Katie James (00:00)
Welcome back. What are we talking about today?
Johanna (00:01)
Thank you. ⁓
it's a good one. It's a good one. And it encompasses a lot of things. It's called weight gain woes.
Katie James (00:12)
until I change the title, but yes, it's probably weight gane Woes. I won't change the title. It's perfect. But if you've heard a different title, you know I've changed it. Not because Joe's title is not awesome, just because of the SEOs.
Johanna (00:19)
I'm yeah as ha ha
Well, let's just say instead we're going to be talking about troublesome things that go along with weight gain issues. Shall we call it that? Is that just, it just rolls off the tongue, doesn't it?
Katie James (00:40)
Yeah, that, that really, like I stayed awake listening to that. I didn't drift off in
the slightest at all. If you've got a baby and they are gaining weight, losing weight, or you are working with anyone with a baby, then this is the episode for you because we're to be talking about all those things. The sun is coming out and now I'm starting to get to a point where I just can't even see. So this is going to be fun. I'm going to have a screwed up face. Where are we starting?
Johanna (01:05)
You don't have to sing.
You don't have to see, just listen, listen to me. I will bring you the light, Katie. ⁓ great. All right. So, ⁓ well, I was thinking when I was writing a few notes about what we could be talking about when we're discussing weight gain issues is that we can talk about a couple of things. are, the ⁓
Katie James (01:13)
Okay, carry on, take it. You roll with this podcast. I'll just sit here enjoying the sun.
Johanna (01:34)
issues that we have about babies losing weight after birth and that this is a ubiquitous thing and where is that magical line where it is too much now? ⁓ There's that scenario. There is also about then the fact that they start to gain weight and then what happens when they plateau? Is that an issue? Is that not an issue? How much do they need to be gaining according to which chart?
And then for me in my practice, the thing I see very frequently that I am going to be really diving into here is the issue with too frequent weighing and people that have gone out and bought their own scale and they're either weighing once a day or they're doing, get ready for it, before and after weights for every single feed for the baby, which is what I see. I wouldn't say frequently, but
regularly is something that I see. So we got quite a bit that we could talk about here.
Katie James (02:36)
Okay.
Yeah. And that's already getting me like, I need to talk about this. Okay. So should we start at the beginning? Which is probably, let's just do some stuff about what, you know, normal weight loss in the beginning and what kind of breaches those boundaries.
Johanna (02:43)
Mm-hmm.
Yeah, yeah, good.
Perfect. What are we looking for with healthy babies and where the things get to?
Katie James (02:59)
healthy babies, it's really normal
for them to lose weight. I mean, they come out, they've been fed 24 seven and all of a sudden that supply gets switched off and they are given these tiny but frequent amounts of colostrum, which is, know, colostrum as we know is really there for immunity, for a glucose boost to keep the brain going, to act as communication, to switch on the milk making cells. Little and often makes them come to the breast really frequently. Every time they stimulate the breast,
They're switching on the milk making cells. It's not there to fatten a baby up. And so what happens? They lose weight. And that is within the realms of absolute normal until we get to certain percentages. And this is where the lines blur and we can go from,
Everything's fine and dandy. You're doing brilliantly. The midwives are telling you you're doing great. Just feed the baby when they cue or on demand. You might've heard that phrase. And then all of sudden they do the weight and the weight is over a certain percentage. And it's like an emergency situation has occurred. I think we've spoken about this already. So where are we sitting? Really between seven and 8 % is probably that area that we want to say totally normal, great, doing brilliant.
we're expecting, probably this mum's going to be showing some signs now or in a few days, depending on when we weigh, that's also, that her milk's coming in. And from around day four plus four to seven, we should see these babies starting to regain their weight. Now, not all babies will lose weight, but the majority will. So all of this realms of normal. Once we hit past eight to 10%, that's...
doesn't mean we have to come in with all guns blazing in any shape or form. However, if you're a midwife or a health professional or a professional looking after a mom and baby, and you have a weight loss of around 9%, what we don't want is that nothing is actioned. The breastfeed isn't checked fully. The positioning and the attachment aren't altered or improved. And we just leave things ticking along because what might happen is this
might be a warning sign that that baby's just not transferring the milk as well as they could. And we just need some slight adjustments. And maybe that mom's missing some feeding cues and that baby's not feeding frequently enough. There's probably these simple reasons why that baby's lost a little bit more.
