss.

This is one more reason weight loss alone should not be used to determine when newborns need formula supplements.   The Academy of Breastfeeding Medicine put this well in one of its protocols: “Weight loss in the range of 8-10% may be within normal limits….If all else is going well and the physical exam is normal, it is an indication for careful assessment and possible breastfeeding assistance.”

No Such Thing as a Free Lunch

Not long ago I was contacted by an Associated Press reporter who asked for my help with an article she was writing on formula marketing by U.S. hospitals.  She asked me to provide contact information for women whose babies had either been given formula in the hospital or who were given formula marketing bags on discharge.  This was not hard to do, as according to the U.S. Centers for Disease Control and Prevention, 25% of breastfed babies receive unnecessary formula supplementation during their hospital stay.  And a recent article in Pediatrics estimates that 72% of U.S. hospitals distribute industry-sponsored formula sample packs to new parents  

Thanks to my online contacts, within 2 hours 12 local mothers had volunteered to talk to this reporter. I had high hopes, but the article was a disappointment.  Formula company spokespeople were given the last word, noting that “it’s good to have a back-up” and characterizing it as “irresponsible” not to give new mothers free formula in the hospital.   

What was not reported was the true cost of this “free” formula to parents and the impact of hospital formula marketing on breastfeeding.  The most recent study on the effect of hospital distribution of infant formula  found that the mothers who received formula samples at discharge were less likely to be exclusively breastfeeding during each of their baby’s first 10 weeks as compared with women who did not receive them.  For a summary of decades of research on this issue, click here.

What’s most important for parents to know, though, is that this is not just about breastfeeding.  The reason formula companies work so hard to establish these unholy alliances with hospitals is that they know from their own research that due to fear of adverse reactions, most parents will continue to buy the formula their baby is given first. 

The “free” formula included in those stylish marketing bags is each brand’s most expensive type.  A cost analysis done by the outstanding nonprofit organization Ban the Bags found that formula-feeding families who use the high-priced formula in these marketing bags will spend $700 more during their baby’s first year than if they bought the generic store brand.  This is the true cost of these bags to families.  No wonder formula companies are so anxious to get this product into their hands! 

What’s in it for hospitals?  In many cases, in exchange for acting as formula marketing agents (and therefore endorsers of infant formula) hospitals receive unlimited free formula for their use.  And when formula flows like water on maternity floors it’s more likely to be fed to newborns unnecessarily to the detriment of breastfeeding: a double benefit for the formula industry. 

How can we convince hospitals that it is inappropriate and unethical to give formula samples to new parents?  In many ways, as Ban the Bags points out, this practice is like giving out free Big Macs on the cardiac floor.  Babies who receive infant formula have poorer health outcomes and higher health-care costs than exclusively breastfed babies.  It makes far more sense for hospitals to focus their energies on marketing health, not commercial products.  Click here for some ideas from Ban the Bags on how to sell this idea to your local hospital.

One last thing.  If you received a formula marketing bag from your local hospital, don’t forget to write a letter of complaint to the hospital's administration.  Patient satisfaction has a huge effect on hospital policy decisions.  Use your influence for the benefit of all new parents.

Formula Supplements Put Mothers at Risk

We know that anything less than exclusive breastfeeding increases health risks for babies.  But what about mothers?  I often talk to breastfeeding mothers who decide to supplement their babies with formula because they assume they will get more sleep and that sharing feedings will reduce the stress of the early postpartum.  Most don’t realize this strategy actually has the opposite effect. 

In an earlier post, I reported on research that found exclusively breastfeeding mothers get more sleep at night than mothers who also feed formula, even when others handled some night feedings.  Now a new study¹ takes this insight one step further by examining how formula supplementation affects the amount of sleep new mothers get, their risk of depression, their overall health, and their feeling of well-being.  During the early postpartum all of these measures profoundly affect a new mother’s enjoyment of her baby and her ability to cope. 

