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Harding et al state that the problem of hypernatraemic dehydration in breast fed babies is attributable to “the reluctance of midwives to weigh breast fed infants”.1 They imply that weighing between 72 and 96 hours would be an effective intervention, but provide no evidence to support this claim.
It does not surprise me that the views of midwives and consultant neonatologists differ on this point. Whereas midwives in this country receive specific training in the management of breast feeding, most paediatricians do not. Indeed most are (to coin a political aphorism) “one club golfers” where the assessment of breast feeding is concerned: weighing might be one indicator of a baby's fluid balance but there are other ways of assessing the adequacy of breast feeding, including feed observation. Given these differences in expertise, one might reasonably ask which group of professionals give the correct answer!
As Harding et al point out “normal weight loss is at its maximum” between 72 and 96 hours after birth. In the view of many midwives (and mine) this constitutes the strongest argument against weighing a baby who has been observed to feed well. Demonstrating this weight loss frequently undermines breast feeding no matter how carefully the physiology of the phenomenon is explained. Additionally (particularly in primiparous mothers), lactogenesis is only just becoming established between 48 and 72 hours. Thus the volume of milk transferred to the infant is still rising sharply between 72 and 96 hours of age.
Before early weighing can be recommended as a screening test for hypernatraemic dehydration more information is required. Firstly the precision of weighing in practice and the accuracy of measured differences need clarification. In relation to this the predictive value of a weight change on day 3–4 needs to be ascertained. Secondly the comparative merits of other methods of assessing breast feeding need more emphasis (the American Academy of Pediatrics consensus statement cited by the authors views weighing as only one aspect of the assessment). Thirdly the nature, effectiveness, and cost of resulting interventions need to be considered (more than “encouragement to continue” may be needed). Finally the potential adverse consequences of weighing (alluded to above) need to be set against any diagnostic benefit.
In summary, I fully agree that the prevention of hypernatraemic dehydration is important but am not persuaded that early weighing is the answer. In my view better training of health professionals, including paediatricians, in the management of breast feeding would go further.