Johanna (05:31)
that's the state where I would say, actually, this is what my mum used to say to me when I was learning how to drive. She used to say to me, Joe, you just need to stay alert, but not alarmed. And that always goes in my brain at situations like this, where it's like, you know what, we're just keeping an eye on things. We are going to just assess to see if we can optimize anything, but we don't have to come in with any kind of like medical intervention in any way.
at that point.
Katie James (06:01)
Totally. This is a little alert as us as health professionals to say, watch a feed. Don't just come in and whisk off out that mom and baby need you to watch a full feed where possible. ⁓ and we also need some follow up to make sure we weigh that baby in a few days, not just send them off into the ether. And 10 days later, they're going for a weight check. And this is when we see everything falling off the peg is because we haven't heeded the warning of like 9%.
Johanna (06:13)
Exactly.
Katie James (06:31)
Hmm, let's just pay more attention without frightening anybody. And so that's what this kind of eight to 10 % marker is a little nudge to go, oops, little doorbell ring. Let's just check in there. Let's see how we can kind of improve is the wrong word, but just change things slightly and look, thank you, optimize because you're starting out. It's like learning to drive. You are not going to get your keys on the first day and by two days later, you know how to drive.
Johanna (06:37)
Yes.
Optimise, optimise.
Katie James (07:02)
It is small adjustments along the way. So then we get to the 10 % and this is where ⁓ it seems like we get a midwife or all of us are trained, right? 10%. This is when you need to phone the pediatricians and that's when we come in with bottles of top-ups and formula. But actually we need to have a look at the whole entire picture as we always look at and is this baby well firstly? What's happening with that breastfeed? Are they breastfeeding? Okay.
Johanna (07:04)
Mm-hmm.
Exactly.
Katie James (07:32)
Is it actually just a case that this baby's got a really shallow latch and is perching on the end of the nipple and all of a sudden you help support this mum and baby, the baby goes on and ⁓ gulp, gulp. ⁓ we've got milk transfer and we didn't before. Well, that's a bit of a clue. ⁓ what's happening in her breasts? she's telling me they're filling. she's telling me they're totally soft. What's happening when she does a bit of expressing? she's got really good knowledge of her breasts. She's getting some milk out.
All these signs show me that this needs support, not a massive feeding plan. This needs support and close follow-up and awareness and acknowledgement. And I'm going to take this to the pediatrician with my full history and say, in my opinion, this mom and baby are doing fine. I'm going to check in in 24 hours or 48, get away the baby. Signs are the milk's coming in. I could see clearly that baby wasn't transferring milk. It now is. And she's expressing.
Johanna (08:08)
Mm-hmm.
Katie James (08:32)
This is what we're going to do. We're just going to make sure that they feed. And she was only feeding five times in 24 hours. So we've changed all these things. I'm going to weigh her in 24 hours, 48 hours. Are you happy with this? Tick? Yes. Or we have a baby who's lost 11.4 % is not having wet and dirty nappies. ⁓ We've got meconium, it's day three, breasts are soft, no signs. She's got a really long, difficult history of birth and labor.
Johanna (08:36)
Mm-hmm.
Right, still got titanium.
Katie James (09:00)
And you've got all these other signs that are showing, baby needs some more fluid. This mom's milk is not on the way in. This isn't just positioning and attachment or the way the baby's attached alone. It probably is as well. This isn't just a case of we can do these things. This is where we might need to put a feeding plan in place for a few days. Recheck the weight, observe the baby, observe the mom. And I mean,
that goes without saying. there, there's a difference. And then that is also a communication to whoever you have to communicate with in your hospital, pediatrician, senior midwife, lactation consultant, whoever, to say, this is the history and this is what I think the plan should be. How are you feeling with that? What sits right with you? And that's where we have this space as a clinician to negotiate a safe feeding plan for that mom and baby with that mom and baby. And follow up.
to reduce the feeding plan.
Johanna (10:00)
Yes, absolutely. And I think it's also worth mentioning that this 10%, like, I mean, I've got, I've got quite a few things to say that are worth mentioning, I hope, but
It's not one of these scenarios where 9.9 % is fine and 10.1 % is suddenly not fine. Right? So there's never this kind of arbitrary, well, it is an arbitrary number that suddenly makes everyone freak out. So when everyone is asking you, what is, you know, how much weight is it okay for them to lose? There's many things we have to factor in. So it's not just the number, but there's also scenarios like.
Did this woman have a very long birth where potentially she ended up in an emergency C-section? There was a lot of IV fluids that was going into this woman through the birth for a long period of time. Maybe she had a very long induction as well. And this baby now, as is the mum, is full of excess fluid from these IV because clearly we know that everything is traveling through the mother into the baby.
