Send letter to journal:
Re: Postnatal Weight Monitoring Should Be Routine

Dear Editor,

The case reports of Shroff et al document a serious clinical problem with potentially devastating consequences. The tragedy of this situation is that the affected infants are all perfectly healthy and, if we only look for it, the condition is preventable. Local experience of precisely such a case led to the introduction of routine post-natal weight monitoring of infants during the first two weeks of life. This policy met with a great deal of resistance on the basis of three unsubstantiated arguments: that inadequately feeding infants can be recognised from other clinical cues, that we don’t know what degree of weight loss is acceptable and that demonstrating weight loss will discourage mothers from continuing to breast-feed.

Hypernatraemic dehydration associated with breast feeding is a problem throughout the U.K. [1-3] Our experience [4] and that of Shroff et al denies that inadequately feeding infants can be reliably recognised from clinical cues. Infants who are not adequately breast-feeding have been reviewed by doctors, health visitors and midwives without any recognition of the clinical problem. If the problem is not recognised due to subjective clinical assessment then it cannot be remedied. In contrast monitoring postnatal weight loss provides an objective assesssment of the adequacy of nutritional intake allowing targeted support to those mothers those infants are failing to thrive or demonstrating excessive weight loss.

Claims that we don’t know what degree of weight loss is acceptable have been addressed by our study of post-natal weight change, which set out clear upper centiles for the degree and timing of initial weight loss and time taken to regain birthweight [5]. This has allowed us to develop clear guidelines for providing additional support to breast-feeding mothers. We now weigh babies routinely around days 3, 6 and 10 with continued monitoring of those who have not regained their birth weight. Breast fed infants with more than 10% weight loss are referred to specialist breast feeding support sisters for supervised feeding, advice on positioning and milk expression. In addition paediatric medical staff see and monitor infants who lose more than 12.5% of their birthweight.

Anecdotal cases may suggest that demonstrating weight loss or poor gain could discourage mothers from continuing to breast feed; however other mothers may be reassured and encouraged to continue breast feeding. We have found no evidence that such weight monitoring discourages mothers from continuing to breast-feed [6]. Our monitored population (in contrast two local control groups) actually demonstrated an increase in six-week breast-feeding rates after introducing a policy of routine weight monitoring.

It would be nice if that which was natural and best could always be easily established, but we must recognise that sometimes it can be hard. We can serve breast-feeding mothers best if we identify those who are having difficulties and provide early help and support. The arguments against routine weight monitoring have been addressed and it is time to offer this safety-net to all infants.

References

1. Laing IA, Wong CM. Hypernatraemia in the first few days: is the incidence rising? Arch Dis Child Fetal Neonatal Ed 2002;87:F158–62.

2. Harding D, Moxham J, Cairns P. Weighing alone will not prevent hypernatraemic dehydration. Arch Dis Child Fetal Neonatal Ed 2003;88:F349–50.

3. Oddie S, Richmond S, Coulthard M. Hypernatraemic dehydration and breast feeding: a population study. Arch Dis Child 2001;85:318–20.

4. Macdonald PD, Grant L, Ross SRM. Hypernatraemia in the first few days: a tragic case. Arch Dis Child Fetal Neonatal Ed 2003;88:F350

5. McKie A, Young D, Macdonald PD. Does monitoring newborn weight discourage breastfeeding? Arch Dis Child 2006;91:44-46.

Send letter to journal:
Re: Risk factors for excess weight loss and hypernatraemia in exclusively breast-fed infants

Dear Editor,

We have read with great interest the article by Shroff R. and et al (1) which appeared on May 2006 issue. Weight loss up to an acceptable degree (<10%) is a physiological event unless a negative imbalance occurs between weight loss and milk production. We have recently shared our expriences related to risk factors for excess weight loss and hypernatraemia in exclusively breast-fed infants (2).

