The Use of the “Early Weight Loss Nomograms” as Compared to a Standard Weight Loss Percentage Protocol Will Decrease Postnatal Formula Supplementation

Abstract

Introduction:

We compared the number of babies who needed formula supplementation, based on the “Early Weight Loss Nomograms,” with the hypothetical outcomes that would have occurred in the same cohort if they had been managed according to a “weight loss percentage” protocol.

Subjects and Methods:

This study included 308 newborns. Supplemental formula was provided to babies whose weight loss was more than the 95th percentile according to the “Early Weight Loss Nomograms.” Pathological weight loss was defined as when a weight loss was >5% at the 24th hour or >8% at the 48th hour. The number of babies who would have needed formula supplementation according to those two strategies were compared.

Results:

The mean postnatal first–second day weight losses for vaginal and cesarean deliveries were 3.06% versus 4.7% and 4.5%, versus 5.8%, respectively, and were significantly higher for babies born by cesarean section (p = 0.001). We found that 89.4% of vaginal deliveries and 89.2% of babies born by cesarean section were exclusively breastfed when the nomograms were in use. If the daily weight loss strategy would be applied instead of the nomograms to the study cohort, the rate of exclusive breastfeeding would be significantly lower for babies born by cesarean section (64.2% versus 89.2%) (p = 0.001).

Conclusions:

The use of the Early Weight Loss Nomograms will decrease the rate of formula supplementation.

Introduction

An early start and maintenance of breastfeeding in the postpartum period is viewed as the gold standard for maternal, infant, and public health.^1,2 Although the World Health Organization (WHO) recommends mothers worldwide to exclusively breastfeed babies, starting within the first hour after birth, and continuing without any supplementary formula or water,^3,4 it has been reported that only 60% of newborns born in the United States are exclusively breastfed within the first 2 days of life.⁵ The most important factor for formula supplementation before discharge is the weight loss beyond physiological levels and the concern that it may result in complications such as dehydration and hyperbilirubinemia.^6,7

The American Academy of Pediatrics states that weight loss of >7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention.⁸ The International Lactation Consultant Association and the Registered Nurses Association of Ontario specify that a loss of >7% of birth weight, after day 3, or failure to regain birth weight in 2 weeks, respectively, is signs of ineffective breastfeeding.^9,10 The Academy of Breastfeeding Medicine advises “Possible indications for supplementation in term, healthy infants include weight loss of 8% to 10% accompanied by delayed lactogenesis.^”11–13 It is thus clear that there is still no consensus for the definition of physiological weight loss, suggesting that this may lead to an overuse of formula supplementation during the early days of life.

In practice, two strategies are used for the evaluation of physiological weight loss. Most commonly supplementation is considered if there is greater than a 3% weight loss in the first postnatal 24 hours and a total loss of >7% after 48 hours regardless of the baby's delivery method.¹⁴

The second strategy involves the use of “Early Weight Loss Nomograms,” developed by Flaherman et al.¹⁵ In this strategy, weight loss is assessed on two different graphics based on the mode of delivery and both graphics including four percentile curves (50th, 75th, 90th, and 95th). In our unit, newborns whose weight loss is above the 75th percentile are evaluated for breastfeeding technique and milk volume. If weight loss persists despite lactation support, and the weight loss ultimately exceeds the 95th centile, supplemental formula is provided.

Until 2017, the daily percentage weight change strategy was used for making decisions regarding physiological weight loss and formula supplementation in our well baby nursery. Since 2017, “Early Weight Loss Nomograms” strategy has been used in our unit.

The aim of this study was to assess the number of babies who needed intervention/formula supplementation, based on the “Early Weight Loss Nomograms,” and compare it with the hypothetical outcomes that might have occurred in the same cohort, if they had been managed according to the protocol in use in 2017.

Subjects and Methods

This cross-sectional study was carried out between July 1 and September 30, 2018, in the well-baby nursery at Marmara University Hospital in Istanbul/Turkey. Out of 380 babies born between these dates, 308 babies who were born during weekdays and met the inclusion criteria were included in the study.

Study sample

The sample size of the study was calculated using the G*Power program. To determine the required sample size, Cohen's standard effect size was assumed to be 0.50 (medium effect). Thus, according to the two-side hypothesis and based on a 1:1 distribution ratio, the minimal sample size was calculated as 305 (α = 0.05, 1 − β = 0.80, d = 0.5). Considering the possibility of losses during the study, it was decided that 308 babies should be included in the study.

Mothers older than 18 years with a singleton pregnancy, without any complications during maternity and/or delivery and also without chronic disease or psychological health problem, were included in the study. Newborns born at ≥36 weeks, with a birth weight between 2,500 and 4,000 g and a 5-minute Apgar score >7 and without any major congenital abnormalities, were enrolled. The study data were collected using a 42-question questionnaire including demographic data, socioeconomic status, and obstetric and neonatal risk factors.

