Baby-Friendly Practices Minimize Newborn Infants Weight Loss

Abstract

Introduction:

It is accepted that newborns lose weight in the first few days of life. Baby-Friendly practices that support breastfeeding may affect newborn weight loss. The objective of this study were: 1) To determine whether Baby-Friendly practices are associated with term newborn weight loss day 0–2 in three feeding categories (exclusively breastfed, mixed formula fed and breastfed, and formula fed). 2) To determine whether Baby-Friendly practices increase exclusive breast feeding rates in different ethnic populations.

Materials and Methods:

This was a retrospective case–control study. Term newborn birth weight, neonatal weights days 0–2, feeding type, type of birth, and demographic information were collected for 1,000 births for the year before Baby-Friendly designation (2010) and 1,000 in 2013 (after designation). Ultimately 683 in the first group and 518 in the second met the inclusion criteria.

Results:

Mean weight loss decreased day 0–2 for infants in all feeding types after the initiation of Baby-Friendly practices. There was a statistically significant effect of Baby-Friendly designation on weight loss for day 0–2 in exclusively breastfed infants (p < 0.01) after controlling for birth weight. Exclusive breast feeding increased in all ethnic groups after Baby-Friendly practices were put in place.

Conclusion:

There was a decrease in mean weight loss day 0–2 regardless of feeding type after Baby-Friendly designation. Exclusive breast feeding increased in the presence of Baby-Friendly practices.

Introduction

Seven to ten percent weight loss in newborns has long been accepted as “normal” and continues to be accepted by professional organizations such as the American Academy of Pediatrics (AAP).¹ More weight loss than normal may indicate poor feeding and often requires medical intervention such as supplementation, or even hospitalization. A weight loss of ≥10% is considered the point at which intervention is required.²

Traditional hospital practices include long periods of mother–baby separation, early infant bathing, frequent supplementation, and tight swaddling. None of these practices has been found to be beneficial to infants and may contribute to newborn stress.^3,4 What is not known is whether or not these practices contribute to newborn weight loss. The “Baby-Friendly Hospital Initiative” represents 10 evidence-based practices, including exclusive breast feeding and support for the mother and baby remaining together 24 hours a day.⁵ The initiative is endorsed by the AAP, American Academy of Nurses, and the Association of Women's Health, Obstetric and Neonatal Nurses among others. In 2015 just 14% of babies born in the United States were born in hospitals with the Baby-Friendly designation.⁶ The hospital where this study took place was awarded Baby-Friendly status in March of 2012.

In the years before 2012 separation of infants was a common practice at the study site, and skin to skin care at birth was not consistently observed. Advertisements for formula companies were posted in clinics and indiscriminant use of infant formula occurred frequently. The elimination of these practices and the adoption of practices consistent with the “Baby-Friendly Hospital Initiative” led to Baby-Friendly designation. We designed this study to address the following questions: (1) Did term newborn weight loss day 0–2 decrease in all feeding categories (exclusively breastfed, mixed formula fed and breastfed, and formula fed) after Baby-Friendly designation? (2) Did exclusive breast feeding increase after Baby-Friendly designation in Black, Hispanic, and White non-Hispanic ethnic groups?

Literature review

A search of the literature using EBSCHOHost with Medline and CINAH revealed information on the benefits of breastfeeding, breastfeeding rates, successful strategies for increasing rates, and newborn weight loss. Although a number of studies were found that examined the relationship between weight loss and breastfeeding, only one study was found that examined weight loss in a Baby-Friendly designated hospital. No studies were found that studied newborn weight loss before and after the initiation of Baby-Friendly designation.