Data were prospectively obtained from exclusively breast-fed healthy term neonates at birth and from healthy mothers with no obstetric complication to determine risk factors for excess weight loss and hypernatraemia in exclusively breast-fed infants. Thirty-four neonates with a weight loss > 10% were diagnosed between April 2001 and January 2005. Six of 18 infants who were eligible for the study had hypernatraemia. Breast conditions associated with breast-feeding difficulties (P < 0.05), primiparity (P < 0.005), less than four stools (P < 0.001), pink diaper (P < 0.001), delay at initiation of first breast giving (P < 0.01), birth by cesarean section (P < 0.05), extra heater usage (P < 0.005), extra heater usage among mothers who had appropriate conditions associated with breast-feeding (P < 0.001), mean weight loss in neonates with pink diaper (P < 0.05), mean uric acid concentration in neonates with pink diaper (P < 0.0001), fever in hypernatremic neonates (P < 0.02), and the correlation of weight loss with both serum sodium and uric acid concentrations (P < 0.02) were determined. Excessive weight loss occurs in exclusively breast- fed infants and can be complicated by hypernatremia and other morbidities. Prompt initiation of breast-feeding after delivery and prompt intervention if problems occur with breast-feeding, in particular poor breast attachment, breast engorgement, delayed breast milk "coming in", and nipple problems will help promote successful breast-feeding. Careful follow-up of breast-feeding dyads after discharge from hospital, especially regarding infant weight, is important to help detect inadequate breast-feeding. Environmental factors such as heaters may exacerbate infant dehydration.

References:

1. Shroff R, Hignett R, Pierce C, Marks S, van't Hoff W. Life-threatening hypernatraemic dehydration in breast-fed babies. Arch Dis Child 2006 0: adc.2006.095497

Send letter to journal:
Re: Preventing hypernatraemic dehydration in babies- Time for action.

Dear Editor,

It was interesting to read the case report by Shroff et al (1) on hypernatraemic dehydration in breast fed babies. Recently published retrospective study from the USA (2) also showed that breast feeding associated hypernatraemia is under diagnosed and its incidence is rising. It is not clear why the incidence of breast feeding associated hypernatraemia is rising, but early discharge from hospital(3) or a higher incidence of breast feeding (2) do not appear to be causing this. Dewey et al had shown that 16% of exclusively breast fed infants born to primiparous women had >10% weight loss by day 3 of life, despite education and support provided by a lactation consultant (4). It is estimated that 10% of breast fed infants develop hypernatraemia (5) and about a third of breast fed infants with weight loss exceeding 10% have hypernatraemia (6). Weight loss and inadequate stooling are sensitive indicators of dehydration among breast fed infants and should be included in the history and evaluation of all infants presenting with feeding difficulty. It is of interest to note that none of the children in this case report had abnormal neurological sequelae, even though all of them required significant medical care. Gucuyener et al had shown that more than one half of infants admitted with breast feeding associated hypernatraemia showed abnormal development on long term follow up (7).

All efforts should be made to promote successful breast feeding and to prevent breast feeding associated hypernatraemia. All breast fed infants should be evaluated by an experienced health care professional between 3 and 5 days of age and this should include a weight check, assessment of breast feeding, infant elimination pattern and assessment of hydration and jaundice. Babies with excessive weight loss or inadequate breast milk transfer should be offered expressed breast milk if available and formula milk if necessary until breast milk production is increased. All the health professionals involved including paediatricians and midwives should take an open approach to supplementary feeding in this select group of babies and breast feeding difficulties should be addressed by a health care provider well trained in lactation support. Both health professionals and parents need better education and guidelines on preventing, identifying and treating breast feeding associated dehydration and this should be a part of the breast feeding promotion campaigns by the Department of Health (UK) and other agencies. Royal College of Paediatrics and Child Health (RCPCH) should take necessary steps to ensure that all the trainee paediatricians get enough training opportunities to deal with breast feeding related complications.

Competing interest to declare: none

References:

1. R Shroff, R Hignett, C Pierce et al: Life-threatening hypernatraemic dehydration in breastfed babies Arch Dis Child 2006; 91:1025-26

2. M.Moritz, M.D.Manole, D.L.Bogen et al. Breastfeeding-Associated Hypernatremia: Are We Missing the Diagnosis? Pediatrics Vol. 116 No. 3 September 2005, pp. e343-e347

3. Edmonson MB, Stoddard JJ, Owens LM. Hospital readmission with feeding-related problems after early postpartum discharge of normal newborns. JAMA. 1997;278 :299 –303

4. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behaviour, delayed onset of lactation, and excess neonatal weight loss. Pediatrics. 2003;12 :607 –619

5. Marchini G, Stock S. Thirst and vasopressin secretion counteract dehydration in newborn infants. J Pediatr. 1997;130 :736 –739

6. Oddie S, Richmond S, Coulthard M. Hypernatraemic dehydration and breast feeding: a population study. Arch Dis Child. 2001;85 :318 –320