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Breastfeeding and Neonatal Weight Loss in Healthy Term Infants

Riccardo Davanzo, Zemira Cannioto, Luca Ronfani, Lorenzo Monasta and Sergio Demarini
J Hum Lact 2013 29: 45 originally published online 3 May 2012
DOI: 10.1177/0890334412444005

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444005
LXXX10.1177/0890334412444005Davanzo et
alJournal of Human Lactation
JH

Original Research
Journal of Human Lactation

Breastfeeding and Neonatal Weight 29(1) 45­–53

© The Author(s) 2013
Reprints and permission: http://www.
Loss in Healthy Term Infants sagepub.com/journalsPermissions.nav
DOI: 10.1177/0890334412444005
http://jhl.sagepub.com

Riccardo Davanzo, PhD, MD1, Zemira Cannioto, MD1, Luca Ronfani, PhD, MD2,
Lorenzo Monasta, DSc, MSc2, and Sergio Demarini, MD1

Abstract
Background: Neonatal weight loss is universally recognized, yet poorly understood. Limited professional consensus exists
on the definition of lower limit of safe weight loss.
Objective: Our aim was to assess the extent of neonatal weight loss and its association with selected clinical variables in a
population of healthy term infants cared for using a specific protocol on weight loss.
Methods: We retrospectively considered 1003 infants consecutively admitted to the regular nursery of the Institute for
Maternal and Child Health “Burlo Garofolo” (Trieste, Italy). We studied the relationship of selected variables with neonatal
weight loss recorded during the hospital stay. We also analyzed all readmissions in the first month of life as a result of weight
loss and its complications.
Results: We observed a mean absolute weight loss of 228 g ± 83g, and a mean percent weight loss of 6.7% ± 2.2%. Weight
loss ≥ 10% and > 12% were 6% and 0.3%, respectively. In multivariate logistic regression, cesarean section, hot season, any
formula feeding, and jaundice not requiring phototherapy were independently associated with neonatal weight loss ≥ 8%.
Conversely, low gestational age status was associated with lower weight loss. Readmission within the first month of life
because of dehydration occurred in 0.3% of infants.
Conclusions: Breastfeeding, compared to formula feeding, may not be a risk factor for greater early neonatal weight loss, at
least in contexts in which weight is routinely monitored, breastfeeding is repeatedly assessed and appropriately supported,
and careful supplementation is prescribed to limit and promptly treat excess weight loss and its related complications.

Keywords
breastfeeding, neonates, protocol, weight loss

Well Established breastfeeding promotion with the prevention of weight loss

It is widely recognized that most newborns will lose weight in
the first days after birth. However, definitions of average normal
weight loss and maximum safe weight loss are not yet well
established.
Newly Expressed
In a context in which postnatal weight is routinely monitored,
breastfeeding is assessed and supported, and supplementation
cautiously prescribed, breastfeeding appears not to be associated
with weight loss, which is instead associated with formula feeding,
cesarean section, and jaundice.
Background
Neonatal weight loss is universally recognized, yet poorly
understood.1 Limited professional consensus exists on the
definition of both the average normal weight loss and the
lower limit of safe weight loss. This lack of consensus does
not assist health workers in maternity wards in combining
complicated by hypernatremic dehydration.
In fact, dehydration and hyperbilirubinemia as well as
their serious consequences (hypernatremic dehydration and
kernicterus) are more common in breastfed infants, possibly
as a result of inadequate breastfeeding.2,3 Consequently,
health care services should adopt strategies to reduce the risk
of severe complications in exclusively breastfed infants. As
support and advice to the breastfeeding mother might not be
Date submitted: November 16, 2011; Date accepted: March 9, 2012.
1
 ivision of Neonatology and NICU, Institute for Maternal and Child
D
Health - IRCCS “Burlo Garofolo,” Trieste, Italy
2
Epidemiology and Biostatistics Unit, Institute for Maternal and Child
Health - IRCCS “Burlo Garofolo,” Trieste, Italy
Corresponding Author:
Lorenzo Monasta, DSc MSc, Epidemiology and Biostatistics Unit, Institute
for Maternal and Child Health - IRCCS “Burlo Garofolo,” Via dell’Istria
65/1, IT-34137 Trieste (TS), Italy
Email: monasta@burlo.trieste.it

