by Emily Oster
This is not, however, entirely true: there may be a very good reason not to choose rooming in. In the days after giving birth, women are often very tired. Your hospital stay includes more support than you are likely to get at home, and sending your baby to the nursery could let you take advantage of their expert care of you and your baby. Knowing that the data is not definitively on the side of rooming in can make this an easier choice for some moms.
Additionally, there could actually be some (small) risks to rooming in. Many women fall asleep while breastfeeding; this is more likely the more tired you are, and not getting a break to sleep can contribute to the risk that an infant could be seriously hurt as a result of an exhausted mom falling asleep with the baby.18 There are also safety concerns about bed sharing in general, whether in the hospital or at home (more on this in the chapter on sleep location).
A 2014 paper on this issue reported on eighteen cases of infant death or near death as a result of hospital bed sharing.19 This research is not equipped to comment on overall risk levels; their goal was simply to collect case reports of this to show it was a possibility.
Another study reported that 14 percent of babies born in baby-friendly hospitals were “at risk of” falling from the bed, mostly due to their mothers falling asleep while nursing.20 Just to be clear, this wasn’t 14 percent of infants falling, just those that nurses felt were at risk of falling.
In my view, the most important thing to come out of this is, if you have the option to send your kid to the nursery for a few hours and you want to do that, you shouldn’t feel shame in doing so. There is no good evidence that you’re disrupting your breastfeeding relationship, if that’s important to you. And if you find yourself falling asleep with your baby in the bed, ask for help.
. . . AND THE UNEXPECTED
Infant Weight Loss
Many new parents are not expecting the tremendous focus doctors and hospital staff place on infant weight gain or loss. If you have (happily) given birth to a healthy baby after a relatively uneventful delivery, the vast majority of your hospital conversations will now revolve around the baby’s feeding and weight. Obviously, you want your baby to thrive, and weight is an important metric of this. But when you’re just postpartum and trying to breastfeed for the first time, this can be a very fraught conversation. It can feel like you are failing—you did such a great job growing this baby inside you, and now that it’s out, you totally suck. (You don’t! That’s just how it feels.)
Infant weight is monitored pretty carefully in the hospital. Every twelve hours or so they’ll weigh the baby and possibly come back to report any change in weight to you. On day 2 after I’d given birth to Penelope, they returned her to me at two a.m. and informed me she had lost 11 percent of her body weight and that we had to start supplementing right away. I was alone, bleary and confused, and ill-prepared to make a decision about this. The lessons from this are that you shouldn’t let your husband go home to sleep, and, possibly secondary, that it’s good to know this is a risk.
Given the focus on weight, it’s important to be prepared. Here is the first thing to know: nearly all infants lose weight after birth, and those who are breastfed lose even more. The mechanisms for this are well understood. In the womb, your baby is getting nutrients and absorbing calories through the umbilical cord. Once the baby is out, he has to figure out how to eat. It is complicated (for both of you), and in the first few days, you won’t yet have a lot of milk. Colostrum may or may not be the magical substance that lactation consultants fantasize about, but there isn’t much of it (especially with your first baby).
The fact that this weight loss is expected means you want to be careful about this issue, but you also want to make sure not to overreact to the design of the system.
The reasons for weight monitoring are good ones. Weight loss is not an issue in and of itself, but excessive weight loss can indicate a problem with feeding—that breastfeeding isn’t working successfully, for example. This can be a clue that newborns aren’t getting enough liquid, which puts them at risk for dehydration. Dehydrated babies may then struggle more to feed, and you get a downward spiral. In principle this can have severe consequences, but these are rare.
Monitoring weight is about catching possible problems early, when you can fix them, and effective monitoring requires understanding how much weight newborns typically lose. Generally, we want to consider something a problem if it’s way outside the normal range. There is nothing in biology that tells you that a baby losing, say, 10 percent of its birth weight is a trigger for problems. If most babies lose 10 percent of their weight, then we shouldn’t worry when one does.
Figuring out the range of normal newborn weight loss requires data that, until recently, hasn’t been that easy to come by. In 2015, however, a set of authors published a really nice paper in the journal Pediatrics that used data from hospital records on 160,000 births to graph out the weight loss among breastfed infants in the hours after birth.21
You can see a version of the study’s graphs for the babies who were breastfed (more on formula feeding on this page). The authors differentiate between infants born vaginally and those born by caesarean section. The horizontal axis shows infant age in hours; the vertical axis shows the percentage of weight loss. The lines indicate how much this varies. The top line, for example, shows the weight loss path over time for the baby at the 50th percentile of weight loss.
From these figures, you can read the average weight loss and the range. For example, at 48 hours, the average infant born vaginally has lost 7 percent of their body weight, and 5 percent of infants have lost more than 10 percent. For at least some infants, weight loss continues through 72 hours.
On average, babies born by caesarean section do seem to lose a bit more weight initially. Note that the C-section graph looks at a longer time frame than the vaginal birth graph, since these babies are typically in the hospital longer (due to Mom’s recovery time).
