What To Do If Your Newborn Is Not Gaining Weight
I recently got another call from worried parents of a newborn.... "Help! Our breastfed baby is 3 weeks old. She was six pounds when she born at 37 weeks, and now the pediatrician is worried because she's only 5# 14oz. She never got back up to her birth weight, and she’s still losing weight at three weeks.”
There are many practical things that can be done to help a baby gain weight in this situation, and even more actions that parents can do to prevent it. Unfortunately most new parents have not been well informed about what their newborn is needing and expecting—which sets them up to be more at risk for an early situation like this—and this topic seems to be completely ignored by nearly all care providers.
In my 40+ years in midwifery, I’m known for staying calm with new parents, and not being an alarmist just based on arbitrary weight numbers. I also work with a lot of parents at both extremes of the spectrum - from those who anxiously see their pediatrician over and over to those who anxiously try to figure everything out on their own. So this blog is to share the criteria I use as a home birth midwife—caring for both mother and baby in the first 6 weeks—to protect and assess the well-being and stability of the newborn. Sometimes there is a real issue, and in those times action is needed without delay.
The story above is actually an urgent one. It is now time to be legitimately concerned, and to take action to turn the situation around. This is not a good time to "see how the weekend goes." There is something about the baby’s care that is interfering with the baby’s wellbeing that needs to change—because a baby who is warm, fed, and lovingly held usually gains weight easily from the beginning. So the baby who is still loosing weight at three weeks old is in at least some kind of trouble, and does need some kind of immediate intervention.
It’s important to understand when the margin of safety has already been largely used up like in a case like this. It means that the tiny baby is in a fragile situation, and it’s time to be focused and attentive to every detail. It’s not “life and death” today, but remedial changes must be prioritized over the next few hours—not tomorrow when somebody has time to do an errand. In my experience, this means evidence of the baby ingesting more food and being more stable within the next 12 hours, and even more so over the 48 hours. So let me explain where the safety margins are, and how to get the improvement you may need.
SIDE NOTE ABOUT PROFESSIONAL BALANCE
To the birth and postpartum professionals who are passionate about supporting parents who want to stay clear of over-medicalization as much as possible:
I’m with you. It can be challenging to strike a happy balance between your commitment to not add to fearful worry, but to also not talk yourself out of being concerned. I know that this sounds odd on paper, but you know it’s been done. Never talk yourself out of getting additional eyes on the baby, even if you have only the littlest underlying anxiety about their situation. Beyond just the issue of medical safety, it is actually kinder and more respectful to not be so reassuring as to be lax. Think of it- when baby is doing well, they are plump and content, and mother can relax. A baby who is struggling with nutrition or weight is not having a good time—their mother is intuitively anxious—and neither are fully free to fully give themselves over to recovery and bonding.
What’s happening with professional care in the example above? Most docs would be asking that the baby be brought back in for a weight check the next day to make sure it’s starting to turn around. This is an appropriate use of professional care, even if you are not a big fan of doctors or have a general philosophical policy of trying to stay out of hospitals.
This particular situation is a sensitive dance between two extremes:
Exhausted parents not knowing how to evaluate a baby who may be very small and sleepy, and
Pediatricians who as a group (unfortunately) are known for routinely striking fear and disempower parents, even when the variations are within normal range.
“A lot of the time things are fine and folks just need to settle in. But occasionally it is actually urgent. I’m glad to share here how I think things through as a medical professional, and to share the suggestions I offer my clients. But this does not replace medical care; use common sense. Don’t let fear—or your bias—push you into decisions that leave you uneasy. If you are worried about your baby, get experienced eyes on them promptly.”
First: Understanding the Landscape of Newborn Care
There is a serious problem with how medical care tends to approach this newborn weight loss issue—particularly with breastfeeding mothers—and as a result they often inadvertently make it worse before it gets better. Pediatricians who are inexperienced with breastfeeding often have only one tool in their toolbox when they are concerned about inadequate weight gain, which is to focus on supplementation. There is certainly a time and place for supplemental milk or feedings, but to have their first response always be instructing breastfeeding moms to immediately supplement with formula is not entirely helpful, and it damages their credibility for those rare times when supplementation is actually indicated.
