Last week in Connecting The Dots, in Part I of The Impact of Common Labor Interventions on Newborn Weight Loss and Breast/Chestfeeding Cessation, we examined how the use of analgesics for pain relief, Pitocin for induction and a large IV fluid load delivered throughout labor, can lead to breast/chestfeeding challenges for new parents in the first few hours and days of life.  

Today, in Part II, we examine the appropriate timing of a newborn’s baseline weight assessment. When, after birth, should a newborn’s baseline weight be established?  Using a weight that may have been impacted by labor interventions can hinder maternal breastfeeding confidence and skew pediatric goals for normal newborn weight gain.  We also look at an evidence based tool for determining if weight loss really falls into the supplementation zone.

Wait on the weight

After the baby is born and presuming they are stable, weight gain is the key indicator of a thriving baby.  Most babies will be weighed within an hour or two after birth and that birthweight will become the baseline against which all future weight measurements will be compared.  But how accurate is that first birth weight?  In 2011, a study (Noel-Weiss, J., et al, 2011) suggested that the baby’s birth weight should be recorded at the 24 hour mark instead of at birth if the parent had received IV fluids during labor.  In the study, there was a positive correlation between the baby’s output (wet diapers) in the first day of life, the amount of IV fluid the parent received in the two hours before birth and newborn weight loss at the 24 hour mark. 

When Noel-Weiss, et al, used the 24 hour weight as the baseline, only 2.3% of the babies had lost 7-10% of their body weight by day three of life and none of the participants lost more than 10%.  However when they used the birth weight at birth for comparison, one third of the newborns had lost between 7 and 10% of their birth weight and 7.3% lost more than 10%. Using the 24 hour weight as the starting point, 90% regained their baseline weight by day nine whereas only 64% had regained their birth weight when the actual weight at birth was used. Finally, by day 14, 12% had not regained their birth weight, but 99% of those who used the 24 hour measurement as the starting point had regained their initial weight measurement..

Based on the evidence, it would be highly useful for childbirth educators and other perinatal professionals to encourage “Waiting on the Weight” - or at least having the baby re-weighed at the 24 hour mark (or at discharge if sooner) if the parent had received IV fluids in labor.  It would also be useful to educate parents on the potential variation in weight loss when using the birth weight versus the 24 hour weight since weight loss can cause parents a great deal of stress which can in turn affect milk production, Lactogenesis II and let-down. 

Educators should also encourage breast/chestfeeding parents to record the number of wet and dirty diapers in the first two weeks so that pediatricians can take all factors into consideration when deciding whether or not the baby has lost an excessive amount of weight.  If the baby had more than one wet diaper in the first 24 hours, it is probable that the baby was offloading retained fluid from labor and may have an inflated birth weight.

In addition to recording the birth weight immediately after birth, most babies are weighed again at discharge if they were born in the hospital and then again at the first pediatric visit – usually around day three of life.  A Canadian randomized control trial (Thomson, T., et al, 2009) found that reweighing the baby on the fifth day of life (versus day two or-three) resulted in less overall use of formula supplementation in the initial two-week period.  The researchers surmise that the timing of weighing the newborn and highlighting (normal) weight loss may affect maternal confidence which in turn may impact the success of the early breast/chestfeeding relationship.

What is considered normal weight loss?

In our “Breastfeeding with Success” class, parents learn that weight loss in the first few days is normal, but what is considered normal is debatable.  Most current clinical practice guidelines suggest that a baby who has lost more than 7% of their birth weight by day three needs intervention (The Academy of Breastfeeding Medicine Protocol Committee, 2009).  Weight loss of  ≥10% is considered to be a sign of inadequate breast/chestfeeding (Manganaro, R., et al, 2001), and supplementing with pumped milk, donor milk, or formula immediately is the recommended course of action.  Weight loss in both scenarios is defined as the percentage of weight lost from the first weight measured (i.e. birth weight).

What else could affect normal weight loss?  In Part I, last week, we highlighted labor interventions that could impact or delay the transition from colostrum to mature milk and lead to greater newborn weight loss.  In both the Noel-Weiss, et al study (2011) and a large 2015 study (Miller, J., et al), mode of delivery (vaginal vs cesarean section) was highlighted as another possible culprit.  The results concluded that babies born by cesarean are more likely to lose a higher percentage of weight in the first 72 hours compared to vaginal births – especially if they are breast/chestfed.

