Small babies can be as healthy as big babies. The key is steady growth. Here are ways to tell whether your infant needs help and how to get him caught up.
When you were pregnant, you lived for sonograms. Now that you're a mom, your newborn's growth chart -- what he weighs, the percentile he's in -- has your full attention. Be reassured that most babies gain as they should, says neonatologist Nancy Wight, M.D., medical director of lactation at Sharp Mary Birch Hospital for Women & Newborns, in San Diego. Use this guide to make sense of your wee one's pounds and ounces.
Days 1 to 14
It's expected your baby will drop a few ounces in the first days after he arrives. That's okay because infants are born with extra water weight to tide them over until your milk comes in. Colostrum, a nutrient-rich, thick substance that your breasts produce after delivery, has everything your baby needs at this point, says Jennifer Shu, M.D., a pediatrician in Atlanta and coauthor of Heading Home With Your Newborn.
Once your milk comes in, at two to five days post-birth, your baby should begin to gain back the ounces he lost, hitting his birth weight between days 10 and 14. "I like to see at least a half ounce of weight gain a day during this time," says Dr. Shu. If your newborn's weight dips by more than 7 percent during his first couple of days (say, a 7-pound newborn loses more than 8 ounces) or he takes longer than two weeks to return to his birth weight, see your doctor, who may advise supplementing. Formula-fed babies are much less likely to have trouble gaining weight than breastfed babies. Bottle-fed infants are more inclined to gain too much weight because formula is more concentrated than breast milk, and parents tend to want their babies to finish the bottle, says Dr. Wight. (Don't push. When your child turns his head away, he's done.)
Take careful note of those soiled diapers. "In the first three days, a baby will pass dark meconium stools. Between days three and four, those should change to the typical yellow, soft breastfed stool or darker, firmer formula stool," explains Richard Schanler, M.D., director of neonatalperinatal medicine at North Shore Long Island Jewish Health System, in New Hyde Park, New York. If your little one's stools aren't making this transition, he may not be getting enough milk. In the first two days, newborns tend to pass about one stool a day. On day three, they pass about three stools, and slowly this number increases until they poop after each feeding, or eight to 12 times a day, for the first couple of weeks. Your baby may produce two to three wet diapers a day in the first two days, but this will increase to six to eight per day by the end of the first week. Call your pediatrician if you find your peanut's pee and poop counts aren't adding up.
Understanding Your Baby's Growth Chart
Children grow along their own curve, which is why a baby who is in the 5th percentile and has always been in the 5th percentile is less of a concern than a baby in the 50th percentile who suddenly starts to drop. "If we see an infant falling significantly on the chart, say from the 60th to the 10th, we'll have the baby come in for more frequent weight checks and try to feed her more," says Dr. Shu. "If she's eating well but still not gaining, we'll run tests to rule out an underlying cause, like a food allergy."
Make sure your pediatrician is using the weight chart from the World Health Organization (WHO), whether your baby is breastfed or formula fed. In 2010, the Centers for Disease Control and Prevention (CDC) recommended pediatricians plot growth with this chart for children under age 2, but not all doctors have made the switch, says Dr. Wight. "The previous, decades old growth chart is based on formula-fed babies. It can make breastfed babies, particularly when they're between 4 and 8 months old, look as if they're falling off the charts, when they're healthy."
Why Your Baby May Not Be Gaining
He's not nursing frequently enough. Newborns need to eat about every two and a half hours, or roughly eight to 12 times in a 24-hour period. "Some infants, particularly if you had any complications, are really sleepy -- like they haven't woken up after delivery," says Dr. Shu. But it's a vicious cycle: When your little one doesn't nurse frequently enough, your body isn't stimulated to increase supply, which means your baby may not get enough nutrients, leaving him too tired to eat. Instead of letting him drift off too soon on your breast, rub his feet to rouse him so he keeps sucking. If that doesn't work, remove him from the breast to wake him, then latch him back on, says Dr. Wight. A sleepy baby may give you nice stretches at night, but you should wake him to nurse every two and a half hours until your pediatrician says you can stop.
Your latch needs tweaking. Helping Baby latch on correctly takes practice, says Dr. Wight. It may not come as naturally for you as you imagined, but it's important to master for nursing sessions that are satisfying (for your baby) and pain-free (for you). In the maternity ward, have nurses help you and don't be shy about asking your seasoned mom friends to observe your latch.
