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Breastfeeding basics: Tips for moms with newborns

In her book, Cara Familian Natterson offers practical advice for feeding a new baby. Read an excerpt.
/ Source: TODAY

Breastfeeding can be a challenging experience. Most moms attempt to nurse after the baby is born, and some are successful immediately. Others go through pain, discomfort and frustration before they are successful, too. And others choose to bottle feed. A

What is happening inside my baby's body?
When a fetus grows inside the womb, nutrition is provided 24 hours a day, seven days a week through the umbilical cord. This means that a growing fetus receives continuous nutrition. But when a baby is delivered and the cord is cut, he does not get fed around-the-clock anymore. Instead he has to work by sucking a breast or bottle every two to three hours. Many times parents cannot believe how often their newborn wants to eat, sometimes as often as every hour. But despite how frequent this feeding schedule may seem to an adult, it is far less than the constant nutrition the baby was used to receiving prior to delivery. For your baby, a couple of hours is a long wait between each meal.

Most newborns manage the two or three hour wait between feedings with no difficulty. There is one catch, however. Humans are not designed to produce breast milk until around the third day of a baby's life. Before then, the breast-feeding baby gets a very concentrated liquid called colostrum. Colostrum is packed with antibodies (which help fight infections), but very little comes out of the breast with each feed an ounce at a time at best. Again, this is normal, so most babies do fine until the third day of life, when the milk comes in.

Because of this delay in breast-milk production, most breast-fed babies lose weight in the first few days of life. Newborns are built to deal with this by having as much as a pound of extra water weight at birth, as you can see in the swollen eyes and puffy cheeks of recently delivered babies. This extra water is gradually urinated out or burned off with lots of vigorous sucking (because sucking burns calories). Bottle-fed babies lose this extra water as well, but they usually drop less weight because they tend to drink more liquid at each feed over the first few days.

Therefore, newborn weight loss is normal . . . up to a point. There are two rules about weight changes in a newborn. First, because excess water at birth equals roughly 10 percent of a newborn's total weight, he shouldn't lose more than 10 percent of his birth weight. This water is meant to be lost, so there is no need to worry that the baby is becoming dehydrated when he loses it. Beyond 10 percent, however, the baby can get dehydrated and may need some extra fluid. The second rule of weight loss is that a newborn should regain enough to be back to his birth weight by two weeks of life. This essentially assures health care providers that the baby is eating well and gaining weight appropriately. Because the average baby gains between one-half to one ounce per day, the baby's body weight after two weeks should be at least the same as it was at birth.

Remember that gaining and losing weight for a baby is often a matter of an ounce or two. Therefore, if a baby is weighed on two different scales, or he is clothed (or diapered) for one weight and naked for another, then the results can be skewed. The weights may differ slightly between the hospital scale and the doctor's office scale or even between two scales in the same office!

An otherwise healthy baby who has lost too much weight or who has not returned to birth weight by two weeks is likely dehydrated. He will look skinny and his lips and tongue will be dry. Sometimes the soft spot on the top of the head is even sunken in. Dehydrated babies need to be treated aggressively and followed closely.

Most of the time, the baby handles the transition from continuous feedings in the womb to intermittent feedings outside fairly well. A newborn, however, can go from happy and content to seemingly starving in no time. This is especially true of big babies (large for gestational age, or LGA) born to moms with maternal diabetes. These infants are at risk for hypoglycemia (low blood sugar) because they can make too much of the hormone insulin. Too much insulin will cause the glucose level to fall below normal. Other infants who are at risk for hypoglycemia include small for gestational age (SGA) babies, preterm babies, newborns with  infections, newborns who are too cold, meconium-stained babies (babies who pooped in the womb before coming out), or infants with central nervous system or congenital metabolic abnormalities. All of these babies can get very hungry between feeds. These topics are covered more extensively in part one.

There are a few medical problems that can cause a baby to lose too much weight or regain it too slowly. A baby may become infected with a bacteria or virus, which can lead to weight loss or poor weight gain. A baby with jaundice who is placed underneath bright lights can become slightly dehydrated because of the heat from the lamps, and this can slow his weight gain. Other causes of slow weight gain such as intestinal or thyroid problems are even more rare.

What can I do?
A breast-feeding baby needs to work to get his mom to produce milk. Remember, this naturally takes time. If a mother puts the baby to her breast for 10 to 15 minutes at a time every two to three hours beginning the first day after delivery, then she will send a repeated message to her body that it is time to start producing the milk. The baby's suck, the sound of his cry, and the hormone shifts in the mom's body after delivery all contribute to the production of breast milk.

There is one important exception to this rule of putting a newborn to the breast at regular short intervals, and that is the very first day of life. After delivery, both mom and baby are often exhausted. It is not unusual for a full-term, healthy baby to sleep six or even eight hours at a stretch the first day of life. After 24 hours, though, even if the baby still seems to want to sleep a lot, the mother must put him to her breast every two to three hours. Otherwise the breasts will not be stimulated enough for the milk to come in. Milk is only produced after regular and frequent stimulation. If the baby is unavailable for breast-feeding (because he is in the NICU or has had some complications), then pumping must be done at regular three-hour intervals.

