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which growth chart to use for my baby, who growth charts, why growth charts matter

Why growth charts matter: using WHO growth charts for your baby

Rebecca Costello, IBCLC MPH

It is not uncommon to hear parents concerned about their chest/breastfed children’s growth “slowing down” around 4 months – the baby’s weight percentile dropping and the baby slipping down the growth curve. Often they’re told that this is “common” or “normal”, and not a cause for concern.

Unfortunately, while it’s good the parents get reassurance, their pediatric care providers are wrong in giving parents the impression that their child’s growth slowing – while perhaps “common” – was “normal”. In fact, they were wrong in giving parents the impression that it was slowing at all! And once that idea is planted in a your head, it’s hard to erase the underlying anxiety you might have, despite reassurance to the contrary, that your milk is no longer quite keeping up with your baby’s needs.

The fact is, some pediatricians’ offices still use growth charts developed in 1977, based on a small sample of babies in Ohio who were primarily formula fed. Similarly, even the 2000 Centers for Disease Control (CDC) growth charts are based on a sample of mixed breast/formula feeders. Formula fed babies grow more slowly than breastfed babies in their first few months of life, then begin to grow more quickly than breastfed babies. When we chart breastfed babies on the formula fed growth chart, it makes breastfed babies look nice and high on the chart for the first few months, and then start to look like they are faltering.

What does it look like when breastfed babies are tracked on charts that accurately reflect their growth? To do that, the newest World Health Organization (WHO) growth charts are a far better choice than any of the CDC charts. The WHO charts are based on a worldwide sample of infants who received optimal breastfeeding and complementary feeding.

This article from the Journal of Nutrition does an excellent job of discussing some of the differences between the CDC and WHO growth charts. They have several great illustrations as well to help you visualize how the growth charts differ:

This chart shows the difference between weight-for-age curves in boys ages 0-60 months. You can see how around 4-6 months, the CDC chart line crosses over the WHO line and generally stays above – sometimes quite high above – the WHO line up through age 5.

I like this chart even better, which shows how an average infant from the WHO sample would track on each chart. A baby who tracks normally on the WHO chart (staying fairly even in growth after an initial drop) looks very different on the CDC chart: after an initial rise the baby appears to slowly fall down the growth curve from the age of 2 months on.

One parent I talked to went back and plotted her all of her children’s growth on the WHO charts herself! She was pleased to see that all of a sudden, instead of slipping down the chart, they were tracking beautifully along the growth curves. She knew all along that they were healthy and feeding well, but it’s always nice to have it confirmed that the charts were wrong – and her instincts were right.

Happily, the CDC formally recommends that all clinicians switch to the new WHO growth charts for ALL infants and toddlers up to 2 years of age. (Note that this means not just breastfed babies – the CDC recognizes that those charts reflect optimal infant growth, and that the more rapid growth of formula fed babies is a potential cause for concern.) If you have kids, do you know which charts their pediatrician or family doc is using? Do your care providers know about the CDC encouraging the growth chart switch?

P.S. Let’s also keep in mind the relative importance of growth charts. I’ve had some great conversations in breastfeeding-related courses about the overall silliness of the American obsession with having every baby “above average” on the growth charts. It’s as if scoring 95th percentile on the growth chart is like getting an A on an important test. Growth charts are tools to be used in conjunction with other indicators of a baby’s health and intake, they do not reflect the normal growth of every child, and it is just as normal and healthy for a baby to consistently be in the 5th percentile as in the 95th. Phew! I’ve said my piece.

Help! Why is my newborn not latching?

Help! Why is my newborn not latching?

Rebecca Costello, IBCLC MPH

When your newborn is placed in your arms, one of their most fundamental things you expect to be able to do is FEED them. So when your newborn’s not latching, it’s easy to feel panicked, rejected, discouraged, or all of the above!

The good news is that newborns are VERY adaptable. Absolutely everything is new to them, and they can forget old habits and learn new ones pretty quickly. So if they’re not latching, it usually doesn’t take long to teach them.

The bad news is that their forgetfulness means that latching can feel like a “two steps forward, one step back” process. You’ll have a couple great feeds in a row, and then the next one it feels like they’ve forgotten everything that they’ve learned. Don’t get discouraged – with a little practice, this phase will soon be a distant memory! 

I’ve worked with thousands of newborns who weren’t latching, and often a few simple tips were all their parents needed to get them latched and feeding beautifully. Here are some common scenarios where a newborn doesn’t latch, and what to do about them:

Newborn not latching scenario #1: They’re sleepy – they just won’t wake up or open their mouth enough to eat.

