What To Do If Your Newborn Is Not Gaining Weight
Got another worried call from parents of a newborn.... "Can you help us? Our breastfeeding baby is 3 weeks old. She was six pounds when she born at 37 weeks, and now the pediatrician is worried because she's only 5# 14 oz. She never regained back to her birth weight, and three weeks after birth she’s two ounces down; it seems like she's still losing weight."
As some of you know, I’ve spent my 40 years in midwifery being deeply passionate about not being an alarmist based on arbitrary numbers; my motto is “Trust nature”, and “Listen to the mothers and babies”. Yet sometimes there is a real issue, when thoughtful, quality care means promptly taking action. A LOT of the time, parents have NOT been well informed of what a newborn is needing and expecting. Our western culture really lets new families down in this area.
So. In this story above, the docs are doing a good job. This is the right place to get on it, be concerned, and do something. This is NOT a good time to "see how the weekend goes." A baby in this situation is in trouble. Also, everybody take a breath, staying calm really helps. I just need to get your attention, every action counts when a new and tiny baby remains fragile like this. Not “life and death” today, but improvement is needed immediately. In my opinion, this means seeing evidence of improvement within the next 12-hours, and over the 48-hours.
Side note to you birth professionals who are wildly passionate about empowering parents in their independence from “Statue Quo Health Care”:
It can be challenging to strike the happy balance between our commitment to not being the fear mongers we rail against, or talking ourselves out of being concerned. Sounds odd on paper, but you know we’ve done it. Never talk yourself out of getting additional eyes on baby if you have even a little underlying anxiety about the situation. Beyond just the issue of medical safety, it is actually MORE kind and MORE respectful of the mother and baby to not be placid. This is because a baby who is doing well is plump and content, and mother can relax. A baby who is struggling with nutrition or weight is not having a good time, and the intuitively anxious mother is not free to fully give herself over to bonding and recovery.
Most docs would be asking the baby to be brought back in for a weight check the next day to make sure there is no more weight loss happening, or to go to the ER. And this is an appropriate use of professional care, even if you are not generally a big fan of doctors and are trying to stay out of hospitals.
This particular situation is a sensitive dance between two extremes:
Exhausted parents not knowing how to evaluate a baby who may be very small and sleepy, and
Pediatricians who as a group routinely strike fear and disempower parents even with normal variations.
A lot of the time things are fine and folks just need to settle in. But occasionally it is actually urgent. I am glad to share information and suggestions; I’m also charging you with using your common sense. Do not let fear shut down making good decisions, which could go either way depending on your bias. I suggest you get very experienced eyes on a baby such as this ASAP.
First though, there is one serious problem with how medicinal care tends to approach this newborn weight loss issue (particularly) with breastfeeding mothers. They generally have only one perspective in their toolbox when they conclude weight gain is insufficient, and the result is a focus only on supplementation. There is certainly a time and place for it, but always telling a breastfeeding mom to supplement with formula as a first response is not that helpful, and damages docs’ credibility for those more rare times when supplementation is actually indicated. (A weak and dehydrated baby MUST have milk immediately, and should be seen by an experienced pediatric care provider ASAP also. If they behaving this way and are also yellow, drive this baby immediately to the nearest ER with a NICU NOW.)
It’s a problem to just push formula supplementation with breastfed babies, particularly without including any of the following other approaches, because this:
May reduce mom's milk supply (farther), because of reduced stimulation when baby feeds away from breast.
May make it harder to get baby back to the breast, by causing nipple confusion from bottle-feeding without coaching parents of the important nuances between feeding methods.
Makes mothers, who may already be freaking out about their milk supply, cry.
Tends to cause digestive disturbances, and possible allergic response in the baby.
Does not address WHY there is an issue in the first place!
Issues often start because no one has told parents how to treat and dress the baby in the first week, or thoroughly explained ‘normal’ in the first week. This information helps to keep babies more stable, improve mothers’ milk supply and babies’ milk transfer. My homebirth babies routinely regain their birthweight by the end of the first week, and only a handful of times have the babies not actually gained weight also!
We can get these extraordinary results
because I make sure that my homebirth parents are extremely well-informed and well-coached about what mama-babies need in the beginning. They are also frequently visited in their home after birth to catch any issues before there’s time for them to become significant problems. All mothers need and deserve to be lovingly and capably attended through the postpartum period, not just “gotten through their birth.”
