Why I stopped worrying about growth charts...

I started this post assuming that a number of my mommy friends who want to exclusively breastfeed their babes are getting inaccurate information from their pediatrician's office. I'm told that they are by reports in the media and in casual conversation. All over the net, there are moms encouraged to head to the 6-month check-up with the WHO breastfed baby growth charts in-hand. However, what I've read on the CDC website and in medical journals doesn't seem to support that assumption. Even the CDC acknowledges that the WHO growth charts should be used for children up to 2 years. This is a more recent development (as in, within the past 4 years), but most doctor's offices should be in the loop on that by now.

"In April 2006, the World Health Organization (WHO) released new international growth charts for children aged 0–59 months. Similar to the 2000 CDC growth charts, these charts describe weight for age, length (or stature) for age, weight for length (or stature), and body mass index for age. Whereas the WHO charts are growth standards, describing the growth of healthy children in optimal conditions, the CDC charts are a growth reference, describing how certain children grew in a particular place and time. However, in practice, clinicians use growth charts as standards rather than references.

"In 2006, CDC, the National Institutes of Health, and the American Academy of Pediatrics convened an expert panel to review scientific evidence and discuss the potential use of the new WHO growth charts in clinical settings in the United States. On the basis of input from this expert panel, CDC recommends that clinicians in the United States use the 2006 WHO international growth charts, rather than the CDC growth charts, for children aged <24 months (available at https://www.cdc.gov/growthcharts CDC growth charts should continue to be used for the assessment of growth in persons aged 2–19 years.

"The recommendation to use the 2006 WHO international growth charts for children aged <24 months is based on several considerations, including the recognition that breastfeeding is the recommended standard for infant feeding. In the WHO charts, the healthy breastfed infant is intended to be the standard against which all other infants are compared; 100% of the reference population of infants were breastfed for 12 months and were predominantly breastfed for at least 4 months. When using the WHO growth charts to screen for possible abnormal or unhealthy growth, use of the 2.3rd and 97.7th percentiles (or ±2 standard deviations) are recommended, rather than the 5th and 95th percentiles. Clinicians should be aware that fewer U.S. children will be identified as underweight using the WHO charts, slower growth among breastfed infants during ages 3–18 months is normal, and gaining weight more rapidly than is indicated on the WHO charts might signal early signs of overweight." (Grummer-Strawn LM, Reinold C, Krebs NF, Centers for Disease Control and Prevention (CDC), MMWR. Recommendations And Reports: Morbidity And Mortality Weekly Report. Recommendations And Reports / Centers For Disease Control [MMWR Recomm Rep], ISSN: 1545-8601, 2010 Sep 10; Vol. 59 (RR-9), pp 1)



M at birth

 They key here is that pediatricians are trained to look at overall growth trends of the individual infant, not to fixate on a goal number. The environment in which the child is raised, the method of nourishment, other health conditions, and gestational age at birth are all factors that contribute to the growth and development of a baby. As a mother, I know it's easy for me to fret when folks tell me how tiny my girl is, and I confess that yes, she's in the 25th percentile for her age. As if I have been deficient as a mother because my kid is small and not yet crawling at nearly 9 months. But those are my issues and have nothing to do with the CDC or WHO.


This is significant to me because my healthy girl, who was 9 1/2 pounds at birth, quickly fell in the percentages (97th percentile to 25th percentile on the WHO charts in the first 4 months), and I was sent home with samples of formula and instructions to see an LC with the assumption that my supply was not sufficient to nourish her. After feeling like a failure as a woman because I couldn't have my homebirth, I needed to know I could at least succeed as a nursing mom. Don't get me wrong, I was ready to supplement if I truly had a supply issue, but I was going to take the appropriate steps first.