Most women decide on how they will feed their children early in their pregnancy.⁷ Studies have shown that providers have an influence on this decision.⁸ Intrapartum care also influences a woman's decision. Mothers who give birth at Baby-Friendly hospitals are more likely to initiate breastfeeding and to continue to breastfeed through 12 months.^9,10 Successful breastfeeding has been shown to be related to parity, delivery mode, length of labor, labor medications, use of supplementary fluids such as water, glucose and formula, and pacifier use.^11,12 Breastfeeding rates vary according to ethnicity. As a group, Black women have the lowest breastfeeding rates in the United States, and White non-Hispanic women have the highest rates.¹³ Latinas and Native Africans exhibit higher rates of exclusivity in their native countries than in the United States. It has been noted that breastfeeding duration is shorter in high-income countries than in those that are resource-poor.¹⁴ Breastfeeding is initiated sooner in Latin American and African countries where a traditional attendant is present and not a healthcare worker.¹⁵ The “Medicalization” of birth in the United States has contributed negatively to the natural progression from birth to breastfeeding without separation.¹⁶

There have been mixed results when researchers have compared infant weight loss in breastfed as compared to formula fed infants. Several studies have found independent relationships between infant weight loss and delayed lactogenesis and infant weight loss and intrapartum fluid administration. In a study conducted in Scotland weight loss for breastfed infants were substantially higher than for formula fed infants. The researchers did not find any connection between feeding method and the timing of weight loss. They did find that breastfed infants took longer to regain their birth weight than formula fed. Although the authors stated that their hospital observes Baby-Friendly practices, they did not indicate whether the hospital had achieved Baby-Friendly designation.¹⁷ In a study that examined weight loss in first born predominantly breastfed infants, the researchers reported that excess weight loss (defined as ≥10%) occurred in 19% of exclusively breastfed infants and 16% of infants who received minimal formula. The authors determined that excess weight loss was independently related to intrapartum fluid administration and delayed lactogenesis.¹⁸ In a small pilot study (N = 53) at a community hospital there was a mean loss of 5.69% for breastfed infants within the first 2 days of birth. These researchers suggested that weight loss in excess of 7% in some breastfed infants might be in response to diuresis as opposed to inadequate breast milk transfer. They urged that further research be conducted to look at voiding and stooling.²

In a retrospective study of 1,003 infants in Italy, the researchers reported a weight loss of 7.5% for formula fed infants and 6.3% for breastfed infants. The mean overall weight loss for the sample was 6.7%.¹⁹ They cited type of delivery, timing of first feeding, and provider support of breast feeding as important determinants in infant weight loss.

Flaherman et al.²⁰ devised a system to predict “appropriate” weight loss for exclusively formula fed and exclusively breastfed babies. The Newborn Weight Tool (NEWT) was developed in a study that included a cohort of over 100,000 newborns (gestational age ≥36 weeks). Mean weight losses at 48 hours in this study were 7.1% for infants of vaginal birth and 8% for infants of Cesarean birth.²⁰ Although this tool is useful and assists clinicians and parents in evaluating infant progress; NEWT was not developed in a Baby-Friendly setting.

Finally, Grossman et al.²¹ examined newborn weight loss at a Baby-Friendly hospital in the United States. In this study, newborns were weighed daily for the first week of life. The authors reported that clinical practices at a Baby-Friendly hospital were associated with moderate weight loss (5.5%) in exclusively breastfed and mainly breastfed infants.²¹ These researchers looked solely at newborns born post Baby-Friendly designation.

The ten Baby-Friendly steps

The 10 Baby-Friendly steps emphasize support of the mother both prenatally and in the postpartum period. The key elements of the 10 steps include education, policy, evidence-based practices, maternal support, and elimination of advertising that pulls mothers away from the normative functions of breast feeding.

The AAP recommends exclusive breast feeding for 6 months and continued breast feeding as foods are introduced for at least 1 year.¹ Using the 2006 baseline of 14.1% of infants born in 2006 and who were exclusively breastfed for 6 months in the United States, Healthy People 2020 set a target to increase the percentage of infants who are exclusively breastfed in the United States to 25.5% by 2020.²²

We did not find any studies that described term newborn weight loss before and after Baby-Friendly designation. We carried out this study to address this gap in the literature. Our hypothesis was that term newborn weight loss would decrease in infants in all feeding types (exclusively breastfed, formula fed, and mixed formula fed and breastfed) day 0–2 post Baby-Friendly designation. Our secondary purpose was to examine the impact of Baby-Friendly designation on exclusive breastfeeding rates at the study site. Our hypothesis was that exclusive breastfeeding would increase in all ethnic groups (Black, Hispanic, and White non-Hispanic) post Baby-Friendly designation.