So fasten your seatbelt, here's a short intro to what I teach my parents, including the baby's view of what would be optimal. Here you will find ways to more effectively support your baby's weight gain, even while you also access professional support and evaluation if needed. If you have unique circumstances, personal needs or limitations that make these suggestions challenging for you, then get help or get creative about how to thoughtfully meet your and your baby's needs together.
Babies are born expecting a “4th trimester in their natural habitat”, a few weeks on mommy's chest as a ‘Womb With a View’, if you will (wink wink.) And mommies need a postpartum recovery that supports them in having several weeks of lounging in bed snuggling their baby, not installed on the couch entertaining, or worse, back to caring for the family with lifting, stairs, and being up on her feet.
Skin-to-skin is what babies need and want.
This helps them
Develop a healthy and essential skin and gut microbiome.
To keep warm, and conserve the calories they need for growing.
Feel safe and ‘at home’ with the same heartbeat sounds they've always known.
Remain close to the food (if breastfed), reducing disruption for quick snacks.
To sleep longer and deeper in this familiar quiet & peaceful environment.
Did you know that newborns rely on physical contact with their parent to regulate all of their vital signs? Yes, heart rate, blood pressure, breathing, and temperature!
2. Babies go from '24/7' connected to their cord inside, to almost 24/7 connected to the breast outside, for a while. The breast becomes their next, step-down, life support.
By several days after birth, babies' stomachs are about the size of a large marble. So every tiny feed in the beginning, 8-10 swallows, must
Replace the calories used to suck and swallow.
Provide the calories this tiny human will need to physically function until the next feed in an hour or two.
Hopefully NOT have to be burnt as fuel to keep them warm.
Hopefully allow for a wee extra available to do a bit of growing.
3. Their job is not only to regain any lost weight by one week old, their job is double their birth weight in the first four months! What would YOU be doing if you had to double your weight in four months? (Think literally, what would your weight be?! ) Oh yah, you’d be just eating and sleeping, that's what!
4. Diapers provide KEY information about how your baby is doing in the first week! Whether they ‘are getting enough to eat’ is not mysterious!
In the first week, a baby should have a wet diaper for every day old. Ie. A four-day-old baby should have at least 4 wets, and some significant stool, in that 24-hour period. If not, then she needs more food. It’s common sense that to come out, it has to go in.
Once a well-nourished baby is a week old or more, she is usually having more wet diapers than parents feel like counting, eight or more, and also some stool daily (or a lot of stool every other day.) A compromised baby like in my story would commonly have only 4-6 diapers/day, with stools rarely and scant, which would be another clue (besides no weight gain) that they needed more volume of milk.
5. Warmth, a whole blog to itself. The baby needs to be kept warm. Europeans get it, and dress infants in a magically soft wool-silk under everything, in just about every season. We're talking a hat all the time, day and night, for several weeks if not months. Yes, I am aware that the hospital makes you take the hat OFF your newborn to prove they can maintain their own temperature. I can't help this, but it's not good common sense. A baby that can't regulate it's temperature would also likely have thermal issues even wrapped up or skin-to-skin, in my experience.
Your baby is not warm enough if they have cool hands or feet, mottled skin, or the hiccups.
Newborns should be in our adult layers, PLUS 1-2 more. NOT dressed in onesies with cold feet, while we wear a sweatshirt. If they get the hiccups, put on an extra blanket and see how quickly they stop.
You'll know they are too hot if they get bright red and/or sweaty. See how handy common sense is?
6. Learn about nursing cues, almost any movement in a newborn is a call to nurse in the early days.
In other words, a breastfed baby who's not gaining may not be invited to nurse often enough. 8-12 x/24 hours is minimal; for a baby who has not been gaining well and is dehydrated and vulnerable, they may very well need to be put to breast or get fed milk nearly every hour this first day/few days to stabilize.
Frequent-feeds are easier on the baby than giant stuffing-the-baby feeds.
7. Sometimes the baby is not latching well to the breast.
This causes poor milk transfer.
Asymetrical latching can make a huge difference!
A poor latch quickly damages mommy's nipples, creating an additional problem. Consider a nipple shield as a temporary rescue. It’s a thin silicon cover which protects the nipple, does NOT hurt milk supply, and often can help babies figure out a more effective sucking pattern. Here's what they look like, read up on how to get the right size.
8. Babies who are crying a lot or having a tough time nursing effectively may well benefit from a chiropractic adjustment or cranial-sacral treatment by someone skilled with infant palates. Frankly, most all babies would benefit.