M at 10 days

1. Determine if I really had a supply issue by either exclusively pumping for 4 consecutive feedings or weighing M before and after each feeding, as recommended in the La Leche League publication, Making More Milk
2. If I did have a supply issue, I'd meet with a lactation consultant, nurse frequently, and drink mother's milk tea to help build my supply
3. If I still had supply issues or needed to supplement in the mean time, I would contact the Mother's Milk Bank or another milk-sharing organization



Thankfully, I did not have a supply issue at all. M was getting plenty of milk. To confirm all was well, our pediatrician had M come in for weight checks every couple of weeks, and she could see that M's weight gain was healthy and within normal paramaters. Breastfed babies put on weight slower than formula fed babies, in general, and our pediatrician took that into account. M was born at 41 weeks, 4 days gestation which really started her out in the 90th percentile for gestational age. Factor in that M dropped to 8 pounds 13 oz before we left the hospital and was down to 8 1/2 pounds before she started gaining within her first week, and that huge percentage change doesn't seem so drastic.

Yes, our ped used the charts as a guideline, but she didn't insist I start supplementing immediately or panic that our child was malnourished. She casually mentioned that our girl was 'a little smaller' than she'd like and wanted to keep tabs on her growth for a while. I was the one who focussed on the charts and the numbers and printed out charts. Turns out, she's doing just fine. So, I put all of that away for now, and we'll just enjoy watching M grow at whatever pace is right for her.  

M at 8 months



Breastfeeding Challenges- Recurring Mastitis



M having a snack



For some nursing pairs, breastfeeding comes easily and has few challenges. For M and me, it's been a bit more difficult. While the benefits still far outweigh those challenges, some days I just want to give up. But that time is fleeting. There are so many great reasons to continue to breastfeed that I just look for solutions to our struggles.

I have had mastitis 4 or 5 times in the eight months since M's birth. I've lost count. Each experience has been different. Sometimes, it's accompanied with a very high fever and delerium, sometimes not much worse than a cold and some soreness. My most recent bout of mastitis started yesterday morning around 4 when I noticed that it hurt while M was nursing. At 4 a.m., that didn't matter too much. We went right back to sleep. By the time we woke for the day, it hurt an awful lot, I was swollen and red, and I knew it was mastitis. Some resources recommend homeopathic treatments as the first course of action when symptoms occur, but since my case is recurring, I go straight to the doc. (I don't want it to become an abscess.)

One of our awesome La Leche League (LLL) leaders sent me a ton  of information on mastitis, potential causes, and repeat infections. Most or all of the information is available on KellyMom and on the LLL site. Some things that may be causing my troubles are the following:

1. Failure to fully recover from a previous case of mastitis
2. Anemia (I've been anemic my whole adult life, but with no menstruation I'm not sure if it's an issue currently.)
3. Sore and cracked nipples
4. Use of a nipple shield (She was off the shield until she got teeth recently. Now, she's back on because it dulls the impact of the bite.Ouch!)
5. Sleeping position- I sleep on my right side most of the night, snuggled up to M

I'm treating this current case with allopathic and homeopathic remedies. So far, this is what I've tried:

A. I'm on day two of a 10-day course of antibiotics
B. Hot compresses on the clogged duct- I use a sock filled with rice and warmed in the microwave
C. Fresh cabbage leaves applied directly to the breast to draw out infection (It sounds wacky, but even the doc at the walk-in clinic suggested this approach)
D. Ibuprofen- OTC dose whenever I have a fever- So far, 6 doses in 36 hours
E. Tablespoon of soy lecithin- I mix it in with applesauce or oatmeal
F. Lots of vitamin C- I've been drinking EmergenC
G. Most important- Nursing frequently on the infected side with M's chin in the direction of the clogged duct

Usually, that all works, but I'm still feeling pretty crummy and having difficulty clearing out the clogged duct. This evening (Sunday), I called my family doctor to make an appointment for tomorrow morning. I'm hoping I'm better by then, but just in case, I want to nip this in the bud.