So now this baby comes out and the first 24 hours, this baby is peeing and peeing and peeing. And they are also just drying out, right? Like I always just think that it is also a part of the reason why these babies are losing weight. It's not massive amounts, but that's a factor. And if this baby in the first 24 hours,
has peed out a massive amount and suddenly we see 24 hours after birth that this baby is already at 8.59 % weight loss. Like that's not accurate as far as how much of like the body mass of the baby has been lost at that point in time. It's not, they just did a lot of pee. So.
When I'm looking at, like if someone comes into me and they've got their ⁓ health booklet and it's got the weights of the baby in there and I'm trying to assess, you know, how healthy is this bubba? How much milk do we need? Do we need supplement, et cetera? I am looking at what was the baby's weight 24 hours after birth. And as soon as I know that, that is where I can kind of accurately start to assess actually.
how much weight are they losing and how much are they actually managing to gain as well? Because I do tend to see them more like from day 10 onwards, sometimes seven, but usually about day 10 onwards. So at that point they should be starting to gain and I'm looking at the rate of gain and what their original loss was.
Katie James (12:51)
Yeah, absolutely. This brings up a couple of things for me. Firstly, completely like we're looking at that entire baby, the wet, the wet debate, the fluid debate is really tricky. Let me backtrack because I totally want to say to you, yes, it's not 9.9 % is fine and 10.1 % isn't. However, most babies are being born in hospitals. Most hospitals have the Cinderella service.
as it's called, unknown for many, many years, is postpartum care. We do not put in the right amount of staff We do not count all babies and mums as a separate patient, like you do on a nursing ward. And so most midwifery and maternity units are understaffed. They're not even watching a full feed. And this is where we have huge complexities with the whole weight thing. And this is why most policies in most hospitals have a 10 % as a cutoff. But like anything that is so sharp.
Like that, has to be a broader view, but how do you get that nuance? How do you get that into a tick and flick when you've got five minutes with a woman? don't, so I suppose that's why I say you can have a number, but it doesn't mean that that mom and baby's feeding journey is the same as the woman in number, room number four is the same as the woman in room number eight. Like it just isn't, you have to then take that full history and then you go and describe what the feeding plan will be. So you're so right. We really can't.
Johanna (13:54)
What's taking you?
Katie James (14:22)
Like there isn't that over 10 % is a definite, it's about looking at it. Then the whole wet thing, I did a whole podcast on this, in a different podcast, because it's so tricky. Like we've known about this for over 10 years now. We've been talking about this as in we give IV fluids through labor. It's eventually going to go into the baby quite likely.
When should we weigh these babies? Now in 10 years, actually more than 10 years, because I remember a paper that was gathering information is from 2014. We have not seen any standardized guidelines come about. Why? None of them were testing the same things. None of them were weighing the babies at the same time.
None of them were saying that over this amount of weight, like 10 % or 8 % was a problem factor. None of them were looking at women who'd had the same amount of fluid volume, and none of them were looking at the same amount of length of time of having the volume. So it's like up in the air of this, yeah, it probably does something, but we haven't done any studies that go, I've tested 10,000 women in Denmark.
Johanna (15:20)
Mm-hmm.
Thank you.
Katie James (15:32)
And we've tested 10,000 women in America. We've tested 10,000 women in India. Ah, all of this is the same right now. Let's make some standardized guidelines. So we're really in the air about this. And this is a really tricky thing for you as a clinician who then has all of that on your head on a home visit as a midwife and feels the panic of that with weight loss. And the other thing is, so a lot came out from that is in a lot of countries, they don't do a 24 hour wait.
They wait till 48 hours or 72. And actually I get a lot of UK midwives who ask me, God forbid, why are we already weighing them at day two and day three, Katie? We should be waiting until a week, which is what we did back in the nineties.
Johanna (16:18)
Mm-hmm. And that is after they've done the birth weight, then the next weight is not for another week. Is that right?
Katie James (16:24)
Yeah, because back then we had more continuity of care and we have more knowledge and we have more time. So as a midwife, maybe I knew this woman through her pregnancy and maybe I was the only midwife going in to visit her. So I was seeing her every other day, but I wasn't weighing her baby because I was looking at the clinical signs. I was seeing a whole breastfeed. I was seeing that wet and dirty nappy progression. I didn't need to weigh that baby to worry her. I could see clearly that clinical picture.
psychological picture was they are well. And I'm going to weigh that baby on day seven when I know that that baby's going to have gained weight.
