The WHO and The What About The Breastfeeding Growth Curve

Cultivate your curves. They may be dangerous, but they won't be avoided. ~ Mae West

The irony of this entire journey is that when I was pregnant, every soothsayer and prophetess in Target, Macy's, or Babies 'R' Us declared that because I was SO big- I gained a whopping 28 pounds- my child would be huge, 8-10 pounds, some predicted. While my yoga students assured me that I would have a fast and easy labor, random grandmothers and even one of the assistants in my OB's office warned that I'd never make it to my due date, I'd never be able to push the baby out, and would definitely have to have a C-section. 

I remained hopeful, but as my estimated due date S-L-O-W-L-Y approached, my hyperemesis continued, my SI joint became increasingly strained, and my breathing more and more challenged, a planned C-section became a good look, despite my intense and intentional preparation with Hypnobabies. 

Hours Before My Induction

As if pregnancy was not interesting enough, I relocated at 32 weeks, moving 3 states away from my mother and the OB/Gyn who had helped us to navigate our fertility challenges. My new OB and I did not know each other very well, but he had delivered all the children of my husband's sisters and nieces, so he agreed to take me under his care, even in my third trimester. He too thought that my daughter was going to be big and was already too big to move within my small frame. We now know that is a common error among obstetricians. 

 Too Many Doctors are Telling Too Many Pregnant Women That Their Babies Are Too Big

At 39 weeks, he asked to induce me and because I felt both miserable and powerless, I consented. Over the next 5 days, I did everything to naturally induce labor. Nothing worked. Two days before my daughter's estimated arrival, I was induced; endured a long, intense, but otherwise unmedicated labor; and birthed a 7.14 lb baby girl. My labor was not short or easy, my child was not huge, I did make it to within hours of my due date, and my daughter was born vaginally. Everybody got it wrong! 

Trust yourself. You know more than you think you do. ~ Dr. Benjamin Spock 

That experience encouraged me to trust my body and to trust the bond that my daughter and I had already created over the last 40 weeks, or at least from the moment that I discovered her floating in my belly on the Mother's Day before. 

That mutual trust would be invaluable as we took on the fascinating act of breastfeeding. I needed to know that I was producing enough milk do that she could thrive and she needed to grow so that I wouldn't worry about not producing enough milk. There were those who constantly talked about how small my daughter was, how she wasn't getting enough to eat, and why I needed to put cereal in her bottle as early as two months. 

Fortunately, my pediatrician was not only supportive of breastfeeding, but also knowledgeable about the differences in the growth patterns between formula fed and breastfed babies. Before I had my daughter, but while supporting other moms, I often heard of pediatricians recommending a formula supplement to "top off" a mother's milk. Without knowing much more than the fact that breast milk exceeds nutritional infant needs, I would question my friends' OB's recommendations. They usually adhered to the recommendation, and as a result, did not make it to one full year of breastfeeding. Now that I know more about the tricky supplement/ low supply cycle, I know that that initial reaction to the idea of supplementation was accurate. I wanted to avoid that unnecessary roller coaster, at any cost. 

My own daughter was peeing, pooping, resting, eating, engaging, and growing well, but she was trending small, and suddenly, at 6 months, she just stalled. Before every appointment, I weighed my daughter, just in case I needed a weight different from theirs to combat the top off recommendation. I was totally that mom who kept track of every everything during her first year of life, with a fancy app. Before your eyes roll all the way to the back of your head, know that I absolutely followed her cues and totally nursed on demand, but I also documented the results. Perhaps it's the healthcare worker in me. Because my daughter was trending small, I always wanted to be able to show (and remember) her intake and output.  

Baby Connect Application

Of course, I was never asked. Our pediatrician never mentioned a word about supplementing- not even when our daughter dropped below the 20th percentile for weight, not even when she remained the same weight for 5 months, and not even when I told her that we were feeding her only vegetables, fruits, and grains. While I was nervous at each and every appointment, our doctor told us how breastfeed babies grow differently: first, they trend a little larger, then they taper off at a about 6 months, then they are smaller, but by two years old, all measurements are comparable. Additionally, our pediatrician did not only rely on her size or the chart, she also considered my pre-pregnancy size, and my husband's pre-it's mandatory that I lift weights in my fraternity-size. We were both twigs, at one point. Genetics and family history are often over looked when considering the size of the baby. Every kid can't be in the 90th percentile. 