9. Lip and tongue ties or ‘tethers’. In recent years, we are having an epidemic of latch issues because of these ties. This is not a fad. This is a very significant issue in spite of experienced moms, determined babies, and pediatricians who swear that it isn’t. The ‘why’ it’s happening is a bigger conversation.
In the recent past, family practice docs and homebirth midwives in the community often resolved this issue easily with a minor snip with scissors. (I know you need to know more, but really, it's not brutal and allows baby to nurse immediately afterwards to soothe and heal.)
However, in my 40 years of experience, tongue ties appear to be getting thicker and more involved.
These ties are best evaluated by skilled pediatric dentists; they use cold laser to release any ties found.
I'm so sorry, but be forewarned - I've honesty not yet met a pediatrician who recognized the tie as a barrier for successful feeding (breast or bottle), even when we were pointing out a heart-shaped tongue from an extreme tongue tether that extended right to the tip of his tongue.
You’re going to have to self-educate about this, and search for local resources that are truly up-to-speed.
A good source of regional support is often Tongue Tie Facebook groups for your area/state.
Fabulous book - Tongue-Tied: How A Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More, by Richard Baxter DMD, MS.
Tongue-tie myths, presentation on diagnosis, consequences of a tongue-tie. THIS IS A procedure with a cold laser in a pediatric dentist office, often covered by insurance. I STRONGLY urge you to get a second opinion if you are directed to an ENT who insists that their only approach is under anesthesia!
10. It is appropriate to get milk into a breastfed baby in other ways besides at the breast, if
Baby and/or mother are getting very worn out and frustrated trying to get baby to latch on to nurse.
There is legitimate concern because baby's vitality is waning.
The baby is getting harder and harder to rouse (they do not wake themselves to feed an average of every 2 hours).
If the baby is also yellow, seek immediate professional evaluation (like right now, GO.)
This is different than the baby who is hardy, was restless and fussy at 3 day, then mom’s milk came in. Baby now gulps milk at their feed, has heavy sopping wet diapers and a giant messy poop twice/day, but sleeps heavily for 3 hours stretches with a tummy swollen with milk. See the difference? That baby would be hard to rouse at two hours, because they are still stuffed. But they wake themselves up at say 3 hours, bright-eyed and enthusiastic to feed.
Other ways of temporarily feeding a breastfed baby could include mom pumping her milk (or a lactating friend sharing milk), which is then offered to the baby via finger feeding, SNS, or cup.
A bottle is an option, but usually the last choice, because the risk of nipple confusion could make it harder to get baby back to breast. However, if the adults and baby are all terribly exhausted, then just feed the baby. This is the priority,
If no breastmilk to supplement with is available, consider organic formula. Or there’s a great European brand (higher quality standards, goat version too) named Holle.
This could be for just a few days to get everyone onto more stable ground.
The baby may need to just ingest calories while spending the absolute minimum in calories to get a little over the hump. This is not a deal breaker for breastfeeding, nor is it disparaging your breastfeeding either.
I’ve seen this actually protect the breastfeeding relationship.
11. For a variety of reasons, the baby emptying the breast poorly may have contributed to mom's milk supply decreasing, especially after the first two weeks. Info on increasing milk supply here.
12. An experienced lactation consultant could be invaluable at this point. (Though their evaluation of tongue ties is suspect if they say one’s “there, but probably not too much of an issue.”)
This can be a lot of detail
to learn off the internet
at a time when mom is dealing with high stress, postpartum pain, and an upset baby.
You'll get through this, really.
Let’s recap -
Babies should kept nicely warm, and either be covered up or skin-to-skin on mommy or a loving family member, or wearing a hat/undershirt/gown/socks/and 1-2 blankets.
Every little tongue action means "feed me now", even if they appear to then lapse back to sleep - think baby birdies and droppers. They love to sleep with their cheek on your breast for a reason.
Get some local, experienced help evaluating your milk supply, the baby's lip and tongue, and baby's latch.
Consider seeing a chiropractor or cranial-sacral specialist.
Pull back, quit doing so much, and keeping asking for help until you get quality support that helps you cope with this situation effectively, calmly, respectfully.
Tell the baby how well they are doing,
and what you need them to do.
They are having an experience also, along with you.
Here are some fantastic resources on parenting your new baby, when you're ready for them.
Pat yourself on the back. Parenting isn't for sissies, I know you can do this. And kiss your sweet baby for me.
P.S. A special thanks to the brave, committed, struggling parents who inspired this post. I'm glad you have caring family, I know you've got this, hang in there and keep at it!