Materials and Methods

Design

This was a retrospective, case–control study. Infants were coded as exclusively breastfed, formula fed, or mixed formula fed and breastfed. Infants born before Baby-Friendly designation (2010) were compared to infants born after Baby-Friendly designation (2013) to determine whether Baby-Friendly practices are associated with term infant weight loss in each feeding category. Mother–baby couplets from the same time periods were identified as Black, Hispanic, or White non-Hispanic and then compared to determine whether exclusive breastfeeding rates increased after Baby Frindly designation.

Measures

Term newborn birth weight, gestational age, neonatal weights days 0–2, feeding type, gender, ethnicity, and type of birth were collected for infants born in 2010 and infants born in 2013. Inclusion criteria for the study were as follows: (1) term infants (≥38 weeks gestation), (2) discharge date day 2 or 3 and, (3) born in 2010 or 2013. Exclusion criteria were as follows: (1) neonates born <38 weeks gestation, (2) neonates discharged before day 2, (3) neonates born with congenital anomalies, (4) neonates born to mothers with gestational diabetes, and (5) neonates transferred to the Neonatal Intensive Care Unit (NICU) after delivery.

Weights were recorded in grams and were rounded to the nearest tenth. Three feeding types were identified and recorded: exclusively breastfed (breast milk only feeds, no water, formula, or other foods for entire hospital stay), formula fed, and mixed formula fed and breastfed. Ethnicity was coded as Black, Hispanic, White non-Hispanic, or other/unknown.

After approval by the organization's Institutional Review Board, data were collected by the investigators through chart review using the Phillips IntelliSpace Perinatal (OB TraceVue) computer charting program. For the 2010 data, the Hospital Image Works Program was used. Image Works is the filing system for paper chart materials that the hospital started using in 2002. Paper items were scanned into the system. It was designed so that patient information could be retrieved using identification numbers.

Procedures

A number was assigned to each birth. There were a total of 2,000 births in 2010 and 2,500 in 2013. The sample consisting of 1,000 charts for each group was randomly selected from all births during the two study years. All information was recorded on an Excel spreadsheet. The data were imported to version 22 IBM SPSS for analysis.

Setting and sample

The study was completed at a Regional Perinatal Center in a community hospital located in the northeastern United States that serves an ethnically diverse, urban and suburban population. The obstetric service is comprised of a Labor and Delivery Unit, a Postpartum Unit, a Newborn Nursery, and a Level III Neonatal Intensive Care Unit. These units are staffed by registered professional nurses, a licensed practical nurse, and several certified nursing assistants. There are 14 labor and delivery beds and a total of 36 mother–baby beds (excluding the NICU).

Approximately one-third of pregnant women enter the system through the hospital's prenatal clinic. The clinic is staffed by registered nurses, physicians, and certified nurse midwives. The rest of the pregnant women who are admitted to the hospital's obstetric service are from private practice groups comprised of both physicians and midwives.

The final sample included 683 newborns born in 2010 and 518 newborns born in 2013. Table 1 provides demographic information on the sample. A majority of the sample dropped from the study occurred because of incomplete or unreadable information.

Table 1.

Sample Demographic Information

	Before Baby-Friendly (2010)		After Baby-Friendly (2013)
Characteristic	%	n	%	N
Infant gender
Female	53	360	49	252
Male	47	323	51	266
Mother's ethnicity
White non-Hispanic	34	233	53	276
Black	33	224	22	114
Hispanic	29	196	20	105
Other/unknown	4	30	4	22
Delivery method
Vaginal	65	442	64	329
Cesarean	35	241	36	189

	Mean (SD)		Mean (SD)
Gestational age	39.19 (0.87)		39.08 (0.97)
Birth weight (grams)	3368.96 (429.15)		3378.55 (449.18)

SD, standard deviation.

Data analysis

Mean percent weight loss was calculated for each feeding type before and after Baby-Friendly designation. A one-way analysis of covariance (ANCOVA) was completed to analyze the statistical significance of the affect of Baby-Friendly designation on newborn weight loss day 0–2 (in grams) for all feeding types controlling for birth weight. A chi-square (χ²) test of independence was performed to examine the relationship between Baby-Friendly designation and feeding type in each of the three ethnic groups (Black, Hispanic, and White non-Hispanic). We used an α level of 0.05 for all statistical tests.

