February 28, 2009

Newborn Won't Gain Weight

A new baby, especially a first baby, comes as a reward for the inconveniences of pregnancy. New parents feel a rush of exhilaration and relief when the baby is finally there. As every parent knows, however, each achievement of parenthood merely punctuates a transition to another challenge. Maybe you just got your kid through high school. Now what? For good and caring parents, the sense of responsibility doesn't have a natural endpoint.

When I first saw this baby 17 days ago, I appreciated the excitement for first-time parents. Mom was about 40, and she told me there was some in-vitro fertilization involved [IVF]. She didn't have to spell out the details, and they didn't matter too much now that the baby was there. But I knew there was a back-story of frustration trying to get pregnant, wanting to be a parent but thinking it might never happen, having a picture of yourself with a child and thinking that might never come to pass, lots of indifferent intimate medical examinations and blunt clinical discussions of frightening risks, and, of course, the money. Now that the baby was in her arms, it was all worth it.

Now, it's my turn.

The baby looked great. Robust and healthy at a little more than 8 pounds, he did everything right. He moved right, acted right, had all the right reflexes. His heart and lungs sounded perfect. It was really fun to hold him. When I checked his hips he started to cry. The parents looked at me suspiciously, but I picked him up right away and quietly talked some sense into him as I walked around the hospital room. Obviously appreciating my point of view, the baby quieted immediately. The new parents were duly impressed with my persuasion skills.

A couple of days later, they were in the office. By now the baby was a little yellow. That didn't worry me too much, since somewhere over 50% of babies get a little jaundice. It usually peaks at about day 3 of life, but sometimes it's day 5. I sent the baby for a test and the level was moderate. That means not high enough to worry about, but high enough to test again in a day or two. The next level was at a high enough threshold to initiate some phototherapy. I know it sounds like every parent's dream: make your baby better by taking lots of pictures. In fact, it has probably been used for centuries. What was told to me many years ago is that it became standard therapy for jaundiced babies in the 19th century. Picture the hospital at the time—big wards, like barracks, in which cots with mothers were lined up. After giving birth, the babies were taken to other big rooms filled with cribs. There was no air conditioning at the time, of course, and disease was suspected to be spread by bad airs (miasma). So hospitals were typically put at the top of a hill (for better ventilation) and fitted with large windows. It was noticed at the time that the babies near the windows were less jaundiced than the babies near the center of the room. Some rudimentary experiments confirmed that the natural light reduced the visible jaundice in the baby. We understand the mechanism of how this works a little better these days. It turns out that the chemical bilirubin, which is the yellow pigment, is not very water-soluble, but is oily. So just like salad dressing, the oil doesn't want to mix with the water. In our bodies, watery stuff is typically blood and other fluids, and oily stuff is skin and fat. That's why our skin is fairly waterproof, and generally keeps our fluids on the inside from leaking out. The light changes the chemical structure of bilirubin slightly, but enough to make it more water-soluble. This helps it get out of the skin and into the bloodstream, where it can be digested and disposed of. It's the reason baby poop is so yellow. Our technology hasn't done better than sunlight. I ordered a bili-blanket for the baby, which is a small electric blanket that produces, instead of heat, an absolutely otherworldly greenish glow that would make any visitor to Roswell New Mexico proud. But I still advised the parents to find a sunny spot in their home, and as long as they could keep it warm enough, let the baby have some nice sun exposure. This regimen only took a few days to lower his bilirubin levels sufficiently to have the medical equipment company retrieve the blanket. The parents were relieved that this jaundice issue was over.

With every visit, I always asked how the breastfeeding was going. Apparently, it was going extremely well. Mom didn't have too much discomfort, and the baby was doing perfectly. I observed several feedings and the baby was doing everything he should, latching on beautifully, sucking and swallowing. It didn't surprise or worry me when, at about 5 days of age, his weight was down about 8% or so from his birth weight, to 7 pounds 10 ounces. That's normal I assured the parents. Babies are born with extra fluid, and this helps them get through the first few days until the mother's milk comes in. As they lose this weight, they typically get pretty hungry, and cry aggressively and often. These signals, too, help with the natural production of the mother.