What is this useful for? Mainly, this lets doctors (and, in principle, parents) evaluate where the child’s weight loss is relative to the average, and thus ask if they are outside the norm. This graph tells us that if a baby is born by C-section, we can expect them to lose a bit more weight, so if they do, it shouldn’t necessarily trigger an intervention.
The authors of this paper created a website, www.newbornweight.org, where you can enter the time of birth of your child, method of birth, method of feeding, birth weight, and current weight and learn where they are in the distribution.
When I had Penelope, the rule in the hospital was if the baby loses more than 10 percent of their body weight, you supplement. But you can see from the graphs that whether this is a reasonable cutoff depends tremendously on when the measurement is taken and the baby’s particular circumstances. At 72 hours, 10 percent weight loss is inside the normal range. At 12 hours, it would be a serious outlier.
These graphs all refer to breastfed infants. Formula-fed infants lose much less weight (unlike breast milk, it doesn’t take any time for formula to “come in”). By comparison, while the average breastfed infant has lost 7 percent of their weight at 48 hours, the average formula-fed infant has lost only 3 percent. Weight loss of more than 7 or 8 percent is very rare in this group. The same authors who made the breastfeeding graphs made ones for formula feeding, and their website lets you do your own calculations.
If you do find, as I did, that your infant has gone over the weight loss limits, what should you do? Typically, hospitals will recommend supplementation with formula or possibly donor milk. Water or sugar water was common in the past, but this isn’t a good idea.
If this happens, you may worry that this will make it harder to breastfeed—I definitely did. There isn’t much evidence on this—it’s hard to really isolate the impact of a small amount of supplementation. But to the extent that we know anything, we know there’s no reason to think a short period of supplementing with formula
should impact breastfeeding success (if that is your goal) in the long run.22 Supplementation would rarely be recommended before 48 or 72 hours, so it’s useful to pay attention to your baby’s weight before that. If she’s losing weight quickly, trying to figure out why may make sense.
A final note: The major concern about weight loss is that it is a signal of dehydration. But this is also something you can monitor directly. If your baby is peeing with some frequency and does not have a dry tongue, there’s a very good chance he’s not dehydrated. Conversely, if you see these signs, supplementation may be a good idea, even if there isn’t too much weight loss.
The extensive focus on weight and feeding is enough to really scare a lot of new parents (myself included). The data here is reassuring in both directions. Some pretty substantial weight loss is totally normal, even expected. So don’t panic. And if you do have to supplement, don’t panic then, either.
Jaundice
With a first child, most of us are prepared to be a bit surprised by the whole experience. After all, you’ve never done it before. Even I, a tremendously neurotic person, knew things would come up that I didn’t expect. For example, we failed to buy any clothes that would leave the umbilical cord exposed while it healed. Emergency runs to Target were common.
With a second child, it’s easier to feel like you know what you’re doing. Before Finn, I felt prepared. I had the correct clothes. I had the bassinet. I was even ready with my weight loss data in case that came up (it didn’t). Surely I wouldn’t unexpectedly face some medical or other issue with no preparation.
Obviously, this was ridiculous. Two days after we arrived home, I got a call from Finn’s doctor: Finn had jaundice. I found myself rushing him back to the hospital in his infant bear snowsuit for another overnight stay. This mostly proves I do not learn from my overconfidence and will always be surprised by it.
Jaundice is a condition in which the liver is unable to fully process bilirubin, a by-product of breaking down red blood cells. Everyone, baby or not, relies on their liver to break these down, and in principle anyone can be jaundiced. Infants are at higher risk for this just after birth for a few reasons. There are more blood cells being broken down shortly after birth, increasing the load of bilirubin presented to the liver. At birth, the liver remains immature and therefore has difficulty excreting this higher load into the gut. Finally, in the first few days of life, babies are not eating a lot, so the bilirubin hangs out in the gut where it gets reabsorbed back into the bloodstream.
In high concentrations, bilirubin is neurotoxic (meaning it can poison the brain), so jaundice is potentially very serious in extreme cases. Severe untreated jaundice can lead to a condition called kernicterus, a form of long-term brain damage.
This is scary, and it’s the reason jaundice is taken very seriously, but in virtually all cases, jaundice will not progress to kernicterus, even if untreated. Jaundice is also very common, especially in breastfed newborns: about 50 percent of newborns will have this condition to some degree. It’s important to note that the brain injury effects are not on a continuum: at low or moderate concentrations, bilirubin doesn’t cross the blood–brain barrier and is therefore not damaging.
To give a sense of the relative risks, there are two to four cases of kernicterus in the US each year. However, tens of thousands of children are treated for jaundice each week. Treatment protocols are extremely aggressive, and doctors are willing to treat many jaundiced babies who would be fine recovering on their own in order to avoid a single case of brain damage. So while it is likely a good idea to undergo treatment if the guidelines suggest it, there is little reason to be worried about the worst-case scenario.