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46 Journal of Human Lactation 29(1)
Figure. Clinical Management According to the Extent of Neonatal Weight Loss
enough, weight monitoring has been commonly used to indi-
rectly assess the adequacy of feeding and the eventual need
for supplementation of the breastfed infant with formula or
expressed breast milk.4
The aim of this study was to assess the extent of neonatal
weight loss and its association with selected variables in a
population of healthy term infants cared for using a specific
protocol on weight loss. In our analyses, we adopted a birth
weight loss of 8%,5 although 10% is also commonly indi-
cated by authoritative sources of the literature.6-9
Methods
In a retrospective cohort study, we reviewed hospital records
of 1003 healthy term neonates consecutively admitted to the
regular nursery of the Institute for Maternal and Child
Health – IRCCS “Burlo Garofolo” (Trieste, Italy) from
January 1-August 15, 2007. Our institute is a level 3 mater-
nity hospital with 1850 deliveries per year and a well-estab-
lished practice of rooming-in since the late 1970s. We
analyzed clinical records regarding readmissions within the
first month of life resulting from weight loss and its compli-
cations. We explored the relationship of common clinical
variables with neonatal weight loss recorded during the
hospital stay. Variables studied were: type of feeding (breast-
feeding versus formula feeding), season (cold season from
January-March; mid-season, April and May; hot season
from June-August), type of delivery (vaginal vs cesarean
section [CS]), birth weight, jaundice treated and not treated
with phototherapy, length of hospital stay, hypernatremia (>
150 mEq/L), and hypoglycemia (blood glucose < 45 mg/
dL). With regard to weight, we considered: (a) weight at
birth, (b) weight at hospital discharge, and (c) maximum
weight loss (both in absolute and percentage terms) reached
at any time during the hospital stay. Every day between 8-10
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AM, all infants were weighed naked, with an electronic
scale, by a nurse, regardless of the feeding pattern.
According to the WHO definition,10 we initially classified
feeding practices into exclusive breastfeeding (EBF), pre-
dominant breastfeeding (PBF), complementary feeding
(CF), and no breastfeeding (NBF). For the analysis, how-
ever, we combined EBF and PBF into breastfeeding (BF)
and CF and NBF into formula feeding (FF). The feeding sta-
tus of newborn infants was routinely categorized by the neo-
natologist at the discharge visit based on a review of the
medical records from birth through hospital discharge.
In our population, mainly composed of Caucasians, we
defined jaundice as obvious yellow color of the skin detected
by nurses and/or pediatricians, followed by a test of bilirubin
serum level. Jaundice was then defined as clinically relevant
if serum bilirubin concentrations were high enough to require
phototherapy, according to the 2004 American Academy of
Pediatrics graphs.11 In all infants with a weight loss > 10% or
with a weight loss between 8%-10% and “not looking well,”
we measured serum sodium concentrations. Hypernatremia
was defined as serum sodium concentration > 150 mEq/L.
Blood glucose was checked only if clinical signs and/or risk
factors were present (birthweight < 10th percentile, infants of
mothers with diabetes). In infants at risk of hypoglycemia,
blood glucose tests were carried out at 1, 6, and 12 hours of
life. Neonatal hypoglycemia was defined as serum glucose
level < 45 mg/dL, regardless of gestational age and postnatal
age. A neonate was considered as small for gestational age
(SGA) if she/he was below the 10th percentile based on our
reference curves.12
Neonatal Weight Loss Protocol
In order to monitor neonatal weight loss in the first days of
life, a specific protocol has been applied since 2004 to all
Davanzo et al. 47