Because a baby loses weight initially, in the first few weeks of life he needs to eat often. In general, after the first day of life, a newborn eats 8 to 12 times per day. You should not let a baby under 4 weeks of age eat fewer than eight times, no matter how well the baby seems to be sleeping. If this happens, then invariably the baby will not gain adequate weight. As babies get older, they become more efficient feeders. When they can take more milk at each feeding, the frequency of feedings will decrease.

When does my doctor need to be involved?
Call your doctor if your baby is taking fewer than eight feedings per 24-hour period (for a baby younger than one month) or if he is feeding poorly. You should also notify your doctor if you think your child is so hungry that he may have low blood sugar. Signs of low blood sugar in an infant may include jittering, shaking, extreme fussiness, or even seizures. Anytime a baby is too sleepy to eat for consecutive feedings, contact your doctor.

A newborn baby can also become dehydrated. If you are worried about this, then notify your doctor. Signs of dehydration include dry lips, tongue, and inside walls of the mouth; extreme sleepiness (lethargy); and a sunken soft spot at the top of the head.

What tests need to be done, and what do the results mean?

The best test to check newborn weight loss is simple: weigh the baby. Use the same scale for rechecking a baby's weight, or use a digital scale that can be zeroed before the baby is weighed.

If a baby is showing signs of low blood glucose (hypoglycemia), then a blood test should be done to check the actual level. This can be performed as a heel stick. If the level is extremely low, or if it fails to increase despite giving the baby sugar water or formula, then more comprehensive blood tests must be done to look for the cause of the low sugar level. These include a check of the electrolytes or the serum glucose, a complete blood count, and sometimes a blood culture. These tests require drawing blood from a vein, not a poke of the heel.

Opinions differ as to the actual numeric value of blood glucose that should qualify as hypoglycemia. Currently the standard of care is that if the blood glucose concentration is lower than 40 mg/dL, then the child is considered hypoglycemic. If the baby has absolutely no symptoms, then some centers will allow the level to go down to 30 mg/dL for full-term infants (and even lower for premature or small for gestational age babies) before intervening. These values can be measured using a finger-prick machine or a blood draw sent to the hospital laboratory.

What are the treatments?
A baby who loses too much weight in the first few days of life or who does not regain enough to reach his birth weight by two weeks often needs to get extra food. A breast-fed baby can be supplemented with pumped breast milk or formula. These supplementary feedings can be given with a bottle, with a feeding tube attached to the mother's breast (called a supplementary nursing system, or SNS), or even with a cup, dropper, or finger.

It is often easier to figure out why a baby has lost too much weight or failed to regain it if he is bottle-fed, because parents can actually measure how much the baby is eating on any given day. Often, increasing the total amount of milk will solve the problem. With breast-feeding, the volume of milk per feed is almost impossible to measure. In order to increase the amount of breast milk a baby receives, you can raise the frequency of feedings or a mom can try to produce more breast milk. Specific methods for increasing milk production include pumping frequently, drinking lots of liquids, and occasionally using herbs or teas that help milk production. Your pediatrician or obstetrician can provide more information about these products.

Babies with low blood sugar need to be given glucose to raise the blood-sugar level to the normal range. There are two ways to give sugar: orally or through a vein. The oral treatment involves feeding the baby. A baby can take sugar water; a 5 percent solution of dextrose (a form of sugar) and sterile water; or formula. If a child seems to need extra calories on a regular basis for the first few days of life, then giving formula is often better than sugar water, because formula has other minerals and nutrients that the child needs.

If a baby cannot take the feedings by mouth, or if the feeds are not working to raise the blood-sugar level, then an intravenous line must be started and a sugar solution dripped directly into the blood. The sugar solution is continued until the baby can maintain his blood-sugar level by drinking breast milk or formula. Beyond immediate treatment of the low blood sugar, additional treatments will depend on the specific cause of the hypoglycemia. Hypoglycemia can result from a variety of problems, including infection, thyroid trouble, and too much insulin production.

What are the possible complications?
A hungry baby who is simply not eating frequently enough will lose more weight than usual in the hospital and gain it back more slowly. Remember, it is normal for a baby to lose up to 10 percent of his birth weight in the first few days of life. The general rule is that a child should start gaining weight around the fourth or fifth day of life, and he should be back to his birth weight by two weeks. The main complications of too much weight loss and slow weight gain are dehydration and hypoglycemia. A baby with low blood sugar can become jittery or agitated. In addition, because the brain depends on glucose as its main source of fuel, having too little glucose can impair the brain's ability to function. Therefore, in extreme cases, severe or prolonged hypoglycemia may result in seizures and serious brain injury.

Additional Resources (Go to search; in upper right-hand corner and type in newborn weight loss.) (Go to health topics and then Your Child's Health. Scroll down to the section on Endocrine, Metabolism, and Diabetes and select category called Hypoglycemia in the Newborn.)