The primary sign of jaundice is that your baby’s skin will turn yellow (this might also look more orange). The fact that your baby is yellow, however, doesn’t necessarily mean they need treatment, and color on its own is not diagnostic. At Penelope’s four-day visit, our pediatrician, Dr. Li, told us, “People will tell you she is yellow. Just ignore them.”
In many babies, jaundice will simply resolve on its own as they eat and grow. Detecting whether jaundice has reached a problematic level requires testing. Many hospitals screen first with a special light that can estimate bilirubin levels through the skin, and use that to decide whether your baby needs a blood test to look at bilirubin levels in the blood. They may also skip straight to the blood test. This test doesn’t need a lot of blood, so they’ll typically use a heel prick to get a drop or two. The test results are reported in a number (11.4, say, or 16.1); higher numbers are worse.
Just as with weight loss, interpreting this test depends on the age of the baby. Bilirubin levels typically increase over the first few days after birth, so doctors will compare your baby’s test results with the normal range for the number of hours old your child is.
The key decision for the doctor is whether bilirubin levels are high enough for “phototherapy”—aka a blue light box. This type of treatment typically occurs in the hospital, and involves having the infant spend time naked (other than a diaper and an eye covering) in a bassinet that is emitting blue fluorescent light. The light breaks down the bilirubin into other substances that are passed out of the body in the baby’s urine.
Time in the box can be as little as a few hours or up to a few days (you take the baby out for feeding), depending on severity and how quickly the infant responds to the treatment. Daily (or more frequent) blood tests keep the doctor updated on how things are progressing.
In general, higher levels of bilirubin are worse—but how high is high enough to need treatment? The answer to this depends on the exact age of the baby in hours, and on their other features.
Specifically, doctors start by looking at whether your baby is low risk (more than 38 weeks of gestation, otherwise healthy), medium risk (36 to 38 weeks of gestation and healthy, or 38 or more weeks with other symptoms), or high risk (36 to 38 weeks of gestation with other symptoms). Once they have the risk level, doctors use graphs like the previous ones to decide whether the baby needs phototherapy. If the bilirubin levels are higher than the cutoffs, phototherapy is started. The following graph is for a low-risk baby. Here, for a baby 72 hours old, a number above 17 would suggest the need for treatment.23 For higher-risk babies, the cutoffs are lower, and doctors intervene more aggressively.
As there is for determining risky infant weight loss, there is also a website that will tell you if jaundice treatment is recommended given bilirubin levels: www.bilitool.org. It’s for doctors, but it’s accessible to anyone who is curious.
It’s worth noting that these guidelines do evolve over time, and as of this writing there is a push to make them more lenient and to treat jaundice less aggressively. If you find yourself in this situation, you may want to ask your doctor which guidelines they are using.
Very rarely, extremely severe or untreated cases of jaundice may need treatment beyond phototherapy. The final treatment option is an exchange transfusion, in which blood is simultaneously removed from the infant and replaced with a transfusion. This procedure can be lifesaving, although with good monitoring technology, it is very rarely necessary.
Jaundice is more common in some babies than others. Exclusively breastfed infants are more likely to develop it. Babies of Asian heritage are at higher risk. It is also more common when mothers and babies have different blood types. Rarely, there are underlying blood disorders that can exacerbate newborn jaundice.
Excessive newborn weight loss is a risk factor, as is bruising in delivery. In retrospect, our experience with Finn shouldn’t have been as surprising as it was, since he got pretty banged up during delivery and came out all squashed and purple.
A NOTE: BACK IN THE DELIVERY ROOM
A few interventions occur right away when your baby arrives—typically before you even leave the delivery room. These include the possibility of delayed cord cutting, a vitamin K shot to promote better blood clotting,
and an eye treatment to avoid possible complications from untreated sexually transmitted infections in the mother.
These interventions are covered in detail in the last chapter of Expecting Better. But since they do occur after birth, I’ll review the conclusions here.
Delayed Cord Clamping
In the womb, the baby is attached to you with an umbilical cord. After birth, the cord is cut, but there is some debate over exactly when the cord should be cut: Do you cut right away, as is the standard practice? Or do you wait a few minutes for the baby to reabsorb some blood from the cord and then cut? This latter option is called “delayed cord cutting.” The argument in favor of delaying is that the reabsorbed blood from the placenta is valuable.
For premature infants, there is very good evidence that you should delay cord clamping.24 Randomized trials have shown improvements in blood volume, less anemia, and less need for transfusion as a result, among other outcomes.
For babies who are not premature, the evidence also largely favors delayed clamping, although it is slightly more mixed.25 In particular, delaying cord clamping lowers the risk of anemia later and increases stores of iron, but also slightly increases the risk of jaundice.
On net, the recommendations increasingly favor delaying the cord cutting, if possible.
Vitamin K Shot
For decades, it has been standard practice to give a shot of vitamin K within the first hours after birth to prevent bleeding disorders. Too little vitamin K can cause unexpected bleeding in about 1.5 percent of infants in the first week of life, and is associated with rare but much more serious bleeding disorders later. Vitamin K supplementation can prevent bleeding.26