Update

I never was able to get into my doctor's office. When I called for an appointment, the nurse called back saying to use a hot compress and take tylenol. :/ I don't think she gave the doctor all of the information I shared, but ultimately it worked out fine. It took the full course of antibiotics to get rid of the infection. And despite taking a probiotic and eating plenty of greek yogurt, I now have thrush. More on treating thrush later...

Learning how to nurse

When M was born, we were immediately separated for two hours, while we were each 'under observation.' Our full term, 9 1/2 lb, healthy girl was carted off to the NICU because there was meconium in the amniotic fluid. This is common in an infant born after 40 weeks. When M was born, her breathing and heart rate were normal, and her apgar scores were high. She had no signs of Meconium Aspiration Syndrome, yet she was whisked away.

My parents got a good look at M before I did. I was vomiting when they tried to show her to me, an effect of the anesthesia. Mom said M looked like a giant baby compared to all the preemies in the NICU. When they finally brought our baby to me, I was relieved. But somehow, it was like being handed a stranger. I didn't feel her come out; I didn't hold her while she was gray and squishy; I didn't even have a chance to offer her milk. When she was finally in my arms, she was dressed in baby clothes from the hospital, wearing a diaper and swaddled in a blanket.

Months before her birth, I watched this great video illustrating how babies will crawl to the breast and latch. Nursing our children is the most natural part of life. It's instinctual.



According to the World Health Organization (WHO), it is recommended that breastfeeding is initiated within 60 minutes of birth. Infants also shouldn't be offered any artificial nipples or pacifiers. Because of our unnecessary separation, we didn't have that opportunity. When the time came to nurse M, the hospital lactation consultant (LC) told me my nipples were flat and handed me a plastic nipple shield. M latched a few times that day, but because of the plastic device, never got much colostrum. I was exhausted, and while B was on baby duty for 2 hours the first night, he found a pacifier gifted by a well-meaning relative. When I woke to see the device, I let B know we would not be using that. But it was too late. M wouldn't latch again. And to this day, M uses a pacifier at night.

Less than 24 hours after M's arrival, another LC insisted our healthy, 9 1/2 lb, full term baby needed to supplement since she hadn't latched again. So, I sat with a breast pump attached to my boobs, trying to get my milk to come in. Across the room, B gave M a bottle of formula. We were able to order donor mother's milk, but not 'in time' for M's feeding. The next three days in the hospital, M had donor milk from a bottle provided by dad while I cried and tried to get my milk to come in. I also continued to try to get M interested in getting milk from me instead of the bottle, but to no avail.

My milk came in on the fourth day, but it took M 3 1/2 weeks to latch. That may not seem like much time, but to a new mom, that is an eternity. And it took even longer for us to bond...but that's a topic for another post. We read books upon books about childbirth and breastfeeding before M arrived. We knew the WHO guidelines, and we hired a post-partum doula to come to our house. But being medicated and exhausted in an environment with 'experts' telling us what to do, we just didn't have the presence of mind or strength to fight it. As first time parents, who were we to argue with the pediatrician insisting M needed formula within her first 24 hours of life? And when the LC was attaching bizarre devices to my breast, like the SNS (a complicated feeding tube), I trusted that it was a necessary evil.

Thankfully, we have a secure, attached relationship, and our little one, now 8 months old, nurses like a champ. With the support of our post-partum doula, local La Leche League chapter, and midwife and family who believe in breastfeeding, we were able to jump those initial hurdles. We spent three and a half weeks enjoying skin-to-skin contact and frequently offering the breast. M rooted instinctually, but a nipple is so different from the plastic substitutes that it took time for her to figure out the real thing. A visit to a recommended LC in town finally ended in a successful latch. M was exclusively breastfed for 6 months, and she still only gets tastes of whole foods.

La Leche League has excellent resources for mothers planning to breastfeed:

http://www.llli.org/

Attending meetings before and after M was born ensured our success.