When you have a baby one of the first things you want to know after gender and time of birth, is their weight. The weight of the baby gives you a clue as to their future growth and trajectory. It also gives you information about how healthy your pregnancy was. At birth your baby will be given a child health record, in New South Wales, Australia this is known as the 'blue book'.
In the UK it was a red book. And other countries will have their own individual child health record. In this book will be a chart or graph with centile or percentile lines and your baby's weight, length and head circumference will be plotted at regular child and family health or well-baby developmental assessments and clinic visits.
Baby Clinic Weigh-in
Regular baby weigh-ins at the baby clinic are a rite of passage for many parents and their baby's. However, many parents look back at this time with a deep sense of failure; when told their child isn’t “gaining enough” weight. Breastfeeding mums are often left feeling like they didn’t try hard enough.
Centile charts were first developed in the 1950s and these are charts many are still using today. And therein lies the problem. None of these charts takes into account multicultural genetics or breastfeeding babies. They are based on formula-fed babies from America. Things have changed in parenting and genetics in the past 70 years. Children are generally taller, heavier and breastfeeding is the norm in many countries.
Trends and Progress
Numbers on the weighing scales have become a defining measure of an infant’s progress. And the silent message being given to parents is more weight gain is better.
"Yet, in the research world, we have known for a decade that being big and growing fast in infancy is a strong risk factor for obesity in childhood, adolescence and adulthood. This evidence has not filtered down to our front-line health professionals and importantly, the advice given to parents. We need to talk about why".
How do Growth Charts Work
Wherever the baby's measurements for weight, length, and head circumference were plotted at birth then discharge from hospital (generally at 4-5 days) is the centile the baby should stay on till 2 years of age. They shouldn't cross major centiles and a major centile is the 25th, 50th or 75th. However, it is normal for exclusively breastfed babies to dip in weight at 4-6 months then increase again once solid food is introduced. It is important to measure head circumference together with weight. This indicates accurately how a baby is thriving. Length is purely down to genetics.
It's important the same health professional measures a baby over time with the same weighing scales, an approved measure mat for length and a tape measure. As a nurse and midwife who has measured and weighed many babies these are crucial. I did another child & family nurse's clinic for 2 weeks of her annual leave. I used my own tape measure ( a new one)and I realised after measuring many baby heads that her linen bonded tape measure had stretched with time. On her return, I had to inform her she needed a new tape measure!
All premature babies (any gestation under 37 weeks) is classed as preterm and it's important to correct for prematurity until the infant is two years of age. So the baby will have an actual age and a corrected age.
Unfortunately, many parents interpret growth charts incorrectly– or have not had growth charts properly explained to them – and think a baby tracking above the 50th percentile is good, and below is bad.
However, this is not how percentile charts work. By definition, half the population has to be above the 50th, and half below. There will always be infants who track on the 3rd percentile and some on the 97th. And this is OK and to be expected.
Your Baby Is So Much More Than A Set of Measurements
A thriving and healthy baby is so much more than a set of measurements. How your baby is developing and how they are sleeping are also important indicators of a thriving baby. Good day naps and a good nights sleep help your baby grow and gain weight better than babies who have lots of broken sleep. Once babies learn to join sleep cycles and can self-settle everything just comes together. A baby needs a good nights sleep to feed well. It's very normal until 6 months for a baby to have 2 night feeds. Its the long stretches in between those feeds that are restorative and regulate the appetite hormones.
Falling Down The Centiles
I regularly have a conversation with a mum about her 6 month plus baby who has fallen down the centiles for weight. They are under the illusion that extra night feeds are the answer for weight gain. In fact the opposite is true. Once babies sleep through the night they take their solids much better and milk feeds in the day. Solid food has 3-10 x the calories of milk per same volume. Milk fills them up but hasn't got the calories they need to sleep well at 6 months plus.
Rather than obsessing over centile charts at the reason for the escalating child obesity problem. And bearing in mind centile charts have been around and in use since the 1950's. The issue is very complex and the centile chart causation is way too simplistic. Lifestyle has changed dramatically and our diets have way too much processed food in them. Processed food leads to cravings of more processed food. As fat levels in diets were decreased in the 1990's the sugar levels in foods increased. Snack foods became very prevalent and we have become a very snack focussed society. And looking at the amount of sleep problems I'm seeing in babies and children. This in itself is very much a risk factor for future obesity issues.