My Daughter's Actual Growth Chart

It is not uncommon for a baby who started out in the middle or high end of the weight chart to slide down well below the 50th percentile by a three- or six-month doctor’s visit. It can be scary when it happens, and many moms wonder if they’re producing enough milk. This is the time when a mother's supply is stabilizing, which she may interpret as a decrease; and it's also when she may be returning to work, so she is further questioning her ability to continue to produce enough milk for her child.  All of which is problematic, since a mother's self-efficacy is the primary predictor of breastfeeding success. Undermining a mother's confidence in milk production, by recommending supplemental formula, could be detrimental to her ability to see it through.  

Most doctors (still) use the CDC Growth Chart for babies. The CDC chart is based on a high formula-fed population however. Therefore, when your breastfed baby is being compared to this chart it does look like she is falling off the charts.

What else is happening? Why would formula fed babies gain more weight? It has to do with caloric content – breast milk becomes more nutrient dense and remains compatible with the infant as the she grows over the first year, whereas formula always provides the same number of calories, so the infant is requiring more milk (containing more calories) as she grows. 

Babies also become easily distracted around the three-month mark, and more mobile around the six-month mark. Short, frequent feedings are the standard at these ages, and sometimes a baby’s weight will naturally dip or stagnate as a result. 

The good news is that, in 2006, the World Health Organization developed a new growth chart based on predominately breastfed children. This chart gives a realistic look at how a breastfed baby grows. 

Weight-for-age Percentiles for Girls Birth to 2 years

Weight-for-age Percentiles for Boys Birth to 2 years

It is suggested that pediatric care providers use the gender-specific WHO charts for breastfed babies until 2 years old. What is different about The WHO charts? 

According to the CDC: 

Why use WHO growth standards for infants and children ages 0 to 2 years of age in the U.S?

• The WHO standards establish growth of the breastfed infant as the norm for growth.
  Breastfeeding is the recommended standard for infant feeding. The WHO charts reflect growth patterns among children who were predominantly breastfed for at least 4 months and still breastfeeding at 12 months.
• The WHO standards provide a better description of physiological growth in infancy.
  Clinicians often use the CDC growth charts as standards on how young children should grow. However the CDC growth charts are references; they identify how typical children in the US did grow during a specific time period. Typical growth patterns may not be ideal growth patterns. The WHO growth charts are standards; they identify how children should grow when provided optimal conditions.
• The WHO standards are based on a high-quality study designed explicitly for creating growth charts.
  The WHO standards were constructed using longitudinal length and weight data measured at frequent intervals. For the CDC growth charts, weight data were not available between birth and 3 months of age and the sample sizes were small for sex and age groups during the first 6 months of age.

Why use CDC growth charts for children 2 years and older in the U.S.?

• The CDC growth charts can be used continuously from ages 2-19. In contrast the WHO growth charts only provide information on children up to 5 years of age.
• For children 2-5 years, the methods used to create the CDC growth charts and the WHO growth charts are similar.

Here is Kellymom’s comparison of the CDC and The WHO charts, where you can clearly see that breastfed babies do not grow like formula-fed babies.

Why these differences matter:

• If you are obsessed with all things growth and development like I was, it means you will know that your baby isn’t dropping off the charts suddenly.

• Mom's who feed on demand may be told in the first few months to feed less often because the baby is trending big (on the CDC chart).  However, if you know that a breastfed baby grows bigger than a formula-fed baby in those first few months, then you know that your baby is probably on track.

• Doctors may become alarmed about the baby's growth around that 6-9 month mark. Suddenly, it appears that your baby isn’t gaining weight like she should and you are sent home with a can of formula and instructions to start supplementing. Check in with your doctor to ensure the he is using The WHO chart.

"Perhaps their breastfed baby isn't falling off the charts, perhaps they do not need that formula."

Note: I am NOT suggesting that you should never supplement with formula! There are definitely times when it is needed. I’m just saying that you might want to compare charts before you buy that can of formula, or accept that sample. 

I am sharing this with you as I have just returned from my daughter's 3 year old check-up, and learned that my petite flower, who is a fully potty-trained, only recently weaned, rear-facing, vegetarian toddler is now at the 63rd percentile in height, and the 58th for weight. It has taken a lot of trust and a ton of reading to get to this point. I want to help families understand that there is a possibility that their "small" breastfed baby is doing just fine, but that the doctor needs to update her charts. 

I will have to write another post on how to deal with well meaning and over bearing family members who make the same recommendations. 

Even though pediatricians are recommended to use the WHO charts, it will take some time for the switch to happen in most doctor’s offices, so ask your pediatrician which charts she’s using if either of you are concerned.