The reason it’s a problem to only push for formula supplementation with breastfed babies is:
This often reduces mom's milk supply, because her breasts have less stimulation when baby feeds away from breast
Using a bottle may make it harder to get baby back to the breast, because of nipple confusion between bottles and breast
Formula may cause digestive disturbances and possible allergic response in the breastfed baby
It makes mothers cry, who may already be upset and anxious about their babies and worried about their milk supply
This does not address why this situation may have developed, so the root issues do not get resolved.
Let’s detail concerning situations that DO need prompt attention, and then I’ll get into some practical approaches that could be helpful to help the stable baby gain weight.
When to Be Concerned
A weak and dehydrated baby MUST have milk immediately, and should be seen by an experienced pediatric care provider ASAP.
The situations below have the potential to be serious enough to need prompt intervention; they are not the same as a baby behaving normally but who is a little behind on a growth curve. Professional evaluation and intervention is very likely needed if your baby is in their first two weeks and—
Has a hoarse, weaker, or higher pitched cry than yesterday or the day they were born
Consistently wants to sleep too many hours in row (3+ hours, more than 1-2x/day) and is hard to rouse
Or is crying constantly and sleeps less than 20-30 minutes repeatedly
Is having less wet diapers daily than they are days old in the first week (ie. 3 wets or more on day 3), and 8-10 daily from then on (and at least a one or two ‘sopping wet’ heavy ones daily after the first few days). Urine that is darker than straw colored or is pungent is TOO concentrated and reflects some degree of dehydration
Is not having several stools/day, including at least one daily ‘blow out’ that requires multiple wipes to clean up
Stool is still dark meconium colored after 4-5 days
Has a sunken fontanelle (soft spot on their head) especially along with another symptom; normal can include it seeming slightly depressed there
Is limp or has poor tone; is flaccid or fusses weakly; sometimes mistaken for ‘being so good’
Has yellow skin or yellow eyes
Does not wake up at least once or twice a day and look around, look you in the eyes, and is interested and alert about their life
All of the signs above are at least a little bit concerning, and if you are dealing with any of them AND a less alert baby, I suggest that you get experienced eyes on your baby today. If they are also visibly yellow with any these signs, please stop reading this and drive the baby immediately to the nearest ER with a NICU NOW. The yellow is a reflection of bilirubin in the baby’s body, called jaundice. A little is in the range of normal, but looking seriously like they have a bad tan AND being less active can reflect a genuinely serious situation. To see yellow on a darker skinned baby, blanch the nose by pressing on it, look at the gums or whites of the eyes.
The ways you can tell the difference between the baby who is sleepy, hard to rouse, and needing help— and the baby who is milk drunk with a full tummy (and is totally fine)— is that milk drunk babies:
Have sopping wet diapers and plenty of stools
They are vigorous and insistent when they are hungry
They have content alert periods with their eyes open looking around.
Have muscle tone even when sleepy or when changing diapers; not limp, unresisting limbs
Problems often start because no one thoroughly explained to parents what ‘normal’ is in the first weeks, or even how to best handle and dress the baby early on. This foundational information is needed to keep babies more stable, improve mothers’ milk supply and babies’ milk transfer. My clients’ home birthed babies routinely regain their birthweight by the end of the first week, and there’s been only a handful of times when the babies not also actually gained!
My clients get these extraordinary results because
These parents are extremely well-informed and well-coached about what mama-babies need in the beginning
They are visited in their home several times after birth so any issues are caught before there’s time for them to become significant problems
All mothers need and deserve to be thoughtfully attended throughout their postpartum period; having a baby is NOT just about the day the baby is born!
Twelve Thoughtful Ways to Turn This Around
Here’s a short introduction to what I teach my parents, including what’s optimal from your baby’s perspective. You’ll find ways to better support your baby’s weight gain, alongside any professional care or evaluation you choose to use. And if your circumstances or limitations make these suggestions hard to follow, get support—or get creative—about how to thoughtfully meet your needs and your baby’s needs together.
1. Babies are born expecting a “4th trimester in their natural habitat”.
This means the first few weeks on mommy's chest as a ‘Womb With a View’, if you will (wink wink.)
Mommies need a postpartum recovery that supports them in having several weeks of lounging in bed, snuggling their baby; not installed on the couch entertaining, or worse, back to caring for the family with lifting, stairs, and being up on her feet.
This down time helps to physically and emotionally stabilize both mom and baby, and protect her incoming milk supply if she’s breastfeeding.