This study, which will appear in the June issue of the journal Clinical Lactation, surveyed 6410 mothers during the first year after birth.  Although all new mothers experience fatigue, it found that exclusively breastfeeding mothers not only slept significantly more hours during the night than other mothers but also reported significantly more energy during the day, a better mood, better overall health, and a greater sense of well-being.  Another surprising finding was that there was no statistically significant difference in any of these areas between the mixed-feed and the exclusively formula-feeding groups. 

This means that rather than making a new mother’s life easier—which is often her goal—feeding her baby formula supplements can significantly decrease her quality of life.  The authors note that some popular books on postpartum depression recommend that after birth at-risk mothers sleep apart from their babies and let others handle night feedings.²  Some hospitals have even begun implementing this strategy among at-risk mothers before discharge.  Even more extreme, others recommend at-risk mothers avoid breastfeeding altogether as a way to prevent postpartum depression, despite the substantial evidence that breastfeeding mothers have a lower risk of postpartum depression.³ 

This new study indicates that although trying to help at-risk mothers get more rest after birth may seem to make logical sense, strategies that separate and supplement newborns are misguided.  They actually put mothers at greater risk of sleep disruption, depression, and poorer health.

References

¹Kendall-Tackett, K., Cong, Z., & Hale, T.W.  The effect of feeding method on sleep duration, maternal well-being, and postpartum depression.  Clinical Lactation 2011; 2(2): 22-26.

²Bennett, S.  Postpartum depression for dummies. Hoboken NJ: Wiley Publishing, 2007.

³Dennis, C.-L., & McQueen, K.  The relationship between infant-feeding outcomes and postpartum depression: A qualitative systematic review. Pediatrics 2009; 123(3):e736-e751.

What's In the Bottle?

Scientists have found that babies not breastfed have a 30% to 40% increased risk of childhood obesity.¹ Milk intake and weight gain vary greatly among formula-fed and breastfed babies.  (For more, see my earlier post.) Formula-fed babies consume 49% more milk at 1 month, 57% more at 3 months, and 71% more at 5 months.² This significant difference in milk intake is due in part to how milk flows from breast and bottle.  Recent studies have examined these feeding differences in more detail to help answer the question “How is obesity risk affected when the feeding bottle contains mother’s milk?”  

The study mentioned above provides a partial answer.  Caregivers’ behaviors during bottle-feeding—which are independent of the milk—influence babies’ intake.  For example, when bottles contain more than 6 oz. (177 mL), babies consume more milk.  Also, babies whose caregivers encourage them to finish the bottle are heavier than other babies. 

An important part of obesity prevention is the ability to self-regulate what we eat to match our energy needs.  Breastfeeding naturally teaches babies this self-regulation by giving them more control over feedings.  While breastfeeding, baby must actively draw milk from the breast.  He learns to take milk when hungry and stop when full.  This helps baby become attuned to his body’s hunger and satisfaction cues.  During bottle-feeding, baby’s role is more passive.  Fast, consistent flow and regular coaxing to take more milk, even when full, can lead to a habit of overfeeding and poor self-regulation.

In one recent study of 1250 U.S. babies, researchers used bottle-emptying as a measure of poor infant self-regulation.³ (An earlier study verified this link.⁴) It didn’t matter whether expressed milk or formula was in the bottle.  The more often the babies were fed by bottle during their first 6 months, the more likely they were to empty the bottle during their second 6 months.  Only 27% of the babies who were exclusively breastfed during their first 6 months emptied the bottle during their second 6 months.  Of those fed at first by both breast and bottle, 54% later emptied the bottle.  Of those fed at first only by bottle, 68% later emptied it.

Mother’s milk plays a vital role in a healthy beginning.  But as these studies demonstrate, there is more to breastfeeding than the milk.  Even when mother’s milk is in the bottle, regular bottle-feeding can increase a baby’s risk of childhood obesity.

References

¹Dewey, K.G., Infant feeding and growth.  In G. Goldberg, A. Prentice, P.A. Filtreau, S., & Simondon, K. (Eds.)  Breastfeeding : Early influences on later health (pp. 57-66).  New York, NY: Springer.