Johanna (17:02)
Right. And you know, I'm telling women all the time that look, a baby that is peeing and peeing and peeing and doing a lot of poos must be taken in stuff. It has to be happening. Right. So for sure, I would love it if more emphasis was put on that in being able to ascertain if a baby is healthy and if they're growing the way that we want, are they taking in enough food? Are they peeing and pooing enough?
That's what we really need to know.
Katie James (17:34)
But it's not possible. Like our current systems don't allow for it. And that's why we've had to bring these weights in before they leave the hospital. And that's where we then can put panic into the clinicians that then goes into that mom, baby, and that whole family. And I don't know how we solve this, but it is a bloody big problem. We solve it by education, by seeing that it's not just a number. That's how we solve it, or one part of it.
Johanna (17:43)
Mm-hmm.
So what,
what do you do yourself? Like, is there a point for you where you're looking at, like, do you have personally a number where you would say, even if P &Poo was fine, would you have a number where you say, actually, this is not okay. We need to get some extra milk into that baby. Do you have a point?
Katie James (18:26)
I wouldn't
have a problem with weight if I had a good wet and dirty nappies. Like if it ain't going in, it ain't going to come out. If it's going in, it's coming out. Like I've spent years and years and years doing phone, telephone consultations. So postpartum telephone consultations with the hospitals I worked at. I couldn't weigh those babies. How did I know as a midwife and the LC to sit comfortably in that seat, write my notes, a legal document and say, I feel that baby's clinically healthy.
Johanna (18:33)
Right.
Katie James (18:56)
Because the first thing I say is how often is your baby feeding roughly? What's wet and dirty nappies looking like? How heavy is that wet nappy? That's the other thing. Like we don't even say how heavy does that nappy feel. We're just like, there was a blue stripe. I'm like, forget the bloody blue stripe. I don't care. When you feel that nappy, your baby's now four days old. I want you to be saying, Ooh, mama, that's like I've poured my cup of tea in it.
compared to the brand new nappy that I'm about to change you with. If they feel the same, but there's a blue stripe, that is not a good output. Yes, they've done a wee, but that's not a big tick wee. That's a, I'm a bit concerned about that wee. And I think that's the nuance.
Johanna (19:44)
This is where I think actually giving people, again, I'm talking about women that have already left hospital and are at home trying to figure this out themselves. And I think that giving people like a particular number that they need to hit as far as P and Poo goes is tricky. Poo obviously is able to be spotted more easily, but I think that, yeah, exactly. Thank you. That's where I was going with that.
Katie James (20:10)
Sorry, I beat you to it grabbing my yellow poo pen.
I want your baby's poo to be the colour of my pen.
Johanna (20:18)
Um, but I think telling someone that, know, okay, they need to be doing say six wet nappies a day. Then I have, okay. Yeah. But then what actually counts as a wet nappy and how wet does it need to be. And what if it's like been 15 hours and there hasn't been a wee then like, what, what should I do in that situation? So when you're saying.
It's rare that we disagree, Katie, but I'm finding, I'm finding a point, right? When you're saying that for you, it doesn't matter about the color change. ⁓ Didn't you? No, no. I mean, color change on the nappy itself, the little blue line.
Katie James (20:56)
I didn't say that. No, I said the color change is super important.
⁓
it's not that it doesn't matter, it's that it doesn't always tell you if it's a good enough wee.
Johanna (21:10)
doesn't tell you.
New ones, my bad, new ones.
Katie James (21:14)
It matters because there's a little bit of wet, but I'm saying if you're asking for heavy wet nappies and all you're writing is I'm expecting five plus wet nappies and we're ticking boxes with women or the women are ticking their own box or filling in their own app. And they're saying that that's counting as a good we, whatever good is. And you can barely feel the difference between the new nappy and the wet.
Johanna (21:17)
There was something going on.
Right?
Katie James (21:42)
nappy in quotes, but it's got a blue line. That's a problem wee for me. That's an easy miss for a clinician to just look at an app and go, this baby's had six wee's and actually it's had six little teaspoon full of wee and it's day five. That's a problem. That's a massive alarm bell for me.
Johanna (21:42)
Mm-hmm. Mm-hmm.
night.
What I would tend to be doing is looking at the fact that they, how can I explain it? I feel like it's really difficult for my women to be able to say, yes, that was a good we, or it was not a good way. And where is the difference between that? ⁓ So what I would say is that if we are doing a big change to their care plan,
We're trying something different and I really need them to independently be able to see if their baby's gaining enough. In the meantime, I don't want them to go and buy a scale to check this. I want them to be watching the nappies and when I'm getting them to watch the nappies in this particular instance, I would get them to change a nappy every time they see a color change. And in that situation, I want them to have eight of those every day.