2. Skin-to-skin is what babies need and want.
This helps them
Develop a healthy and essential skin and gut microbiome
Keep warm, and conserve the calories they need for growing
Feel safe and ‘at home’, near the same heartbeat sound they've always known
Remain close to the food (if breastfed), reducing disruption or delay for quick snacks
Sleep longer and deeper in this familiar quiet + peaceful environment.
Did you know that newborns rely on physical contact with their parent to regulate all of their vital signs? Yes, heart rate, blood pressure, breathing, and temperature!
3. Babies need to eat quite often.
They are transitioning from being connected to their cord on the inside 24/7, to being connected to the breast on the outside almost 24/7 for a little while.Breastfeeding is their next, step-down, life support connection.
By several days after birth, babies' stomachs are about the size of a walnut. So every tiny feed in the beginning, which is about 8-10 swallows, must:
Replace the calories they used up sucking and swallowing
Provide the calories they need to physically function (run their body) until they feed again in an hour or two.
Be burned as fuel to keep them warm, if they are cosy skin-to-skin or wearing enough clothing
Hopefully have at a least a few calories left over to do a bit of growing
Their job is not to just regain lost weight by one week, their job is to double their birth weight in the first four months! THINK! What would YOU be doing if YOU had to double your weight in four months? Oh yah, you’d be just eating and sleeping, that's what! Feed them!
4. Pay attention to their diapers.
They provide KEY information about how your baby is doing! Knowing whether they are “getting enough to eat” is not mysterious!
In the first week, a baby should have as many wet diapers each day as they are days old. For example: A four-day-old baby should have at least 4 wet diapers, and some significant poos, in that 24-hour period. If not, then they need more food; to come out, it has to have gone in.
Once a well-nourished baby is a week old or more, they are usually having more wet diapers than parents feel like counting, eight or more, and also some stool daily (or a lot of stool every other day.) A compromised 3-week-old baby like in the story above may be having only 4-6 diapers/day and rarely having stools of any amount; these are big clues (besides no weight gain) that they are needing a greater volume of milk. ‘Smudges’ of stool in the diaper do not count, how about at least the amount of a small clementine?
5. Warmth is a whole blog to itself.
The baby needs to be kept warm.
Europeans get it, and dress infants in a magically soft wool-silk underclothes in just about every season. This means a hat all the time, day and night, for several weeks—if not months.
Yes, I am aware that the hospital makes you take the hat OFF your newborn to prove they can maintain their own temperature. I can't help this, but it's not good common sense.
In my experience, a baby who is allowed to be too cool is very often uncomfortable, restless, waking easily, not gaining weight well, having constipation issues, and is generally less relaxed.
How cranky are you feeling when you are chilled out at the game and unable to do anything about it?
Your baby is not warm enough if they have cool hands or feet, mottled skin, or the hiccups.
Newborns should be wearing the same as our adult layers, PLUS 1-2 more.
NOT dressed just in a onesie with cold feet, while their parents are wearing sweatshirts!
If they get the hiccups, put on an extra blanket and see how quickly they stop.
You'll know they are too hot if they get bright red and/or sweaty, which should be carefully avoided.
See how handy common sense is?
6. Learn about nursing cues.
Almost any movement in a newborn is a call to nurse in the early days.
A breastfed baby who's not gaining may not be being invited to nurse often enough.
10-12 feeds per 24 hours is minimal
For a baby who has not been gaining well and has become dehydrated and vulnerable, they may very well need to be put to breast or get fed milk nearly every hour this first day—or few days—to stabilize.
They may also tire easily in this state.
The priority is getting milk in with minimal work for them. If breastfeeding needs some help, that may have to wait until they are a little stronger.
So frequent-feeds may be easier on them than giant-stuffing-them feeds.
7. Sometimes the baby is not latching well to the breast.
This causes poor milk transfer.
Asymetrical latching can make a huge difference!
A poor latch quickly damages mommy's nipples, creating an additional problem. Consider a nipple shield as a temporary rescue. It’s a thin silicon cover which protects the nipple, does NOT hurt milk supply, and often can help babies figure out a more effective sucking pattern. Here's what they look like, read up on how to get the right size.
A lactation consultant may be needed. If these links don’t solve your issues quickly, look for local help sooner rather than later.
8. Adjustments and body work
Babies who are crying a lot or having a tough time nursing effectively may well benefit from a chiropractic adjustment or cranial-sacral treatment by someone skilled with infants and/or infant palates.
Frankly, most all babies would benefit.
