Early Weight Loss Nomograms for Exclusively Breastfed Newborns

Abstract

BACKGROUND: The majority of newborns are exclusively breastfed during the birth hospitalization, and weight loss is nearly universal for these neonates. The amount of weight lost varies substantially among newborns with higher amounts of weight loss increasing risk for morbidity. No hour-by-hour newborn weight loss nomogram exists to assist in early identification of those on a trajectory for adverse outcomes.METHODS: For 161 471 term, singleton neonates born at $36 weeks' gestation at Northern California Kaiser Permanente hospitals in 2009-2013, data were extracted from the birth hospitalization regarding delivery mode, race/ethnicity, feeding type, and weights from electronic records. Quantile regression was used to create nomograms stratified by delivery mode that estimated percentiles of weight loss as a function of time among exclusively breastfed neonates. Weights measured subsequent to any nonbreastmilk feeding were excluded.RESULTS: Among this sample, 108 907 newborns had weights recorded while exclusively breastfeeding with 83 433 delivered vaginally and 25 474 delivered by cesarean. Differential weight loss by delivery mode was evident 6 hours after delivery and persisted over time. Almost 5% of vaginally delivered newborns and .10% of those delivered by cesarean had lost $10% of their birth weight 48 hours after delivery. By 72 hours, .25% of newborns delivered by cesarean had lost $10% of their birth weight.CONCLUSIONS: These newborn weight loss nomograms demonstrate percentiles for weight loss by delivery mode for those who are exclusively breastfed. The nomograms can be used for early identification of neonates on a trajectory for greater weight loss and related morbidities. WHAT'S KNOWN ON THIS SUBJECT:Exclusively breastfed newborns lose weight daily in the first few days after birth. The amount of weight lost varies substantially between newborns, with higher amounts of weight loss increasing risk for morbidity. WHAT THIS STUDY ADDS:This study presents nomograms demonstrating percentiles for weight loss by delivery mode for those who are exclusively breastfed. The nomograms have potential to be used for early identification of neonates on a trajectory for greater weight loss and related morbidities.

Categorizing Weight Loss in Breastfed Infants: A Good First Step

“…For example, these investigators found that the nadir in weight for neonates at the 50th percentile on their nomograms occurred at ∼60 hours of age. 3 This is similar to data from MacDonald et al and Marchini and Stock, who reported that the nadir occurred on the third day of life. 4,5 The nomogram data for weight loss in neonates born by cesarean delivery are jarring, with Flaherman et al reporting that 25% of these newborns have a weight loss $10%.…”

“…3 Using a large database and an elegant methodology, Dr Flaherman and her colleagues have constructed nomograms that describe weight loss in breastfed infants during the first few days of life. With the nomograms, clinicians can plot the percent weight loss for a neonate at a specific age and determine, with precision, whether this percentage is normal for a breastfed newborn (eg, at the 50th percentile) or excessive (eg, $95th percentile).…”

“…For instance, rather than informing a mother that her breastfed infant, born by vaginal delivery, is "down 7%" at 48 hours of life, the same information can be rephrased as "normal" (ie, at the 50th percentile on the nomogram), much as we assure parents of older children that weight gain is normal by using standard growth charts. 3 More important, using the nomograms, neonates with significant breastfeeding problems may be identified because their weight loss is $95th percentile for age or because the trajectory of weight loss is atypical.…”

Excessive weight loss in exclusively breastfed full-term newborns in a Baby-Friendly Hospital

“…Thus, the evaluation of other variables associated with weight loss and breastfeeding difficulties13 , 20 was not performed, which can be seen as a study limitation. Also, the longer duration of hospital length of stay after a cesarean delivery when compared to vaginal delivery would predispose to the observation of weight loss nadir in this first group 21. However, this effect was suppressed by adjusting the regression analysis for the length of stay in hours.…”

“…, 5 , 11 , 15 , 20 - 22 Thus, 2.45 to 25%21 of newborns lose more than 10% of weight according to studies with different types of feeding. The absence of newborns with weight loss>10% has also been described 3…”