Poor Sleep Habits
Poor sleep is increasingly common in children and associations between short sleep duration in early childhood and obesity are consistently found. Less is known about the infancy period, and the findings in teenagers are inconsistent. Sleep timing patterns may also contribute to obesity risk. Only 20% of adolescents get their optimal 9 hours of sleep on school nights, and one-third of 2–3 year olds sleep less than recommended. Studies have consistently shown an association between short sleep during early childhood (age 3–7 years) and either concurrent or later obesity. Studies suggest a late bedtime may be a unique contributor to obesity risk.
Maintaining a regular and early bedtime routine during the week, as well as across weekdays and weekends, may be an important obesity prevention strategy. This strategy works by reducing the behavioural and metabolic changes occurring as a result of shifted sleep timing.
Teaching Your Baby To Self-Settle Reduces Obesity Risk
Infant sleep cycles are interrupted by the baby waking to be fed. Subsequently the routines parents establish around sleep can also affect the number and frequency of milk feeds. Especially when the baby is breast fed and this impacts energy intake. This has a knock on effect and consequences for infant weight gain.
Also how parents respond to their baby's crying has huge variability in their baby's ability in developing self-regulation skills. It is important the caregiver avoids the use of feeding as the first response to calm the baby by using alternative soothing strategies. This can increase parental responsiveness to infants’ needs and promote infants’ self-regulation.
Using the breast, bottle or a dummy to calm the baby prevents the baby learning to self-regulate and it can also teach the baby to literally eat their feelings. Early life growth has long-lasting metabolic and behavioUral consequences, intervention during this period of developmental plasticity may alter long-term obesity risk.
The Intervention Nurses Starting Infants Growing on Healthy Trajectories (INSIGHT). Study is a longitudinal, randomized, controlled trial evaluating a responsive parenting intervention designed for the primary prevention of obesity.
The parenting intervention uses a responsive parenting framework with obesity prevention messages delivered at each visit correspondING to four infant/toddler behavioUr states: Drowsy, Sleeping, Fussy, and Alert and Calm.
INSIGHT’s central hypothesis is responsive parenting and specifically responsive feeding promotes self-regulation and shared parent–child responsibility for feeding, reducing subsequent risk for overeating and overweight.
The INSIGHT study recruited 316 first-time mothers and their full-term newborns from one maternity postnatal ward. Two weeks following delivery, mum and baby dyads were randomly assigned to the “parenting” or “safety” groups. Subsequently, research nurses conducted study visits for both groups consisting of home visits at infant age 3–4, 16, 28, and 40 weeks, followed by annual clinic-based visits at 1, 2, and 3 years.
INSIGHT’s parenting intervention is grounded on parenting sensitivities and centres on responsive feeding. Parents are taught how to identify and respond sensitively and appropriately to infant hunger and satiety cues. This early intervention is thought to positively influence the developing of control of food intake by avoiding controlling, restrictive, or coercive feeding by parents. It is thought these controls can reduce the risk and override the children’s responsiveness to hunger and satiety cues. Thereby promoting eating in the absence of hunger. Leading to preferences for energy dense foods, and increased obesity risk.
Current advice to parents to make healthy food choices for older infants and toddlers is failing to produce the desired outcomes and highlights the significant need for changes to clinical practice. Data from the Feeding Infants and Toddlers Study (FITS) revealed unhealthy habits start early; energy intakes among infants and toddlers exceeded requirements by 20-30%.
Many mothers are currently told by midwives and health professionals to feed their baby to sleep, it won't do any harm. As the INSIGHT study has discovered this is not the case when feeding to sleep becomes the only way a mum is taught to calm her baby. It's time to look at current advice and practice if we are to tackle this obesity epidemic in those early weeks and months.
Growth Chart Education
During early infancy, INSIGHT study parents are educated on typical patterns of growth and weight gain including factors such as nutrition and genetics contributing towards growth. Beginning at the 16 week home visit, color-coded growth charts are shared with parents similar to those used with older children These growth charts are used for discussions about the definition of percentiles and healthy patterns of growth. Each parent is provided with tailored feedback based on the individual child’s anthropometrics. One important specific message communicates higher percentiles on the growth chart are not desirable in the way they are for school performance. This parental education is vital to help modern day parents avoid the obesity trap for their children and achieve lifelong health and wellness.
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