 Enter the nomogram

If the amount of fluid a baby sheds in the first 24 hours can skew the birth weight and weight loss can have many underlying factors including both labor interventions and the mode of delivery, how do we really know if a baby is thriving and/or needs supplementation?  The results of a large four year study (Flaherman, VJ., et al, 2015) were used to create a database for weight loss comparison when a baby is exclusively breast/chestfed and delivered vaginally or exclusively breast/chestfed and delivered by cesarean section.. 

From that database, Penn State Health and Children’s Miracle Network created and released a handy tool called the Newt (newborn weight) nomogram which differentiates mode of birth for plotting and comparing weight fluctuation against the percent weight loss of other babies in the same situation.  The tool is similar to the ‘Bilitool’ (Bhutani, et al, 1999) which allows clinicians to plot a baby’s bilirubin levels.

The tool helps pediatricians (and parents) determine if the weight loss is within the acceptable range for their birth and feeding circumstances instead of urging the parent to supplement based on weight loss alone.  Another nomogram exists for formula fed babies which is very appropriate.

 Key takeaways

Many factors affect the early days of breast/chestfeeding and newborn life. As labor becomes a distant memory and parents adapt to life with a newborn, the focus shifts to feeding and caring for the infant.  However interventions from the labor can have a continued effect on early latching, milk supply and newborn weight loss.  Weight loss, in particular, can be a huge stressor for new parents and negatively impact  maternal confidence, leaving the parent to question  their ability to appropriately feed and nurture their baby.  While newborn weight protocols and tools continue to evolve, parents need to keep all aspects of feeding and weight loss into focus.

As educators, our role is to support parents through education.  Discussing true birth weight parameters, encouraging parents to have the baby (re)weighed at the 24 hour mark and accurately recording the times and number of breast/chestfeeding sessions and diaper counts – can help clinicians and families come together to make decisions to help a baby thrive while not undermining the lactation relationship.

References

The Academy of Breastfeeding Medicine Protocol Committee. ABM Protocol 3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeed Med. 2009;4:175–182.

Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics.1999

Flaherman VJ, Schaefer EW, Kuzniewicz MW, Li SX, Walsh EM, Paul IM. Early weight loss nomograms for exclusively breastfed newborns. Pediatrics. 2015;135(1):e16-e23. doi:10.1542/peds.2014-1532

Miller J, Flaherman V, Schaefer E, Kuzniewicz M, Li S, Walsh E, Paul I. 2015 www.hospitalpediatrics.org doi:10.1542/hpeds.2014-0143

Manganaro R, Mamì C, Marrone T, Marseglia L, Gemelli M. Incidence of dehydration and hypernatremia in exclusively breast-fed infants. J Pediatr. 2001;139:673–675. doi: 10.1067/mpd.2001.118880.

Noel-Weiss J, Woodend AK, Peterson W, Gibb W, Groll DL: An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss. Int Breastfeed J. 2011, 6: 9-10.1186/1746-4358-6-9

Thomson T., Hall W, Balneaves L, Wong S. Can. Nurse . 2009 Jun;105(6):24-8. Accessed 4.20.21: https://www.canadian-nurse.com/en/articles/issues/2009/june-2009/waiting-to-be-weighed-a-pilot-study-of-the-effect-of-delayed-newborn-weighing-on-breastfeeding-outcomes.

About Mindy Cockeram

Mindy Cockeram is a guest contributor for Connecting the Dots and a LCCE since 2011.  She initially trained with the United Kingdom’s National Childbirth Trust (NCT), teaching both private classes and for the National Health Service at St Georges Hospital, London from 2004.  Graduating from Villanova University in 1986, she earned a bachelor's degree in Communications and a minor in Business Studies. Currently, she teaches childbirth and breastfeeding for a large non-profit hospital in Southern California. She released Cut Your Labor in Half: 19 Secrets to a Faster & Easier Birth in 2017.  Two years later, she published Breastfeeding Doesn’t Have to Suck: Tips, Tricks and Knowledge for a Great Experience. She is currently writing her third book Pregnant Again? A Refresher for Childbirth & Breastfeeding due out in summer 2021.

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