Results

Mean percent weight loss decreased day 0–2 for all three categories of feeding types after Baby-Friendly designation (Table 2). One-way ANCOVA revealed a significant effect of Baby-Friendly designation on weight loss day 0–2 in exclusively breastfed infants after controlling for birth weight, F(1, 470) = 40.96, p < 0.001. Further analysis was completed to examine the differences in weight loss for day 0–2 in two subgroups (exclusively breastfed infants of Cesarean birth and of vaginal birth). There was a significant effect of Baby Friendly designation on weight loss day 0–2 in exclusively breastfed infants of Cesarean birth F(1, 137) = 29.72, p < 0.001 and in exclusively breastfed infants of vaginal birth F(1, 768) = 5.93, p < 0.02 controlling for birth weight. The decrease was not significant in either formula fed infants F(1, 281) = 1.80, p = 0.18 or mixed formula fed and breastfed infants F(1, 441) = 0.269, p = 0.60. The adjusted means for each group are displayed in Table 2. These results suggest that Baby-Friendly practices are associated with a decrease in term newborn weight loss day 0–2 when controlling for birth weight with the most significant differences seen in exclusively breastfed infants. While infants born by Cesarean generally experience the highest percent weight losses^9,19 these losses were significantly diminished in our study.

Table 2.

Comparison of Mean Percent Weight Loss in Infants Before and After Baby-Friendly Designation Day 0–2

Comparison of mean percent weight loss (in grams) in infants before and after Baby-Friendly designation day 0–2 for each feeding type
	Before designation	After designation
	Mean (SD)	Mean (SD)
Breastfed	−6.15 (2.60)	−4.89 (1.75)
Formula fed	−2.57 (2.44)	−2.26 (2.04)
Breast and formula fed	−4.25 (2.53)	−4.01 (2.44)

Adjusted mean weight loss (in grams) for infants before and after Baby-Friendly designation day 0–2 for each feeding type
	Adjusted mean	Adjusted mean	Difference
Breastfed	208.16	165.89	42.27
Formula fed	87.85	75.41	12.44
Breast and formula fed	144.23	139.40	4.83

SD, standard deviation.

Exclusive breastfeeding increased from 13% (2010) to 37% (2013) in Black infants. A χ² test was performed and a significant relationship was found between Baby-Friendly designation and feeding type, χ² (2, N = 338) = 27.10, p < 0.00 in this sample. Exclusive breast feeding increased from 15.8% (2010) to 52% (2013) in the Hispanic sample. A χ² test was performed and there was a significant relationship found between Baby-Friendly designation and feeding type, χ² (2, N = 301) = 45.76, p < 0.00 in this sample. Exclusive breastfeeding increased from 46% (2010) to 66% (2013) in the White non-Hispanic sample. A χ² test was performed and there was a significant relationship found between Baby-Friendly designation and feeding type, χ² (2, N = 509) = 36.42, p < 0.00 in this sample. A relationship between exclusive breastfeeding and ethnicity was identified with each group demonstrating more exclusive breastfeeding after Baby-Friendly designation than before Baby-Friendly designation. During this same time period initiation “any breastfeeding” increased in both Black infants (from 42% to 61%) and slightly more in Hispanic infants (84.2%–87.6%). All three ethnic groups demonstrated decreases in mixed feeding (Table 3).

Table 3.

Chi Square Test and Descriptive Statistics for Ethnicity and Feeding Type of Mother Baby Couplets Before and After Baby-Friendly Designation

Feeding type	Before designation	After designation
Black mother baby couplets
Exclusively breastfed	29 (13%)	42 (37%)
Formula fed	107 (48%)	45 (40%)
Breast and formula fed	88 (39%)	27 (24%)
Note: χ² = 27.10,^* df = 2. Numbers in parentheses indicate column percentages.
Hispanic mother baby couplets
Exclusively breastfed	31 (16%)	55 (52%)
Formula fed	31 (16%)	13 (12%)
Breast and formula fed	134 (68%)	37 (35%)
Note: χ² = 45.76,^* df = 2. Numbers in parentheses indicate column percentages.
White non-Hispanic
Mother baby couplets
Exclusively breastfed	106 (46%)	183 (66%)
Formula fed	35 (15%)	49 (18%)
Breast and formula fed	92 (40%)	44 (16%)
Note: χ² = 36.42,^* df = 2. Numbers in parentheses indicate column percentages.

p ≤ 0.05.

