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EXCLUSIVELY BREASTFED INFANTS: FIRST 6 MONTHS OF LIFE

Should we be concerned about RAPID WEIGHT GAIN?

Concerns about exclusive breastfeeding (EBF) usually arise, when a baby is not gaining enough weight or is put in the category of “failure to thrive”. Ever so often however, I have mothers of exclusively breastfed babies come to me crying that they and their baby’s paediatrician are concerned that the baby is being overfed.

 

Background

In general, it is recommended that healthy full-term babies, be exclusively breastfed on demand. “This may range from 8-14 or more feedings daily (Lauwers, Swisher, 2021)”. As often as the baby wants and for as long as the baby wants. Technically you cannot overfeed a breastfed baby as they will generally stop when they are full. However, there may be increased frequency, referred to as cluster feeding and may happen when they are teething, getting sick, or about to achieve a new developmental milestone. This is also seen during growth spurts which typically happen between 10 days and 2 weeks old, around 6 weeks old, 12 weeks old and 6 months old.

Overfed? Feeding Cues

In my assessment of mothers who are concerned about their exclusively breast-fed baby being overweight or overfed, I usually ask about their recognition of feeding cues, the frequency and length of feeding time as well as spit up patterns. Excess spitting up is also a sign of reflux (evident in both breast fed, and formula fed babies).

Tips such as:

  • resting your baby on an incline after feeding,
  • encouraging paced bottle feeding,
  • checking the flow of a nipple,
  • assessing the consumption of fore milk vs hind milk and adjusting accordingly (in breast fed babies)

are usually recommended.

Restriction of feeds, whether reducing the amount of milk per feeding session or stretching out the time between feeds is never recommended.

If a baby is continuously spitting up and has a distended stomach, then this indeed may be a case of overfeeding, in that case it is necessary to discuss feeding cues with the family.

Overweight EBF Babies

It is important to note that there aren’t many studies that provide information surrounding rapid weight gain in exclusively breastfed babies, so I genuinely understand the concern in the paediatric fraternity. Most studies supply conclusions surrounding long term obesity in formula fed babies, understandably so because formula feeding has been quite common. However, considering the gradual change in mother’s desire to exclusively breastfeed for varying reasons (keeping in mind our current formula shortage crisis) there is dire need for further research in this area.

WHO, AAP, CDC, MOHW and many other international health organizations recommend exclusive breastfeeding for 6 months, after which there is the introduction of complementary foods and continued breastfeeding for up to 2 years and beyond. It is in our best interest to encourage mothers who have committed to this action for their babies as it is no easy feat.

The suggestion or recommendation of restricting feeds for an EBF infant can create significant stress for the lactating mother as well as for a healthy hungry child. Mother may think by feeding her baby she is doing something wrong! This can disrupt the feeding dyad and lead mothers to wean early, supplement or replace breastfeeding with formula unnecessarily and introduce other foods before 6 months. If you are uncomfortable managing an overweight or overfed EBF infant reach out for support.

Should you have any questions or concerns, would like to have a discussion on the above matter, please do not hesitate to contact me.

Simeca Alexander-Williamson, BSc. D/N, MPH, IBCLC

(876)871-4849 consultant@cradleoflifeltd.com

Below are resources that support the concept that rapid weight gain in exclusively breastfed babies in the first 6 months of life is normal.

  • ·         “If your exclusively breastfed baby has tripled his birthweight by three or four months and is already causing you an aching back, people may suggest supplements or solid foods because he’s so big or may warn you that your “chunky monkey” is on the way to a lifetime of obesity. No worries. Unlike formula-fed babies, exclusively breastfed babies who gain rapidly are not at an increased risk of obesity. Most of these babies start to slow their growth by size months or so and once they become mobile, they tend to slim down quickly” (The Womanly Art of Breastfeeding, 2010).

·         It is normal for breastfed babies to gain weight more rapidly than their formula-fed peers during the first 2-3 months and then taper off (particularly between 9 and 12 months). There is absolutely NO evidence that a large, breastfed baby will become a large child or adult. https://kellymom.com/bf/normal/weight-toomuch/#:~:text=It%20is%20normal%20for%20breastfed,a%20large%20child%20or%20adult.

·         It is a common concern that exclusively breastfed babies are chunky. This is usually normal and just your baby’s own growth pattern. Often these chunky babies become very lean and light when they start to crawl, walk, and run. https://www2.hse.ie/babies-children/breastfeeding/a-good-start/concern-about-overfeeding/#weight-gain

·         Breastfed infants with excessive weight gain, had catch down growth when other foods were introduced. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6164044/

·         While factors related to exclusive breastfeeding may be responsible for high weight gain, there is a marked decrease in standard deviation scores when other foods are introduced. It is still the general belief among health personnel that there is no reason to worry about exclusively breastfed infants with high weight gain. https://doi.org/10.1177/0890334418756580

·         Both infant feeding practices and rapid weight gain determine different growth trajectories in terms of BMI and weight during childhood. Even though infant feeding practices do not seem to mediate the association between early rapid weight and BMI later in life, formula feeding is independently related to higher BMI growth patterns later in childhood. 10.3390/nu12103178

·         Babies need a diet high in fat to support growth during infancy. A baby who’s exclusively breast-fed gets about half of his or her daily calories from the fat in breast milk. As a result, caloric restrictions aimed at reducing weight are not recommended for babies 2 years and under. https://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/expert-answers/baby-fat/faq-20058296#

Below is information from the WHO with respect to interpreting growth charts

·         If a child has gained weight rapidly, look also at height. If the child grew in weight only, this is a problem. If the child grew in weight and height proportionately, this is probably catch-up growth from previous undernutrition, because of improvement in feeding or cure of previous infection. In this situation, the weight-for-age and height-for-age charts should show inclines, while the weight-for-height growth line tracks steadily along the z-score curves.

·         BMI does not normally increase with age as do weight and height individually. Looking at the BMI-for-age charts in the Growth Record, you will notice that an infant’s BMI goes up sharply as the infant rapidly gains weight relative to length in the first 6 months of life. The BMI comes down in later infancy and remains relatively stable from age 2 to 5 years. https://apps.who.int/iris/bitstream/handle/10665/43601/9789241595070_C_eng.pdf?sequence=3&isAllowed=y

Baby from birth to 6 months of age

Is the baby exclusively breastfed? If yes, →

• Encourage the mother to feed only breast milk until age 6 months.

• Reassure the mother of an exclusively breastfed infant that such babies become leaner when they begin to crawl and walk.

• Encourage the mother to continue breastfeeding until 2 years of age and beyond.

https://apps.who.int/iris/bitstream/handle/10665/43601/9789241595070_JobaidCauses_eng.pdf?sequence=13&isAllowed=y

Babies are considered overweight if they are approximately 2 categories above the weight-for-height standard, as determined by standard height and weight charts. A normal weight gain is 1 to 2 pounds per month for the first 4 or 5 months of life. This rapid weight gain should not continue into the second half of the year. An older baby who often spits up or vomits from an overly distended stomach may be overfed. In such a case, milk production may be overly abundant. It is possible to shorten or decrease feedings and substitute other activities for breastfeeding until the spitting up diminishes.

Overfeeding may potentially occur when a baby nurses frequently for comfort or has a great sucking need. You can suggest other ways to comfort the baby so that feeding is not used as a response to every cue. These include:

·         Nurse at one breast per feeding allowing the baby to continue to suckle on the less full breast

·         Learn other ways to interact such as reading, singing or simply talking with the baby

·         Interest the baby in other activities including tummy time or playing with age appropriate toys

 

(Lauwers, Swisher, 2021)”.

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