9. Consider that your baby may have lip and/or tongue ties, sometimes called ‘tethers’.
In recent years, there has been an epidemic of latch issues because of these ties.
It’s not a fad; it’s a very significant issue that can cause problems even though moms may be experienced, babies are determined, and even if their pediatricians swear that tongue ties aren’t a real thing. The ‘why’ it’s happening more now is a bigger, different conversation.
These ties are best evaluated by skilled pediatric dentists, who use cold laser to release any ties found. If ties are to be released, current wisdom is to include body work and function release work before and after the procedure.
Pediatricians rarely recognized the tie as a barrier for successful feeding (breast or bottle), I’m sorry that this can be confusing.
If you feel that your baby’s tongue is hurting your nipple or it’s movement is not supporting their best milk transfer—even after carefully working on their latch—then one of the things to check on are tongue or posterior ties in their mouth. You’re going to have to self-educate about this, and search for local resources that are truly up-to-speed.
A good source of regional support is often Tongue Tie Facebook groups for your area/state.
Fabulous book - Tongue-Tied: How A Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More, by Richard Baxter DMD, MS.
More info here: Tongue-tie myths, and consequences of a tongue-tie. THIS IS an procedure with a cold laser in a pediatric dentist office, often covered by insurance. I STRONGLY urge you to get a second opinion if you are directed to an ENT who insists that their only approach is under anesthesia.
There are cutting edge providers who are doing less cutting of ties and more work with reflexes, muscle and nerve releases in the body, and other less invasive care. This is an evolving field so you will find conflicting advice—keep asking questions and remember that YOU are your baby’s best expert!
10. It may be appropriate to temporarily get milk into a breastfed baby in different ways if—
Baby and/or mother are getting very worn out and frustrated trying to get baby to latch on to nurse.
There is legitimate concern because baby's vitality is waning.
The baby is getting harder and harder to rouse (they do not wake themselves to feed an average of every 2 hours).
If the baby is also yellow, seek immediate professional evaluation (like right now, GO!)
This is different than the baby who is hardy, was restless and fussy at 3 day, and then mom’s milk came in. Baby now gulps milk at their feed, has heavy sopping wet diapers and a giant messy poop twice/day, but sleeps heavily for 3 hours stretches with a tummy swollen with milk. See the difference? That baby would be hard to rouse at two hours, because they are still stuffed. But they do wake themselves up regularly, bright-eyed and enthusiastic to feed.
Other ways of temporarily feeding a breastfed baby could include mom pumping her milk (or a lactating friend sharing milk), which is then offered to the baby via finger feeding, SNS, or cup.
A bottle is an option, but usually the last choice, because the risk of nipple confusion could make it harder to get baby back to breast. However, if the adults and baby are all terribly exhausted, then just feed the baby. This is the priority,
If no breastmilk is available to supplement with, consider organic formula. There’s also a great European brand (higher quality standards, goat version too) named Holle.
This could be for just a few days to get everyone onto more stable ground.
The baby may need to just ingest calories while spending the absolute minimum in calories to get over a little hump. This is not a deal breaker for breastfeeding, nor is it disparaging your breastfeeding either.
I’ve seen this actually protect the breastfeeding relationship.
11. Making more milk.
For a variety of reasons, the baby emptying the breast poorly may have contributed to mom's milk supply decreasing, especially after the first two weeks. Info on increasing milk supply here.
12. An experienced lactation consultant could be invaluable at this point.
Check for referrals from your doula, midwife, OB, friends, prenatal group or class, or local on-line search.
This is a lot of detail at once
Especially at a time when you may be dealing with high stress, postpartum pain, and an upset baby.
You WILL get through this, really. 💗
To Recap
Babies should kept nicely warm, and either be covered up or skin-to-skin on mommy or a loving family member, or wearing a hat/undershirt/gown/socks/and 1-2 blankets.
Every little tongue action means "feed me now", even if they appear to then lapse back to sleep - think baby birdies and dropper feeding. They love to sleep with their cheek on your breast for a reason.
Get some local, experienced help evaluating your milk supply, the baby's lip and tongue, and baby's latch.
Consider seeing a chiropractor or cranial-sacral specialist.
Pull back, quit doing so much, and keeping asking for help until you get respectful support that helps you cope and capably move through this challenge.
Tell the baby how well they are doing,
and what you need them to do.
They are having an experience also, along with you.
Here are some fantastic resources on parenting your new baby, when you're ready for them.