And if I see eight color changes, whether they feel different or not, and we get the poo going on, we're going to talk about the poo as well. Then I feel secure that things are going okay. Even if it's a really tiny, tiny wee where, you know, potentially doesn't feel any different. And that's a way that I can kind of like, like there's an external source that is a color for them to be able to feel confident that that's.
Okay, that's the only way that I tend to use the color change situation. And that is also how I would much prefer a woman to be able to check if her baby is getting enough milk. I feel like that is a much more accurate way of doing that rather than going and buying a scale and weighing their baby every morning or before and after every feed.
Katie James (23:56)
Definitely not to buy scales. But what you're talking about is a, is a change in a plan. So then what's happening is you're using that as a way to indicate the difference going forward over that 24 hours, the next 24 hours. What you will then see is you're marking down any amount of fluid to show a change. What I'm talking about is that initial, she's at home, they're on their own. You're on the telephone as a midwife and you want to get across.
Johanna (24:03)
Yes.
Exactly.
Katie James (24:26)
what is going on from a quick telephone call or a quick visit. And you have your limited time and you have an app that she shows you and it's got eight ticked on there. Now that's when you want to go into the nuance of, okay, she's changed it because she's probably seen a line, but is it starting to get heavier? Often we're not asking about the heaviness. And I think before we even use your way or
Johanna (24:30)
Mm-hmm. Mm-hmm. Mm-hmm.
Katie James (24:56)
that way of looking at the nappies, which is absolutely the best way to see whether a baby is taking more in than anything else. Like I'm obsessed with nappies and poo changes. Me too. I get sent them all the time. Absolutely. So, but if we're taking it from the beginning and taking it from a care plan, there are different ways of looking at the nappies. However, there are minimums that we should be looking for, but we could also have...
Johanna (25:06)
I know, right? I know, my phone is full of pooey photos in here.
Katie James (25:25)
that that baby is peeing quite a lot, yet that poo stays brown. And it's day four, day five. my God, look what else is poo colored. My jacket. I literally am surrounded by baby poo colored things at the moment. I've got some tiles on my desk. They've got baby poo yellow as well. So it's also not taking one without the other. And the reason why I bring these up is because I see it.
Johanna (25:30)
Mm-hmm.
You're crazy.
Katie James (25:52)
time and time and time again for the last 20 years in practice, that we look at a tick box as clinicians and we don't look at the nuance. Once we put a feeding care plan in place, it's different because we're working with that mum solely alone and we can look at those differences.
Johanna (26:11)
So I want to talk to you about this scenario where we have somebody who is weighing their baby every morning, for example. And have you had people that are in that situation before? I get it quite frequently.
Katie James (26:28)
Rare,
rarely. They weren't such a big thing until fairly recently as well, maybe the last five years or so.
Johanna (26:31)
Okay.
I think it's actually COVID related. think that when we didn't have the ability to frequently go somewhere and check or to have the midwives come and check with you, then people were told to go and buy your own scale.
Katie James (26:52)
Right.
Johanna (26:52)
And then you have someone
who has a baby now and their friend had a baby a few years ago and says, well, why don't you get a scale? Because I had a scale. And we have that kind of scenario, right?
Yeah.
Katie James (27:05)
That's how I feel about it.
I mean, what do we say to us as adults if we're stepping on the scales every day?
Johanna (27:07)
deep.
I know, right? No. I fluctuate like two kilos up and down on any particular day. Right? I mean, not that your baby's going to be fluctuating two kilos, but let's talk about like percentage of overall weight, right? Absolutely. When did they last do their poo? And when did you last feed them? And was that feed a like spaghetti bolognese feed or was it a cup of tea feed? Right?
Katie James (27:12)
Like, should we be doing that?
Well, I hope not.
Johanna (27:39)
All of these kinds of, like there's too many variables for you to change everything about your feeding on one weigh-in. And that's the thing that I see is that people are weighing their baby and they get one weight that's maybe not quite ideal and everything changes. And suddenly all of their instinct of being able to see actually, am I reading my baby's cues correctly?
How does it feel when I'm feeding? Should I swap sides now or not? All of these kinds of things that they're doing by instinct suddenly disappear because they have this anxiety and they, things start to get tricky at that point in time, right? And then even if they had done nothing, the next day, the weight would have potentially tipped up again and it would have been fine. But now they have changed everything they're doing and now the weight goes up.