²Kramer, M. S., Guo, T., Platt, R. W., Vanilovich, I., Sevkovskaya, Z., Dzikovich, I., et al. Feeding effects on growth during infancy. Journal of Pediatrics 2004; 145(5): 600-605.

³ Li, R., Fein, S.B., & Grummer-Strawn, L.  Do infant fed from bottles lack self-regulation of milk intake compared with directly breastfed infants?  Pediatrics 2010; 125(6): e1386-e1393.

⁴Li, R., Fein, S.B., & Grummer-Strawn, L.M.  Association of breastfeeding intensity and bottle-emptying behaviors at early infancy with infants’ risk for excess weight at late infancy.  Pediatrics 2008; 122 Suppl 2: S77-S84.

Biological Nurturing® and Late Preterm Babies

A whole section on this blog is devoted to the concept of “laid-back breastfeeding,” but its main proponent, UK midwife and researcher Dr. Suzanne Colson, actually refers to her brainchild as “Biological Nurturing,” or BN for short.  Is BN the same as laid-back breastfeeding…or is there more to it? 

I’ve had the privilege of discussing this in depth with Suzanne during the past few months while we’ve labored together on a new DVD that Geddes Productions will release in May.  Called “Biological Nurturing: Laid-Back Breastfeeding for Mothers,” this DVD shows mothers and babies using BN in the hospital, at home and even in an outdoor café.  

When asked to describe BN, Suzanne is cautious about providing a strict definition, because she wants it to be something mothers discover with their babies.  After being asked by countless mothers in my private practice if they were doing their breastfeeding holds “right,” I can understand her concern about being too specific.  Here’s what she wrote for the DVD’s back cover:  

Is BN breastfeeding in a laid-back position?  Or is it about babies’ feeding reflexes?  Perhaps it can be a kind of skin-to-skin contact.  Actually, all of these are a part of Biological Nurturing, but there is so much more!

Biological Nurturing is as much about your relationship with your baby as it is about breastfeeding. It involves the sort of baby-holding and cuddling that many pregnant mothers dream about. Promoting continuity from womb to world by keeping mothers and babies together and comfortable, it features close body contact where mother-baby interactions work in harmony with gravity.  These important factors are all related and interact to release an amazing cocktail of instinctive behaviors that help mothers and babies get started with breastfeeding. 

After birth, BN naturally begins with skin-to-skin holding in laid-back positions, but later it also includes cuddling in these positions while lightly dressed. 

In a 2003 study, Suzanne examined the effects of BN on early breastfeeding among 11 late preterm babies and one who was small for gestational age.¹ To explain BN, the study mothers were told that since they couldn't put their babies down during their nine months of pregnancy, "it made physiological sense to incubate them in their arms" during the first days after birth.  The midwife's primary job was described as helping "the mother realize she knew more about her baby than anyone." 

With these instructions and this perspective, during the first 24 hours the study mothers kept their babies tummy down on their bodies in laid-back positions for between 4 and 16 hours, with a mean duration of breast contact of 7 hours and 40 minutes.  This extended body contact naturally triggered breastfeeding behaviors in both mothers and babies and during this first day on average these mostly late preterm babies suckled actively for an amazing 2 hours and 35 minutes.  Even while the babies slept, the mothers helped them to the breast and they fed actively without waking. 

I had to wonder after reading this study if the root cause of many of the breastfeeding problems we see among late preterm babies is restricted mother-baby body contact.  By keeping these babies in their own little beds most of the time, their feeding behaviors are not released, putting them at much greater risk of underfeeding. 

More than just laid-back breastfeeding, BN includes the comfortable, close mother-baby body contact that that helps new mothers and their newborns become attuned to one another.  Reflexes and instincts play a key role in deepening their bond.  And as the mothers and babies in this new DVD demonstrate, all this leads to frequent early breastfeeding, the best possible start for everyone.  

Reference

¹Colson, S., DeRooy, L., & Hawdon, J.  Biological Nurturing increases duration of breastfeeding for a vulnerable cohort. MIDIRS Midwifery Digest 2003;13(1), 92-97.