How to Correct Latch-On Problems
Your infant has tongue-tie. In about 5 percent of infants, the piece of skin that attaches the tongue to the bottom of the mouth (the lingual frenulum) is abnormally thick or short, and this may restrict the movement of the tip of the tongue, making nursing difficult for your baby. A lactation consultant or your pediatrician should check for tongue-tie if your baby is struggling. One clue: if the tip of his tongue curls under when he cries with his mouth wide open. During an outpatient procedure, your pediatrician or a specialist will clip the frenulum. "Tongue-tie is less of a problem for bottle-fed babies," says Dr. Schanler, since less tongue movement is required to get the milk from the bottle. "But severe tongue-tie needs to be treated, regardless of breast or bottle, to prevent later speech problems," he says.
You aren't mixing formula precisely. "Sometimes parents add extra water because they think formula is constipating their baby or they want to save money," says Dr. Shu. Don't. Diluting formula can be fatal to your infant if she takes in too much water and not enough calories.
You delivered slightly early. Babies born between 34 and 37 weeks, considered "late preterm," may struggle to breastfeed since they aren't as developed as we used to think, says Dr. Wight. "Their brains are smaller at birth, they have an immature nervous system, and they may have low muscle tone or jaundice, or be dehydrated, all of which can affect the ability to suck, swallow, and breathe during nursing." You may have to combine nursing, pumping, and supplementing with formula until your early bird gets the hang of sucking and swallowing. A lactation consultant who specializes in premature babies can help you plan. "I recommend pumping after every feeding until your infant reaches his original due date," says Dr. Wight.
Your baby has reflux or a possible allergy. It's normal for most babies to spit up and fuss after nursing, but too much of either may be caused by excessive reflux. Feeding your baby in an upright position and burping him more frequently can help. Talk strategy with your pediatrician. In rare cases, a prescription antacid might be needed. One reassurance: Most babies outgrow reflux on their own between ages 1 and 18 months.
Extreme fussiness could also signal her tummy hurts from a food allergy (at this age, often to dairy). A baby who can't tolerate cow's milk or soy, either in formula or in your own diet if you're nursing, may have diarrhea, and you might spot blood in her poop, says Dr. Shu. If you're breastfeeding, your doctor may first have you eliminate the suspect food from your diet to confirm the allergy. Or tests may be run. If your child is found to have an allergy, you'll have to stop eating whatever she's allergic to (the top offenders: dairy, soy, eggs, tree nuts, peanuts, fish, shellfish, and wheat). Formula-fed infants should be given a special hydrolyzed formula, in which the proteins they can't tolerate are already broken down.
You have a supply problem. "It can be hard to trust your baby is getting enough from nursing, but as long as he's peeing and pooping, and seems satisfied, you are probably producing sufficient milk," says Dr. Shu. Phew! Your biggest threat: lack of support. "Problems develop when new moms don't have anyone to help them at the beginning and so they don't establish their full supply," says Dr. Wight. Talk to other women or a lactation consultant early and often.
Learn to Pump With Confidence
While you and your little one figure out breastfeeding, pumping can boost your supply so the milk is there when you need it. Some moms pump first thing in the morning when they feel fullest; others do it after feedings. To empty your breasts, key for cranking up production, massage them while you pump -- what Dr. Wight calls "power pumping." You're doing great if you express 3 ounces after 15 minutes.
Offer your infant an ounce or two of this pumped breast milk in a bottle after nursing sessions or freeze it for your child-care provider to give him when you return to work. Don't worry, most babies won't become confused between breast and bottle, Dr. Shu says. If your infant is struggling to gain weight, adding those extra formula calories can make a substantial difference to her health, as well as your state of mind!
3 Moms, 3 Feeding Fixes
"I had a sleepy newborn."
"My son would fall asleep on the boob and didn't gain his birth weight back by 14 days," says Meredith Sargent, a Brooklyn, New York, mom.
The Fix: "When I gave Harrison formula for the first time, he lit up," says Sargent, who began nursing on both sides and then supplementing with 2.5 ounces of formula afterward. "He quickly started to gain weight and demand more."
"The latch was so difficult."
"I didn't try enough at the hospital, thinking I'd focus on it at home," says Amy Bhattacharyya, of Edison, New Jersey.
The Fix: After a month of practice, as well as pumping, I got my son to latch well, says Bhattacharyya. "With my second baby, I asked every nurse who came to my room for advice."
"My baby had tongue-tie."
Marisa McMahon's son Caden was born in the 50th percentile. However, at 8 weeks he fell to the 20th and by 3 months, he'd hit the 2nd percentile.
The Fix: A pediatric specialist diagnosed tongue-tie and found Caden had a palate that made it difficult to latch. "He was working so hard to nurse that he burned more calories than he took in," says McMahon, of Pelham, New York. She started giving her son expressed breast milk from a bottle (far easier for him) and supplemented it with formula. By 9 months, Caden was in the 65th percentile.
Originally published in the February 2013 issue of American Baby magazine.
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