To tackle the case of a mother who brought her first 5-day-old term newborn, named Mary for well-baby exam and presented to have a concern to her infant’s birth weight of 2.8 kg and now at the clinic to be 2.5 kg. Mary is exclusively breast fed and the mother raised her concerns on not feeding enough and weight loss. The pertinent questions to ask the mother before proceeding in answering her concerns and the questions that would elicit more information are the following; how often do you change her diaper, how many stools does she produce in a day, do you observe Mary able to suck well on your nipples and swallowing content, do you notice a more dry, peeling skin and appearing more starved even after breastfeeding her?
It is best to explain to the concerned mother that breast fed babies have signs that they are growing and getting enough breast milk including counting diapers that should be between 6-8 diapers a day and counting stools at least one bowel movement a day until week 4.
This is a common and an understandable question for a new mother and could be simply explained that what goes in should come out.
Newborns are expected to lose some weight in the first 5 to 7 days of life and a normal weight loss is 7 to 10 percent for breastfed infants. Most of the newborn regains this loss on days 10 to 14 of life (American Pregnancy Association, 2018). Given that Mary is a term baby and the 2.5 kg current weight is still within the expected weight loss of 10 percent.
If Mary was born prematurely, it may take about 3 weeks to gain back the lost weight.
Further assessment would be required if there are clinical signs of wasting with Mary such as dry, peeling skin, wrinkled skin and little muscle in the upper legs. This is an alarming condition as it is a metabolic loss of active lean tissue and cause increased in mortality, disease contribution and growth development. A thorough physical assessment would need to be done to rule out any other abnormalities including any dysmorphic appearance, edema, skin, hair color and texture, the heart and respiratory function (Homan, 2016). Early interventions would result to appropriate growth parameters and prevent developmental delays such as referring to a dietician and a lactation specialist.
Though Mary is exclusively being breastfed, circumstances may arose and the mother may need to supplement with formula. This is perfectly fine and safe. Such situation would be, the need to go back to work that inhibits pumping breast regularly and some doesn’t get enough breast milk and sometimes, it is a personal choice to have the freedom and let other family members give occasional bottle that would promote relationship but whatever reason there may be, supplementing is way better than not providing the newborn anything at all. Though formula feeds are providing nutrients to the newborn, it is still best to educate the mother that it lacks the immune factors that protects the baby from illnesses (Baby Center, 2015). Other education would be the supply of breast milk depends on the baby’s demand so, the less often the breast is used, the less milk it would produce. If supplementing with formula is a decided route with at least a bottle or two a week, it would have a minimal effect on the supply of breast milk. To help with this situation, pumping of breast milk could be done and used later. This would also keep the supply abundant.
As Mary’s mother had concern on weight loss it is important to tell that starting day 5 of life, about an ounce a day is expected and should be back to the birth weight by 2 weeks. Checking breasts is also important as if it doesn’t feel soft or empty after breastfeeding, it could be a sign that the infant is not getting enough milk and if fussiness is observed most of the time (Baby Center, 2015). The best time to introduce formula feeding is at least after a month to allow breastfeeding routine and allow milk supply to be established but mixing breast milk and formula in a bottle is not recommended by lactation consultants as this might waste the hard-earned breast milk if bottle is not finished. The best way to deal with this is to try to breast feed first or pump and if newborn seems to be hungry still after, offer a bottle with the formula.
The risk in introducing formula is the start of refusing breastmilk as some of the bottles may deliver milk faster than the nipples that could get the newborn the preference to choose between the two. With bowel movements with formula feeding, they will become firmer and be like the texture of a peanut butter, it may have stronger smell and probably would be less frequent that with only breastfeeding. The most important sign of milk intolerance is when the newborn vomits or stooling blood after formula introduction (Better Care, 2018).
The American Academy of Pediatrics has set a schedule recommendations from birth to 24 months (Yang, 2014). The schedule is first between 3 to 5 days of life then, the following months; 1 month, after 2 months, every 2 months until 6th month, and then every 3 months until 18th month then at 24 months. At every appointment, the baby would be examined head to toe and will be assessed for alertness, expected body function or milestones. At the next appointment of Mary at 1 month-old, she might also get a skin test to check strain of tuberculosis and will be read 48 to 72 hours after. The second dose of hepatitis B may also be given as the first dose was given at birth usually at the hospital.
If Mary’s mother would ask for birth control options. The education would be, breastfeeding stops the ovaries from releasing eggs that protects her from getting pregnant. Menstrual period could also stop but it doesn’t guarantee not being pregnant. The only safe type of birth control method during breastfeeding is the mini-pill but at the same time it may also decrease the supply of breast milk (Rhode Island Breastfeeding Coalition, 2018). Given all these information, not all newborn would have the same size at birth but it should be known especially to a first time mom to be informed of what is an expected weight loss to prevent from worrying too much and having more focus in nursing the baby and caring for self (Eule, 2017). It is highly advisable that breastfeeding mothers should maintain a balanced diet and watch closely the food being digested that could make newborn fussy and be able to limit or avoid this specific food.