Discussion

The hospital moved into a new facility at a new location in 2012, ∼5 miles from the original site. Although the new hospital continued to draw its patient population from the same census tracts as the old hospital, the Black and Hispanic populations were slower to use the new location for the first year of the relocation. This initially resulted in a 10% decrease in the Black and Hispanic populations at the new site. The infants in the “after” Baby-Friendly designation group reflect these changes during the transitional period and it accounts for the differences in the number of subjects from these two ethnic groups before (2010) and after (2013) designation. (Table 1) Each ethnic group was examined independently for comparison of exclusive breastfeeding rates before and after Baby-Friendly designation.

Black mothers historically have the lowest rates of breastfeeding.¹³ Exclusive breastfeeding increased from 13% to 37% in the Black sample in our study. Initiation (any breastfeeding) in this group increased 52% to 61%. In Hispanic mothers exclusive breastfeeding increased more dramatically than initiation. Initiation rates in the Hispanic population have historically been very good with a tendency toward higher percentages of mixed feeding.²³ The White non-Hispanic sample in this study also demonstrated increases in exclusive breastfeeding (46%–67%) and a decrease in initiation (39% to 16%). A decrease in mixed feeding for both of these ethnic groups in the presence of increased exclusivity may reflect both Baby-Friendly practices and aggressive educational interventions first introduced in 2006 and continuing to the present at this hospital's prenatal clinic.

These results support the belief that supplementation is not usually necessary for breastfed babies in the first 2 days of life, and that weight loss is not adversely affected when Baby-Friendly practices are followed. Mixed feedings disrupt the processes that are required for optimal milk supply and may mask infants who are having breastfeeding difficulties. Mixed feeding is not recognized by the Joint Commission as a feeding method for this reason.²⁴ Our findings support the contention that hospitals should examine practices that disrupt the mother—baby couplet remaining together both immediately following birth and then for the entire hospital stay. Keeping infants and mothers together may reduce infant stress and promote weight maintenance.

Limitations

Due to time and resource constraints we were limited to reviewing 2,000 charts. Because this was a convenience sample and the two groups were not randomly assigned, associations found in this analysis may have been the result of exposure to another, unknown variable. These factors should be taken into account when interpreting the results. For example, there was an absence of data for both use of nipple shields and prepartum intravenous fluid administration. Nipple shields have been found to increase milk transfer in babies that are having difficulties with feeding.²⁵ Fluid retention can affect infant weight and is dependent on the type and amount of prepartum intravenous fluid administration.²⁶ Future studies should include information on such variables.

To offset the possibility of bias, we used carefully defined eligibility and exclusion criteria to define cases and controls. Medical records are not designed for the collection of research data, and there were subjects that had to be excluded because of incomplete data and illegible handwriting.

The breastfed groups met all of the necessary assumptions for ANCOVA. The formula fed and the mixed formula and breastfed groups met all of the assumptions except for homogeneity of variance as indicated by the Levine's test. Although parametric tests such as ANCOVA are robust and can overcome many violations we suggest some caution in interpreting the results for these two groups.

Conclusion

Because we did not find any studies that looked at newborn weight loss before and after Baby-Friendly designation, it is not possible to compare these findings to those found in previous studies. The next logical step is to conduct randomized, multi-site studies to determine whether the findings from this study can be duplicated. We examined rates for days 0–2. It is important that future studies follow mother–baby couplets over time to determine the impact of Baby-Friendly practices post hospital discharge and up to 6 months. Baby-Friendly practices are evidence based and the results of this study support the use of these practices to improve newborn outcomes.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics, 2012; 129:e827–e841.

Mulder

, Johnson

, Baker

. Excessive weight loss in breastfed infants during the postpartum hospitalization. J Obstet Gynecol Neonatal Nurs, 2016; 39:15–26.