Katie James (28:18)
Mm.
Johanna (28:36)
And now that's reinforcing the fact that, okay, I have to stay on high alert on top of this. I relax, then we're to have an issue with the weight gain again.
Katie James (28:47)
my God. Yes. And it's just, it's, it's such a roller coaster because when we listen to our instincts and we give it some time and you've given it a few days and you see the weight go up, you believe in yourself and you realize, gosh, give myself a pat on the back. did, I'm doing an excellent job. If you're changing everything every 24 hours. we are in a tailspin. Like what the hell was it that worked?
Johanna (29:13)
Exactly.
Katie James (29:13)
What can
I pinpoint and go, ⁓ it was this position or I felt more comfortable here or I, whatever, like, ⁓ my God, it's just anxiety inducing for us, think, as well as for mom.
Johanna (29:27)
Mm-hmm. And then I'm not
going to go into the ones that are doing the before and after way for every single feed. You can then imagine the anxiety that's going along with that.
Katie James (29:39)
think we
do need to touch on that in terms of in the NICU, because I have a rant about that. So, but I want you to come back to that. I just, my God, scales, anything where we check, check, check, particularly when there is a really good way of seeing if your baby's getting enough. And that is, if it's going in, it's going to come out. So let's look at that in the big scale of things of number, color, consistency, how
Johanna (29:43)
okay. Okay, well. Okay.
Yes. Yes. Yes!
Katie James (30:07)
Are they increasing? Are they getting heavy? Are they not? Are they tailing off? And also when you really know your baby's output, by the first week and it kind of, okay, it's going to change again at six weeks, but you get a feeling for it. And if you don't, often tell the women I work with is take out eight nappies from the pack. If they're using disposables, put them in a separate side and that's your 24 hours. So from say 9 a.m. you're going to start using that new pile. Then you'd have to count.
Johanna (30:37)
Mm-hmm.
Katie James (30:37)
a worry in your head because if you finish them, you know they've done eight. If you're going for more, you know it's even brilliant.
Johanna (30:41)
Yes, that's what I do. I love it.
Yes, every time then if you ran out and you have to go underneath the bed and pick up another nappy like yes, yes.
Katie James (30:54)
And that can keep you going for a couple of days and then you're like, I got this. yeah. And then, you know, you get the mighty explosions, the number threes up the neck and down the legs and the bright yellow. And then you, the thing is when you get really in tune with wees and poos, like we are, you will see it instantly when it changes. You will see the day your baby gets a bit snuffy in a cold and they feed more or they feed less. There's something.
Johanna (31:04)
Mm-hmm, the poonami.
That's all we need.
Katie James (31:23)
like not quite right and they have a bad day and the wees and poos changes. Keep an eye on it. You don't panic, but you know that you might need to wake them and feed them a bit more. You notice everything about them because you're relying on your inner instinct.
Johanna (31:38)
Mm-hmm. Mm-hmm. For sure. I also wanted to mention that if there is ever a thing for me that is a real proper red flag for postpartum mood issues, for postpartum anxiety, particularly in OCD, for me, it is shown when I have got people that are really fastidious.
about the tracking of the weight. And yes, it can show up in other ways, but it's very rare to me that it shows up in other ways and not also with the weighing. And I would say that the biggest red flag that I've had in my career was people that are weighing the poo as well and the pee of the baby. So they know what is
the weight of a nappy when it's empty and then they're weighing every time they're changing the baby so that they can try to track how much is actually being taken in and having a look at the difference there. I also had someone as well that was measuring how much fluid she was taking in and then how much pee she was making. So there are so many ways that
Katie James (33:00)
my god.
Mm-hmm.
Johanna (33:06)
There are way too many variables and there's so many ways that this can all spiral very, very quickly to become a really destructive situation. So for me, as soon as I see that someone has got a scale in their house that is like a baby scale, I really have to keep an eye on this woman. And I really have to make sure that I also have got other people in my corner that I can
immediately refer out to. And I will always give that woman the contacts of postpartum psychs and counsellors and other emotional support systems in their care plan immediately as soon as they've got a scale at home.
Katie James (33:37)
Mm.
Yep.
It's a red flag. It is definitely. I suppose this should bring us to a question of what are we expecting to see? And also the fact that sometimes we can have this micro view, like with health visitors, maternal child health nurses of looking week to week. And actually we've implemented certain changes, strategies, improvements, optimization, sorry. ⁓
Johanna (33:55)
Mm-hmm.
you
Katie James (34:19)
So sorry, no one take offense. said improvements. and you know, having that micro view and sometimes having to take that, that larger view of how is this baby generally doing? And also looking at like the genetics of the parents. And I think we can forget that sometimes like, and also that whole big thing of my baby was born on the 20th percentile and somehow not only new parents, but
Johanna (34:35)
Yes, yes.