The first 24 hours of a baby’s life are usually pretty snoozy ones. They’re tired from birth, they may still have amniotic fluid in their tummy making them feel full, and they’re not really feeling a strong need to eat yet. Keep waking them up to offer them regularly, but don’t panic that this means your baby won’t ever latch. Ask for someone to show you how to hand express your colostrum into a spoon so you can feed it to them. What you express doesn’t look like much, but their tummy capacity on that first day is very tiny! They’ll benefit from every drop you can give them, and often the taste of milk gets them interested in latching. Do lots of skin-to-skin between feeds, rest, and prepare for the second night after birth when they’ll be feeding non-stop.

If your baby is older than 24 hours and still not waking up to eat, we want to get a little more pushy. Getting them undressed, changing their diaper, using a cool wipe on their body, and tickling them can all help wake them up. If you haven’t been able to wake your baby up for 2 feedings in a row, contact your baby’s doctor to check in.

Newborn not latching scenario #2: They’ll latch and suck a few times, then fall off…then latch, then fall off…over and over until they get frustrated.

Newborns, despite not having a whole lot of skills, are pretty smart when it comes to feeding! If they realize they don’t have the nipple far enough back in their mouths to get a good suck going, they’ll usually let go and start again. 

While it looks like they’re latching and sucking in this case, the latch is probably so shallow that when the baby does a few “test sucks”, they realize it’s wrong and start again. You may notice that you barely even feel those sucks – that’s because of the shallow latch. And while it may look like your baby is feeding when they do this, they aren’t actually getting much milk out. That’s why they start getting frustrated! Help your baby get on more deeply – see the deep latch tips below.

Newborn not latching scenario #3: They’ll suck on a bottle, paci, or finger, but when you try to latch them they just scream and shake their head back and forth frantically.

If you stick your (clean) finger into your baby’s mouth, you’ll notice they almost always suck willingly. Why is that? They have a “trigger spot” on the roof of their mouth – when it’s touched, it triggers them to suck. It’s easy to find and put pressure on that spot with your finger. That’s because your finger is longer and firmer than your nipple – same goes for bottle and pacifier nipples.

If your baby is willing to suck on your finger, but is just screaming and shaking their head when you try to latch them, they may just need a little more help finding the nipple. See the tips below for getting a deep latch.

Newborn not latching scenario #4: They’ve gotten a few bottles, and now they don’t want to latch anymore.

Bottles feel very different to newborns than your nipple does – see above about bottles hitting the “trigger spot” in the roof of their mouth. Plus the milk flows much faster, too – who doesn’t like an easy meal? When the baby goes to latch on to you again, the feel and flow is more difficult. So they fuss until they get the bottle again, which reinforces their bottle skills even more.

Remember, babies can learn and forget very quickly – so if they’ve “learned” the bottle most recently they may have “forgotten” your nipple. It can help to make your own anatomy feel more like the bottle for a few feeds, then ease them back into latching without the extra tools. This may mean:

  • adding a nipple shield (with careful monitoring – see below)
  • an extra flow of milk via a syringe or at-breast supplementer (an IBCLC can help with this)
  • or just using some of the tips below to make sure they’re getting as deep a latch as possible.

The key is to keep trying! Many babies well past the newborn stage have re-learned how to latch. So if your baby is a few days or a few weeks old, they’re easily still in the zone for learning.

Deep latch tips:

  • Try different positions (football, laid back, cross cradle, side lying) to see if those help get your nipple into your baby’s mouth at a better angle.
  • Make a “nipple sandwich” – position your fingers just outside of your areola (the dark part around your nipple) and compress, to make it easier for your baby to grab on
  • If you’re engorged, do reverse pressure softening (pressing gently around the base of the nipple to soften it up) for a few minutes before trying to latch
  • If you’re in the hospital, ask for lots of hands-on help from your nurses and/or lactation consultants
  • If you have short or flat nipples, someone may suggest using a nipple shield – these can be very useful, but should be used with close monitoring of your baby’s weight. Some babies have difficulty getting milk out with the shield – you want to make sure your baby is getting enough! You should also ask for a follow up appointment with a lactation consultant to help you learn how to feed without the shield, once your baby has gotten the hang of feeding with it.

Still struggling with your newborn not latching?

It’s time for a visit with a lactation consultant! I’ve found that often a single visit is all a family needs to leave latching successfully. Try to find an IBCLC local to you for hands-on help; if you haven’t found anyone, contact me and we’ll discuss whether a virtual visit might help. If not, I’ll help you look for your closest resources. 

In the meantime, pat yourself on the back – you are doing a great job, and you will figure this out!

Can a “relief bottle” help you get more sleep with a newborn?