Bergman

, Bergman

. Whose choice? Advocating birthing practices according to baby's biological needs. J Perinat Educ, 2016; 22:8–13.

Moore

, Bergman

, Anderson

, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev, 2016; 11CD003519.

Baby-Friendly

USA

. The ten steps to successful breast feeding. Available at www.babyfriendlyusa.org (accessed January 4, 2018).

Centers for Disease Control (CDC). Hospital actions affect breastfeeding infographics. Vital signs. Available at www.cdc.gov/vitalsigns/breastfeeding2015/infographic.html (accessed January 4, 2018).

Andrew

, Harvey

. Infant feeding choices: Experience, self identity and lifestyle. Matern Child Nutr, 2011; 7:48–60.

Odom

, Li

, Scanlon

, et al. Association of family and health care provider opinion on infant feeding with mother's breastfeeding decision. J Acad Nutr Diet, 2014; 114:1203–1207.

Steube

. Enabling women to achieve their breastfeeding goals. Obstet Gynecol, 2014; 123:643–652.

10.

Venancio

, Saldiva

, Escuder

, et al. The baby-friendly hospital initiative shows positive effects on breastfeeding indicators in Brazil. J Epidemiol Community Health, 2012; 66:914–918.

11.

Fonseca

, Severo

, Barros

, et al. Determinants of weight changes during the first 96 hours of life in full-term newborns. Birth, 2014; 41:160–168.

12.

Nommsen-Rivers

, Chantry

, Peerson

, et al. Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr, 2010; 92:574–584.

13.

Centers for Disease Control (CDC). Racial and ethnic differences in breastfeeding initiation and duration, by state—National Immunization Survey, United States, 2004–2008. MMWR. Available at https://cdc.gov/mmwr/preview/mmwrhtml/mm5911a2.htm (accessed January 4, 2018).

14.

Victora

, Bahl

, Barros

, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet, 2016; 387:475–490.

15.

Quinn

, Guyon

, Schubert

, et al. Improving breastfeeding practices on a broad scale at the community level: Success stories from Africa and Latin America. J Hum Lact, 2005; 21:345–354.

16.

Torres

JMC

. Medicalizing to demedicalize: Lactation consultants and the (de) medicalization of breastfeeding. Soc Sci Med, 2014; 100:159–166.

17.

Rautava

. Neonatal weight loss and exclusive breastfeeding. Acta Paediatr, 2015; 104:965–966.

18.

Faught

, Sheehan

, Plyley

, et al. The role of intrapartum intravenous therapy and newborn weight loss: Challenging the 7% rule. Clin Mother Child Health, 2015; 12:181.

19.

Davanzo

, Cannioto

, Ronfani

, et al. Breastfeeding and neonatal weight loss in healthy term infants. J Hum Lact, 2011; 29:45–53.

20.

Flaherman

, Schaefer

, Kuzniewicz

, et al. Early weight loss nomograms for exclusively breastfed newborns. Pediatrics, 2015; 135:e16–e23.

21.

Grossman

, Chaudhuri

, Feldman-Winter

, et al. Neonatal weight loss at a baby-friendly hospital. J Acad Nutr Diet, 2012; 12:410–413.

22.

Healthy People 2020.. Maternal, infant, and child health. 2015. Available at www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives (accessed January 4, 2018).

23.

Linares

, Rayens

, Gomez

, et al. Intention to breastfeed as a predictor of initiation of exclusive breastfeeding in Hispanic women. J Immigr Minor Health, 2015; 17:1192–1198.

24.

Feldman-Winter

, Douglass-Bright

, Bartick

, et al. The new mandate from the joint commission on the perinatal care core measure of exclusive breast milk feeding implications for practice and implementation in the United States. J Hum Lact, 2013; 29:291–295.

25.

Chertok

, Schneider

, Blackburn

. A pilot study of maternal and term infant outcomes associated with ultrathin nipple shield use. J Obstet Gynecol Neonatal Nurs, 2006; 35:265–272.

26.

Schaefer

, Flaherman

, Kuzniewicz

, et al. External validation of early weight loss nomograms for exclusively breastfed newborns. Breastfeed Med, 2015; 10:458–463.