Katie James (34:46)
Doctors and pediatricians are like, you've got to get to the 50th and stay there. What? Where has that ever come from? I mean, what does that even mean? Why would you start at the fifth and have to get to the 50th? This really irks me because it's so worrying inducing. And again, another way that we can just put more pressure on women to become more...
Johanna (34:50)
Yes!
Yes.
Mm-hmm.
Katie James (35:10)
⁓ sensitive to it and then even obsessing over it.
Johanna (35:14)
Right. Right. And I think, mean, a very, very simple reason that I've seen that people want to get to the 50th percentile is that when you have a look at a lot of the charts, the 50th percentile is in green and the fifth and the 95th are in red. And you've got like these red lines and then the orange line, the yellow line and the green line and the green line is a healthy line. It's not that way. So.
I mean, I've got my, my app on my phone to track babies growth and I actively change this to change the colors. So I've got like a yellow and a purple and a green, and I make sure that a hundred percent, you know, my babies, I, I'm a six foot tall person. My husband is a six foot tall person. We are both not little people. We're not going to have little babies. Right. And.
If my 95th percentile baby gets down to 40th percentile, this is not great either. So I do not expect the woman who is only four foot 10 with a husband who's potentially five foot one to have babies that are the same size as mine were.
Katie James (36:13)
Mm-hmm.
God forbid.
Johanna (36:28)
No, no! ⁓
Katie James (36:30)
I'm just thinking of myself there being five foot three and a half.
I can remember there was a time in, when I worked in Australia, I just got there. There was no home visiting. There was a lot of weigh your own baby with a nurse. Could have had any background. So we're not talking necessarily pediatric nurse or not talking maternal child health nurse. Could just be a nurse who works in a pharmacy. You weigh your baby next to all the tins of formula. And that's how it was. There was no home visiting.
There was no drop in center. We started that. And so as the lactation consultant I was being paged. That's how long ago it was. I was being beeped down to emergency all the time for babies with weight loss. Yet what I was finding horrified me coming from the UK where I'd done home visits was babies who are three weeks old with a 19 % weight loss. Babies who are three weeks old with a, a 12 % weight loss. And these babies were
very clearly, very, very hungry and potentially on the border of being extremely unwell. Now that is a very, very different scenario to a baby who's coming every week to a child health clinic, being weighed And we can take a bit of a bird's eye view and know that there's the safety parameters And we might see a little bit of a plateau.
Johanna (37:36)
Mm-hmm.
Katie James (37:53)
we're not seeing a consistent dip in that weight. Like that's a different scenario.
Johanna (37:57)
Absolutely. Yeah. And actually I'm really glad that you did mention that because pretty much everything we have talked about are reasons why we shouldn't worry about the weight and that everything is actually okay. And absolutely there are points where we do need to worry for sure. And, and it is very, very tough when people come in and they have got their points on their graph and they are just plateau from the beginning.
all the way through and now it's way underneath the fifth percentile. Right. And yes, this happens. And yes, that is a scenario, you know, always in this job, number one priority, make sure babies are fed always. And that is never going to be something that we risk for babies. We were always making sure that they are getting enough to eat. just that there are better ways to be able to spot if they are getting enough to eat.
Katie James (38:28)
Yeah.
Johanna (38:54)
than just checking what their number is on a scale.
Katie James (38:57)
Yep. So true. So true. I'm going to go to the NICU now, the neonatal intensive care unit or special care baby unit. And a long time ago, we did some pre and post weights and then we found that it caused more anxiety. It wasn't very accurate and we threw it out with the bath water.
And in recent years, we've actually started to use that better. And what I want to say is just there is a time and a space for it, which I know you know in terms of, we have often looked at preterm infants and we're feeding them and we're checking everything about a preterm infant. Now we're checking their oxygen levels, we're checking their pulse, we do blood tests, we kind of make it up with the feeding.
Johanna (39:46)
I did some swallows. It seemed okay.
Katie James (39:47)
You know, we just kind of time it.
Yeah, did some swallows. We might count the swallows and the suck swallow ratio, but actually that's not always that accurate, particularly with these, great pretenders because they're like 35 weeks. We might time a feed. Well, we know that is utter bullcrap and that's not going to us anything. Cause if you've got sleepy babies, it's tick 40 minute feed. Yeah, but it was the sleep for most of the bloody feed. So none of this is actually accurate.