Procedures

The mothers were encouraged to breastfeed their babies and were supported by the lactation nurse. The LATCH scale (a breastfeeding charting system and documentation tool), which was developed by Jensen et al. in 1994, and was adapted to the Turkish language by Demirhan,^16,17 was applied to all newborns during their hospital stay.

The babies were routinely weighed by the same nurse every morning at the same time. The weight was plotted on the “Early Weight Loss Nomograms” developed by Flaherman et al.¹⁵ In our unit, babies below the 75th percentile were considered to be in the “normal” physiological weight loss group, whereas babies between the 75th and 90th percentiles were closely followed by the lactation nurse. This follow-up included breast milk pumping procedure, milk quantity, breastfeeding method, duration, and frequency and evaluation of breastfeeding. The expressed breast milk was given using appropriate techniques, mainly with a spoon. Laboratory investigation, including blood sodium, potassium, and urea, was performed in babies for whom weight loss was more than the 95th percentile. A sodium level >145 mEq/L and a weight loss at the mentioned level are our threshold levels for formula supplementation. Mothers and their infants were not discharged until breastfeeding was established. Babies' daily weight loss percentile was routinely checked and recorded. Our previous (before 2017) practice was to supplement with formula when the percentage weight loss was >5% within the first 24 hours or >8% by the end of the second day of life.

In accordance with the recommendations of the Turkish Ministry of Health, mother–infant pairs are followed up in the hospital for at least 24 and 48 hours, for vaginal and cesarean section (C/S) deliveries, respectively. For this reason, vaginally born babies frequently had only one measurement, whereas babies born by cesarean section had at least two measurements.

This analytical cross-sectional study investigated the relationship between the use of “Early Weight Loss Nomograms” for the evaluation of physiological weight loss of newborns and babies' breastfeeding status at discharge. The number of babies who needed intervention/formula supplementation, based on the “Early Weight Loss Nomograms,” was compared with the calculated hypothetical outcomes of the same group if they had been managed according to protocols in use in 2017.

Analysis

The NCSS (Number Cruncher Statistical System) 2017 software was used for statistical analyses. Significant differences between the groups were analyzed using the t-test and Mann–Whitney U test and one-way ANOVA test, as appropriate. Pearson chi-square test and Fisher's exact test were used to compare the qualitative data.

Ethical aspects

Written informed consent was obtained from all participant mothers. The study protocol was approved by the ethics committee of Kocaeli University (KU GOKAK 2017/164) and was in compliance with the principles of the Helsinki Declaration.

Results

The demographic and clinical characteristics of the newborns are presented in Table 1.

Table 1.

Characteristics of the Mothers and Newborns

	n (%)
Mother's age
Min–Max (median)	18–44 (28)
Mean ± SD	28.35 ± 5.46
Mother's education level
Illiterate	21 (6.8)
Literate	10 (3.2)
Primary school	99 (32.1)
Secondary school/high school	147 (47.7)
University	31 (10.1)
Mother's employment status
Working	20 (6.5)
Unemployed	288 (93.5)
LATCH score, mean ± SD
Vaginal delivery	9.4 ± 0.6
Cesarean section	8.7 ± 0.6
Gender, n
Girl	148 (48.1)
Boy	160 (51.9)
Gestational age, weeks
Min–Max (median)	38.5–41.7 (39.4)
Mean ± SD	39.6 ± 1.3
Classification of term babies
Early term	95 (30.8)
Full term	188 (61.0)
Late term	25 (8.1)
Mode of delivery
Vaginal delivery	160 (51.9)
Cesarean section	148 (48.1)
Birth weight, g
Min–max (median)	2,520–4,000 (3,335)
Mean ± SD	3302.2 ± 361.8
Head circumference, cm
Min–Max (median)	32–39 (35)
Mean ± SD	34.84 ± 1.34
Height, cm
Min–Max (median)	45–56 (50)
Mean ± SD	50.08 ± 2.15
Apgar score (fifth minute)
MinMax (median)	8–10 (10)
Mean ± SD	9.89 ± 0.34

SD, standard deviation.

The mean postnatal first day weight loss of the newborns born by vaginal delivery was 3.7%, whereas the mean postnatal first day and second day weight loss of the newborns born by cesarean section was 4.5% and 5.6%, respectively. Weight loss of the cesarean babies was significantly higher than that of babies born by vaginal delivery (p = 0.001; p < 0.01) (Table 2). Factors related to formula supplementation of the newborn are presented in Table 3.