I was seeing the baby every 2-3 days, because the baby was jaundiced and because he hadn't started to gain weight yet. He was still 7 pounds, 10 ounces. When the baby was 5 days old, I didn't think twice about his mild weight loss. He didn't keep losing weight, but when he was 10 days old and hadn't gained even one ounce, I had a harder time reassuring myself and the parents that all was definitely well. Then the baby was two weeks old, he was still 7 pounds 10 ounces, and had not gained a single ounce from his lowest weight. My decision process got difficult. Ironically, I would have had a sadder but easier set of choices if the baby didn't look great. I could have done all kinds of blood tests, looking for signs of infection or rare metabolic diseases which could interfere with the baby's weight gain. I could have admitted the child to the hospital for regimented feeding. It's not breastfeeding-friendly, but it could be crucial diagnostically to figure out if there was something wrong with the baby. I didn't tell the parents this step was now on the not-so-distant horizon. I didn't like any of these options, but would do them if the baby showed any signs of a problem.

Now I was seeing and weighing the baby every day. This was extremely hard on the parents, especially the mother. It's typical enough for new mother to worry if the baby is getting enough, and to conflate their breastfeeding issues with their own sense of success as a mother. Here in Berkeley, breastfeeding is equated with parental adequacy. People breastfeed their kids pretty much through college, it seems. This culture of breastfeeding dogmatism has had both good and bad effects. It's great that breastfeeding is now widely acceptable socially and openly. People talk about it and there's lots of resources available to help with it. Research does show benefits to breastfeeding, for both mother and child. Whether these benefits outweigh the need for therapy resulting from your mother attempting to nurse you at your prom, is unclear. The bad part of breastfeeding as a cultural necessity is the pressure it puts on the mother. The dogma implies that breastfeeding comes naturally to good mothers, and that successful breastfeeding is simply a matter of caring and motivation. In fact, lots of mothers and babies find it to be a little tricky, though many problems can be overcome. There are lots of variations in babies and breasts, so there is no single method or position or technique that works for everybody. Still, it is sad for me to feel the overwhelming sense of failure and inadequacy that some mothers feel when nursing isn't going as easily as in the brochure. This is a contributor, at the most vulnerable time, to postpartum depression.

But this baby was feeding like a champ. His mother was getting all the right signals, and doing all the right things. So why wasn't he gaining weight?

The next day the parents told me that the baby had started to become a little fussier than usual, not sleeping as much, and was harder to comfort.

I decided that I certainly could wait any more and had to take some action. First, I sent her to a lactation consultant. A good lactation consultant, I like the IBCLC certified ones (http://americas.iblce.org/registries.php ), can be a huge help and knows much more than I do. So even though I couldn't see anything wrong, I wanted to get some expert help. (Another resource is www.breastfeeding.com . Their lactation consultants are at http://www.breastfeeding.com/directory/lcdirectory.html .) I also wanted to get some formula into the child.

Formula isn't poison. It had a couple of serious medical uses in the current situation. First, it provides a known volume and known calorie input for the baby. I needed to find out if he was taking in the volume needed to support himself and thrive. If he was, I needed to know if he was absorbing and metabolizing the energy content of what he was getting in an appropriate way. I told the mother to give him formula every other feeding. At the time of the formula feeds, I wanted her to pump. This had the additional advantage of helping figure out how much she was producing. The pumping, though not as effective as a nursing baby, would help to maintain her milk supply. This was important because I was hopeful that we would soon return to exclusive nursing. And of course, we weren't going to waste that milk. I told the mother to freeze it so that dad can do some feeding when she's sleeping.

At first, mom was even more frustrated. The baby didn't want a bottle, and would spit up after bottle feeding when he didn't after breastfeeding. I told her to be patient, and that like all of us, when we're hungry we're not as selective.

Twelve hours later they were in my office. Mom had a great meeting with the lactation consultant, who was concurring with my assessment that the baby is a great nurser. She was optimistic that this would all work out fine. With the new regimen of formula every other feed, used for just 24 hours, 7 pounds 11 ounces. The baby gained an ounce!

Today, 24 hours later, is Saturday and the baby is 17 days old. He still looked a bit scrawny, a little yellowish. We did another bilirubin test today. His parents said he spent a better night, with less fussing and more time awake and alert but not crying. Maybe he was just less hungry. Today he was 7 pounds, 12.5 ounces. It’s a great day.


  1. Oh I remember the anxiety of the first few days so well!
    I'm just so happy that you take the time to help us moms through it - step by step.
    We each have our own story, worries, joys. I'm just so grateful to have a doctor like you who can be supportive and right there for the bumps in the road and from whom I can ask directions when I get a bit lost... And who can tell jokes at my expense (all with that flawless comic timing to be really inappropriate) and make me laugh!!
    I am grateful that you are so perceptive.

  2. What if the child is now 1 month old and still 5oz shy from birth weight? My niece is in the hospital right now. Her parents aren't the brightest and I'm worried. Thanks for wrting about this by the way!


Please let me know what you think. Do you know a child or situation like this?