Johanna (39:58)
Mm-hmm.
Yes.
Exactly.
Katie James (40:14)
And then based on often the time the baby was sucking, we work out how much top up to give them down the nasogastric tube, for example. So we might give a quarter top up, a half top up or a full top up based on what evidence. So.
There's been some good work looking at if we do a full 24 hour profile. And I say this slowly because it's not a one-off feed. And this is where the problems came from back in the nineties was we were just weighing a baby, feeding the baby. weighing the baby again and going, your baby took 32 mls Therefore it equals 32 mls at every feed.
Johanna (40:38)
Mm-hmm. Thank you. Thank you.
Katie James (40:57)
And we didn't weigh that baby again. The other thing was that we were using different scales. We were using the scales we weigh babies on, not feeding scales, which are accurate within more like two grams rather than 30 grams in accuracies. So we had all these problems and no wonder it was rubbish. And we suddenly had to go, this is not helping us in the slightest. chuck out this practice. When we use it in a clinical state with a clinician, with a pediatrician, with a nurse, with a baby who's unwell, it can be exceptionally helpful.
Johanna (40:57)
Yes, exactly.
Katie James (41:26)
full with the same scales in the same position, with the same clothing on, with the same mom sitting with the same baby and doing it for 24 hours, we can then get a profile of how much milk that baby transfers for a 24 hour period. And we can have a bit of a picture to then make a plan of how much top-ups that baby needs. Because usually at that point that baby's maybe having a nasogastric tube being given extra food, whether that's her milk.
or formula and what we don't want to do is overfeed this baby. And that baby doesn't wake up in three hours time and she misses the opportunity to breastfeed. We also don't want to underfeed that baby And we go, well, your baby's not gained weight. And she puts all that guilt on herself. So this is where it can be exceptionally helpful. But when we take that into the home environment and we end up doing what we were doing back in the nineties with one feed here or one feed there.
Johanna (41:56)
Mm-hmm.
Mm-hmm.
Katie James (42:19)
This is anxiety inducing. up the wazoo.
Johanna (42:22)
Mm-hmm.
And I think the thing for me is that I really want there to be, you know, I mean, it's the same thing again. We just keep, banging on about the same stuff is that I want there to be a plan for this woman that when she comes home and she's gotten very used to having these numbers that give her the confidence to know if her baby is fed and she's got the numbers that tell her exactly how much supplement she needs to give. Then she gets sent home and is.
told to now figure it out, then she's going to go by herself a scale. Right. So my dream, my dream would be that before they get discharged is that they get away from having to do that to feel confident. Right. But again, that's just a dream and.
Katie James (43:10)
No, it will become reality. I'm with
you, I'm with you. my God, I'm with you.
Johanna (43:15)
So yeah, I mean, we need to find a way to, that's what I see so frequently is that this is the people who often are doing that really, really frequent weighing is the people that had only gained the confidence that the baby was going okay via frequent weighing in a medical setting beforehand. Very often that's the case. So it's quite tricky to then get them to.
to step away from that without causing further anxiety for them. So yeah, we need to try to offer a different way of getting them that. Yeah.
Katie James (43:53)
the
Yep. That is when rooming in would be amazing.
Johanna (43:59)
When people come to our fantasy
clinic again, Katie.
Katie James (44:02)
Well, it's also when they send babies home with, you know, there's some programs from NICUs or special care units where they send the baby home still with a nasogastric tube in. And they do that transitional home program. They've had such good results in terms of they then become in their home environment. They've got an NG tube. They're managing that without everything around them. And they're learning to wean that baby off, trust what's going on, read the baby's cues.
Johanna (44:11)
Yeah, yeah.
Katie James (44:32)
monitor stuff to keep them feeling safe for a certain period of time, but also slowly transition. So it can be done.
Johanna (44:41)
Mm-hmm. For sure.
Do we have a take home message? ⁓
Katie James (44:46)
No, it's too big. think don't
just take the number on the scale. Look at the whole picture.
Johanna (44:52)
Yeah, good one. Look at the whole picture. And also the thing that we said quite a few times is about like nothing is going to come out if it's not going in. So if you've got output, there must be input going in. Let's have a look at that more closely.
Katie James (45:06)
Absolutely get your head in those nappies.
Johanna (45:08)
Yes! That's another one for a t-shirt. Get your head in the nappies.
Katie James (45:13)
UGH