Rebecca Costello, IBCLC MPH

The problem: broken sleep

Some people have virtually no problems while nursing their new baby, while others feel like they’re working down the list, checking off every possible problem you could possibly have! But there’s one struggle that’s almost universal: sleep.

There’s a simple biological reason behind this: newborns have tiny tummies and they’re not very efficient eaters. So by the time one long feeding session is done, it feels like it’s almost time for the next one to start! Many people discover that by the time they get the baby settled, they only have time for an hour or two of sleep before the baby’s asking to eat again.

Newborns are happy to sleep this way – in fact, their REM sleep cycles are designed for short sleep stretches. But adults are not!

The advice to “sleep when the baby sleeps” is a wise one – despite the shorter stretches, your baby is getting 15+ hours of sleep every day! So if you join them in their daytime naps, you’ll get a lot more sleep than if you try to stick to a more conventional adult sleep schedule.

But some people have difficulty sleeping during the day, and others don’t feel restored by these short, newborn-length bursts. If you can’t get enough sleep, it’s not unusual to feel stretched to (and past) your breaking point. In a study that looked at the correlation between sleep and postpartum depression symptoms, how well someone slept (for example, how many times they woke up) appeared more important than how long they slept in total (adding up all the minutes they slept). For those who are dealing with postpartum mood disorders like depression and anxiety, protected sleep can be part of the treatment plan.

Whether you’re coping with postpartum mood issues, or just desperate for a night or two to catch up, you may hear people suggesting a “relief bottle”.

Can a "relief bottle" help you get more sleep with a newborn?

What’s a relief bottle?

A relief bottle means that instead of you waking up for a middle-of-the-night feeding, you sleep while someone else gives a bottle of milk that you pumped earlier. Timed right, you may be able to get 4, 5, even 6 hours of sleep before you need to wake up for the following feeding. (Would pre-baby you have thought that was a lot of sleep? Probably not, but now you appreciate it!)

But you may have questions – will the baby still nurse well? Will it impact your milk supply? When will you pump? Here are some thoughts about when a relief bottle might help – and when it might not:

Can a “relief bottle” help you?

Relief bottles may not help if…

You get so full, so quickly, that you wake up at the next feeding time anyway. Some people make so much milk, at least in the early days, that they can’t go longer than a few hours without emptying before they get very uncomfortable. You may be able to prolong this by nursing or pumping right before you lie down, but if your full, aching chest wakes you up 3 hours later, you’ll probably decide it’s easier just to nurse the baby again.

You have trouble fitting in pumping sessions throughout the day to get enough milk together for the overnight bottle. When you’re nursing non-stop, you may wonder how you could possibly find time to pump when you can’t even find time to go to the bathroom! Passive suction milk collectors like the Haakaa may help, but not everyone gets much milk with these.

Relief bottles may help if…

You have a support person who will use paced bottle feeding techniques to give your baby the bottle, to minimize the chances your baby will have difficulty going back to nursing.

You have a space where you can sleep separately from your baby and support person, so their noise doesn’t wake you up when the next feeding time comes. If you live in a small apartment or house, you may need to get creative – earplugs and/or a white noise machine can help you stay asleep.

You’re able to pump enough milk at other times of the day to get enough for a feeding. (Often 1.5-3 oz for a newborn, depending on their weight and how often they feed.)

Could you give formula or donor milk in the bottle instead, so you don’t have to pump?

Yes – but it may impact how much milk you make. Milk production is based on a supply and demand system. Pumping – even if it’s not at the exact same time as the feeding – tells your body that there’s a demand for milk. If you simply skip a feeding and don’t pump at another time of day, your body will see that there’s less demand for milk. Your body will then begin to decrease your milk production. (How much of an impact it will have is hard to predict, and depends on a lot of individual factors.) This trade-off may be worth it to you, or it may not – only you can decide. Don’t let other people or outside expectations pressure you into making decisions that don’t feel right for you.

Reach out if you need more help

Whether or not a relief bottle is right for you, if you feel like you’re at the end of your rope with how to balance sleep and feeding – reach out. I have supported many parents through managing their sleep needs while continuing to nurse their babies – it does not have to be an either/or choice! An International Board-Certified Lactation Consultant can also help you think through how to manage your feeding goals while taking care of yourself – look for one local to you, and feel free to reach out to me if you need help with the search.

If you’re concerned about postpartum depression or anxiety, reach out to your care providers (no, you don’t need to wait until your next appointment – you can call them now), talk a trusted friend or family member, or use the resources and helpline through Postpartum Support International.

Almost no one looks back at this time in their baby’s life and says “Wow, I slept so well! That was so easy!” – but I hope you can look back and say “I had the resources I needed to manage through a challenging phase in my baby’s life.”