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Column originally published Jan 15, 2013

Exclusive Breastfeeding And Weight Gain

Question: Our daughter is four months old. She is a healthy baby. I have been nursing her since birth, and she is doing very well. I have not introduced any solid food as yet, and she doesn’t take any formula. She has many soaking diapers and one to two bowel movement every day. We thought we were doing well. When our family doctor checked her last week, he said that she is not gaining weight fast enough, and wanted me to supplement her with formula. In the meantime, he is going to make a referral to a paediatrician. This makes me really worried. Our daughter is happy after nursing; she is full of energy, and she has never been sick. She is matching all the developmental milestone that I can find in baby books. Is it possible that my milk is not nutritious enough for her that I need to give her formula?


I can understand your anxiety when you hear that your daughter is not gaining weight as expected. Before you get too worried, you can make some observation and see whether your baby is getting adequate nutrition from breastfeeding.

Most mothers are able to breastfeed their babies; human evolution over millions of years has ensured that mothers’ breast milk is most suitable for their babies. The World Healthy Organization (WHO) as well as the Canadian Paediatric Society (CPS) recom- mend that newborn babies should be exclusively breastfed for the first 4 to 6 months of life. Most healthy mothers receiving adequate nutrition are able to produce enough breast milk that is sufficient for the healthy growth and development of their babies for these 4 to 6 months. After that, solid food should be introduced in increasing amounts to these babies.

You can assess whether your breastfeeding is effective or not by paying attention to the transfer of breast milk from your breasts to your daughter during nursing. Some mothers will notice that when they start nursing on one breast, the other side will leak some milk. You can also listen to her swallowing while nursing. The time it takes a baby to finish a nursing is quite variable; some babies eat faster than others. Most of the time, a nursing can last from 15 to 30 minutes. If a baby takes a long time to nurse, it is possible that the mother’s milk supply is low. If a baby nurses only for a very short time, it is possible that she didn’t get a good nursing, and will be hungry much sooner.

Most breastfeeding babies need to nurse more frequently than formula-fed babies. It is because formulas stay in the stomach for longer, so babies don’t feel hungry as quickly. Breastfeeding babies may need to nurse every 2 to 3 hours, and this is perfectly normal. Another good way to gauge whether breastfeeding is effective is to check whether she has 6 or more soaking diapers of urine a day. The frequency of passing stool is much more variable. Some babies can have one or two stools a day at four month of age, while others may have stool only once every few days.

Breastfed babies often gain weight slightly slower than formula-fed babies. For many years, doctors in Canada have been using growth charts distributed by various formula companies. These growth charts were based mostly on formula-fed babies. Therefore, healthy breastfed babies would appear to be smaller according to these growth charts.

As a result, WHO, in conjunction with United Nations Children’s Fund, released new international growth charts in 2006. These charts were generated from six different countries and according to recommended nutritional and health practices, including exclusive breastfeeding, for the first 4-6 months of life. These are now regarded as gold standards in monitoring children’s growth, and have been adopted by Canadian Paediatric Society and several other Canadian national organizations.

It is quite possible that your daughter’s weight and height were plotted on one of the earlier growth charts that I have mentioned above. As a result, she would appear to be too slow in gaining weight. If these measurements were plotted on the newer growth charts, she might be completely normal.

Of course, there are babies who have medical conditions that slow down their growth and development. Sometimes it is difficult to tell unless they are observed and monitored for a period of time. It may be necessary to conduct tests to make sure a baby’s growth is normal. Therefore, it is advisable to consult a paediatrician to check out these potential problems.

In the meantime, if your daughter is nursing well, and she seems to be satisfied after nursing, and has good amount of urine and bowel movements, you can continue to nurse her while you are waiting to see the paediatrician. There is no rush to give her formula, unless if she appears to be hungry after a good nursing.