Table 2.

Weight Loss Measurements According to the Mode of Delivery

		Delivery method		p
		Vaginal delivery (n = 160)	Cesarean section (n = 148)	p
Weight loss measurements, %
13–24 hours	n	160	148
13–24 hours	Mean ± SD (median)	3.72 ± 1.09 (3.6)	4.51 ± 1.25 (4.5)	0.001^a,^**
25–36 hours	n	27	29
25–36 hours	Mean ± SD (median)	5.12 ± 1.08 (5.1)	5.81 ± 0.80 (5.8)	0.001^a,^**
37–48 hours	n	52	148
37–48 hours	Mean ± SD (median)	4.66 ± 1.26 (4.7)	5.63 ± 1.34 (5.8)	0.001^a,^**
61–72 hours	n	68	39
61–72 hours	Mean ± SD (median)	3.34 ± 1.44 (3.2)	4.61 ± 1.57 (4.7)	0.001^a,^**
>72 hours	N	48	72
>72 hours	Mean ± SD (median)	2.60 ± 1.89 (2)	3.57 ± 1.45 (3.2)	0.001^a,^**

Mann–Whitney U test.

SD, standard deviation.

p < 0.05.

Table 3.

Factors Related to Formula Intake of Newborns

	Formula intake		p
	No (n = 275)	Yes (n = 33)	p
Gender, n (%)
Girl	128 (86.5)	20 (13.5)	0.127^a
Boy	147 (91.9)	13 (8.1)	0.127^a
Gestational age, weeks
Mean ± SD (median)	39.2 ± 0.9 (39)	39.2 ± 1.0 (39)	0.867^b
Classification of term babies, n (%)
Early term	86 (90.5)	9 (9.5)	0.290^a
Full term	169 (89.9)	19 (10.1)
Late term	20 (80.0)	5 (20.0)
Birth weight, g, n (%)
Mean ± SD (median)	3302.9 ± 369.2 (3,350)	3296.2 ± 298.1 (3,210)	0.920^b
Apgar score fifth minute
Mean ± SD (median)	9.89 ± 0.4 (10)	9.94 ± 0.2 (10)	0.406^b
Delivery method, n (%)
Vaginal delivery	143 (89.4)	17 (10.6)	1.000^a
Cesarean section	132 (89.2)	16 (10.8)	1.000^a
Hospital stay duration, hours
Mean ± SD (median)	36.1 ± 11.8 (36)	43.0 ± 7.4 (48)	0.002^c,^**
Discharge status, n (%)
On time	265 (96.4)	25 (75.8)	0.001^d,^**
Delayed	10 (3.6)	8 (24.2)	0.001^d,^**

Pearson chi-squared test.

Student's t-test.

Mann–Whitney U-test.

Fisher's Exact test ^**p < 0.01.

SD, standard deviation.

According to the “Early Weight Loss Nomograms,” 92.5% (n = 148) of the babies born by vaginal delivery and 90.5% (n = 134) of the babies born by cesarean section were below the 75th percentile, whereas 1.6% (n = 1) of the babies born by vaginal delivery and 1.4% (n = 2) of the babies born by cesarean section were above the 95th percentile within the first 24 hours (Table 4).

Table 4.

Comparison of the Weight Loss Nomogram Percentile Groups According to the Mode of Delivery

Percentile	Mode of delivery
Percentile	Vaginal delivery (n = 160), n (%)	Cesarean section (n = 148), n (%)
<50	115 (71.9)	93 (62.8)
50–75	33 (20.6)	41 (27.7)
75–90	8 (5.0)	7 (4.7)
90–95	3 (1.9)	5 (3.4)
>95	1 (1.6)	2 (1.4)

Babies born by vaginal delivery were breastfed earlier, usually within the first 30 minutes of life, but all babies were breastfed within the first hour. There was a statistically significant difference between the first 24 hours LATCH scores depending on the mode of delivery, favoring vaginal delivery (p = 0.001; p < 0.01) (Table 1).

It was found that 89.4% of vaginal deliveries and 89.2% of babies born by cesarean section were exclusively breastfed. If the daily weight loss strategy (a weight loss of >5% within the first 24 hours) would have been applied instead of the “Early Weight Loss Nomograms” strategy, the rate of exclusive breastfeeding would be lower for both vaginal and cesarean deliveries, but this decline would be more pronounced for babies born by cesarean section (Table 5).

Table 5.

