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3.5 Slowing of growth

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.
You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or choose to bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.
Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.
Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.
Topic 3.4: Milk composition
The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant.
Is there any concern about a slowing of growth around this time?
Topic 3.5: Slowing of growth
Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.
Is there any concern about a slowing of growth around this time?

Infant growth is highest in the first few months postpartum and then begins to slow so a decrease in the rate of growth at this age is normal. Additionally, after three months of age breastfed infants gain weight at a slower rate than formula-fed infants, so that by six months they are lighter1 and this is maintained until at least twelve months.2

Most growth charts in use were developed in the United States from cross-sectional data of cohorts of infants who were mainly formula-fed, or contained a mixture of formula-fed and breastfed infants. On these charts, breastfed infants often began to deviate from a specific percentile after four to five months although they continued to thrive otherwise. In 2006 the WHO released new growth standards based on longitudinal data of healthy breastfed infants and children from seven countries. These charts reflect how well-nourished breastfed infants 'should' grow rather than the actual growth in a given population.3,4 In comparison to the CDC charts commonly used, the mean weight in the WHO standards is higher for the first six months but is lower from 6 to 32 months.5WHO standards for infant BMI are also available to allow for difference in growth parameters between different racial groups.

Notes

  1. # Dewey KG et al. (1992) Growth of breast-fed and formula-fed infants from 0 to 18 months: The DARLING study
  2. # Dewey KG et al. (1993) Breast-fed infants are leaner than formula-fed infants at 1 y of age: the DARLING study
  3. # Grummer-Strawn LM et al. (2010) Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States.
  4. # Tawia S (2009) The WHO Child Growth Standards: are they an inconvenient truth?
  5. # de Onis M et al. (2007) Comparison of the WHO Child Growth Standards and the CDC 2000 Growth Charts