Comparison of Two Different Postnatal Weight Loss Assessment Strategies on Exclusive Breastfeeding According to the Mode of Delivery

Feeding type	According to the nomogram		According to percentile loss^a
Feeding type	Vaginal delivery (n = 160), n (%)	Cesarean section (n = 148), n (%)	Weight loss assessment	Vaginal delivery (n = 160), n (%)	Cesarean section (n = 148), n (%)
Formula supported	17 (10.6)	16 (10.8)	≥5%	19 (11.9)	53 (35.8)
Exclusively breastfed	143 (89.4)	132 (89.2)	<5%	141 (88.1)	95 (64.2)
χ²: 0.003			χ²: 25.5
p ^b	0.95		p	0.001^**

Five percent weight loss was considered as a lower limit for formula support.

Pearson chi-squared test.

p < 0.05.

None of the babies in the study group had a weight loss of >10% of birth weight nor hypernatremia (Na >145 mEq/L). The babies who were supplemented with formula stayed significantly longer in the hospital (36.05 ± 11.83 hours versus 43.00 ± 7.44 hours, p = 0.002) (Table 3).

Discussion

All newborns tend to lose weight before they begin to gain weight. This is called physiological weight loss.^12,18 It is well known that there are no standard cutoff values for the definition of pathological weight loss and intervention. The differentiation between normal physiological and pathological weight loss is defined according to different methods. To date, the most commonly used is the percentage change in weight loss.^8–19 According to our previous unit protocol, a weight loss of >5% at the 24th hour or >8% at the 48th hour were the indication for intervention.⁸

The mean first day rates of weight loss of the newborns when the data were stratified according to the mode of delivery was 3.6% and 4.5%, for babies born by vaginal delivery and by cesarean section, respectively (p = 0.001) (Table 2). In the study of Flaherman et al., the mean percentage of weight loss in the first 24 hours was 4%. Our results were similar to the results reported by Flaherman et al., 4% on the first day,²⁰ and Hamilcikan et al. also reported 4.2% on the first day.²¹

Turkey is among the countries with very high cesarean delivery rates with a rate of cesarean section ∼50% of all deliveries.²² This high rate also has a great impact on discharge. In Turkey, the ministry of health recommends that babies born by vaginal delivery and cesarean delivery are discharged after 24 and 48 hours, respectively, if they fulfill the discharge criteria. Pathological weight loss is one of the major reasons that lead to delayed discharge and the overuse of formula supplementation. For this reason, in recent years we have implemented the use of the “Early Weight Loss Nomograms”²⁰ as part of routine practice in the well-baby nursery. The main advantages of these nomograms are the hour-specific values for the evaluation of weight loss and the use of different charts according to the mode of delivery.

In the study cohort using the “Early Weight Loss Nomograms,” 3.5% of babies born by vaginal delivery and 4.8% of babies born by cesarean section had a weight loss of above the 90th percentile 24 hours.

In our well-baby nursery, formula is supplemented to babies whose weight loss was more pronounced than the 95th centile, after performing standard lactation support. Our previous strategy was to start formula support when the weight loss was >5% at the end of 24 hours and >8% at the end of 48 hours. According to this strategy, 11.9% of the babies born vaginally and 35.8% of the babies born by cesarean section would have received formula support. When we applied the same data to the nomogram, the number of babies who were supplemented with formula was considerably smaller and this was striking for babies born through cesarean section (35.8% versus 10.8%).

Our study was conducted in one center, using the same scale, calibrated daily by the same nurse. Great care was taken so that caregivers did not initiate formula without the permission of the nurse. Feeding reports were obtained daily by the same nurse from the mothers and the LATCH breastfeeding chart was used for all babies during the study period to assess and document breastfeeding. LATCH scores of mothers who had a vaginal delivery were higher than those who delivered by cesarean section, similar to previous reports.^23,24 This underlines the importance of breastfeeding support to decrease formula supplementation especially for babies born by cesarean section.

A study population with a different socioeconomical and educational background may have produced different results.

Conclusions

This study showed that the value of the use of “Early Weight Loss Nomograms” for the evaluation of physiological weight loss increased the rate of exclusive breastfeeding, especially in babies born by cesarean section. It was further observed that the weight loss of newborns differed depending on the mode of delivery, which shows it should be considered an important variable when evaluating physiological weight loss and breastfeeding success. We believe that hospitals with a high cesarean section rate will especially benefit from the use of these nomograms to decrease formula supplementation.

Further studies including a larger number of babies from different hospitals and from different maternal populations are required to confirm our results.

Footnotes

Authors' Contributions

This authorship statement confirms that the listed authors meet the authorship criteria, and that all authors agree with the content of the article. N.T., A.E., and H.S.B. designed the study. N.T. collected the data. A.E. and N.T. analyzed the data. A.E., N.T., H.S.B., and E.O. drafted and wrote the article. All authors approved the final version for submission.

Acknowledgments

The authors thank all the families who participated in this research.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was provided for this article.

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