neonates during hospitalization (Figure). This protocol sug- Table 1. General Features of the Study Population (N = 1003)
gests different interventions according to: (a) the percentage
Demographic and Median (IQR), Mean
of weight loss; (b) the infant’s physical examination; and (c) Clinical Data (SD) or Proportions (%)
evaluation of breastfeeding, including the onset of lactation
(lactogenesis II). Mean gestational age (wk) 40 (39-40)
Thus, in the assessment of weight loss and to identify 1 minute Apgar score (median 9 (9-9)
appropriate interventions, we considered the following: [IQR)]
5 minute Apgar score (median 10 (10-10)
[IQR)]
1. Effective breastfeeding: All breastfeeding mother-
Length of hospital stay, d (median  
infant pairs were evaluated (primarily by nurses) [IQR)]
during hospitalization, in order to promptly   All infants 3 (2-4)
identify problems and intervene. First, nurses   Vaginal delivery 3 (2-3)
evaluated possible maternal problems and capa-   Caesarean delivery 4.5 (4-6)
bility to respond to the infant feeding demands. Mean birth weight, g (mean ± SD)a 3404 ± 442
Second, the following items were assessed: Cesarean delivery, n (%) 208/1003 (20.7%)
achievement of lactogenesis II (the onset of Exclusive breastfeeding at 603/1003 (60.1%)
copious milk volume), breast and nipple mor- discharge, n (%)
phology before and after a feed, latch-on, and Breastfeeding (exclusive or 667/1003 (66.5%)
newborn and mother position during breastfeed- predominant) at discharge, n (%)
ing sessions. Abbreviations: SD, standard deviation; IQR, interquartile range.
2. Weight loss > – 8%: Eight percent has been indi- a
Distributes normally: skewness and kurtosis joint test (P = .059).
cated by Livingstone and colleagues as the safest
upper limit, excluding concurrent hypernatremic
Statistical Analysis
dehydration, as infants losing < 8% usually have
natremia ≤ 145 mEq/L.5 During the hospital stay, Continuous data were reported as means and standard devia-
all infants were weighed at least once daily. On tions if normally distributed (according to the skewness and
any given day, when clinically indicated, a sec- kurtosis joint test) or as medians and interquartile ranges if
ond weight check was performed and recorded. not distributed normally. Weight loss was analyzed as both a
If neonatal weight loss was ≥ 8%, extra support continuous and a dichotomous variable (≥ 8% or < 8%).
during the feeds was provided and special atten- Bivariate relations were evaluated by the t test, Mann-
tion was paid to assess the oral cavity (palate, Whitney nonparametric test, or χ2 test, depending on the
tongue tie) and ability to suckle. Serum sodium nature of the variables. Multivariate logistic regression was
concentration was measured in infants with (1) a used to study the association between weight loss ≥ 8%
weight loss ≥ 10 % and (2) an 8%-10% weight (outcome) and all covariates. In the saturated model, vari-
loss with either clinical signs of dehydration ables associated with the outcome of P >.1 were excluded
or “not looking well.” Such infants were given from the final regression model. Results are presented as
supplemental feeds of expressed breast milk and/ adjusted odds ratios (OR). All data management and analy-
or formula, and weight was reassessed after 12 ses were done using the SPSS package, version 11.5 (SPSS
hours. Inc. Chicago, IL, USA. 2002), and Stata/IC, version 11.2 for
Windows (StataCorp LP. College Station, TX, USA. 2009).
Discharge and Follow-up Policy
Healthy infants were routinely discharged from the hospi- Results
tal at a postnatal age ≥ 36 hours, according to the recom- Demographic and selected clinical data of our study popula-
mendations of the American Academy of Pediatrics.13,14 tion are summarized in Table 1.
Babies with a neonatal weight loss > 10% were not con- Weight loss distributed normally (joint skewness/kurtosis
sidered for discharge until they regained enough weight test for normality: P = .8). We observed a mean weight loss
to fall below 10% weight loss. A weight check of dis- of 228 ± 83 g, with a mean percentage weight loss of 6.7% ±
charged infants was scheduled within 2-4 days after dis- 2.2%. In our population, the rates of weight loss between
charge,15 and was carried out either at the hospital 10% and 12% and ≥ 12% were 6% and 0.3%, respectively
outpatient clinic by a registered nurse or at the health (Table 2). During the hospital stay, weight loss ranged
districts of the Trieste province, by a midwife. A hospital- between 0%-13.2%.
based post-discharge weight check was scheduled for Mean weight loss was significantly higher in FF infants
some infants depending on: (a) extent of in-hospital (255 ± 93 g or 7.5% ± 2.4%) if compared with BF infants
weight loss, (b) uncertainty of breastfeeding, and (c) need (215 ± 73 g or 6.3% ± 2.0%; P < .001). During the cold months,
for jaundice reassessment. the incidence of weight loss ≥ 8% was significantly lower than

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48 Journal of Human Lactation 29(1)
Table 2. Incidence of Weight Loss during Hospital Stay
Extent of Weight Loss Incidence, n(%)
< 8% 731/1003 (72.9)
≥ 8%, < 10% 212/1003 (21.1)
≥ 10%, < 12% 57/1003 (5.7)
≥ 12% 3/1003 (0.3)
in the hot months: 23% (88/383) versus 32% (110/347; P =
.008). In the midseason, such incidence was not significantly
different than in the cold season: 27% (74/273; P = .23).
Cesarean section was associated with a higher neonatal weight
loss if compared with vaginal delivery: 254 ± 89 g (or 7.6% ±
2.2%) versus 222 ± 80 g (or 6.4% ± 2.1%; P < .001). A weight
loss ≥ 8% affected 23% of infants delivered vaginally versus
45% of those born by CS (P < .001).
With regard to jaundice, 59 infants needed phototherapy
(5.9% of the total sample). The mean bilirubin serum con-
centration of jaundiced infants requiring phototherapy was
16.9 mg/dL. Upon bivariate analysis, no difference in weight
loss ≥ 8% was found between jaundiced infants requiring or
not requiring phototherapy (32% vs 38%; P = .4).
Fifty-one out of 1003 (5%) infants were SGA. Weight
loss ≥ 8% was reported in 12% of SGA infants versus 28%
of non-SGA infants (P = .01).
In our infants, high serum sodium concentration before
hospital discharge was a rare event: serum Na levels > 145
mEq/L were reported in 60/1003 infants (6%), but only 2 had
serum Na levels > 150 mEq/L, and none had a serum Na
concentration > 155 mEq/L. All cases of hypernatremia
occurred in infants with a weight loss ≥ 8%.
Blood glucose was measured in 268 infants (26.7%).
Hypoglycemia unrelated to weight loss, as it occurred before
weight loss, was detected in 40 babies (4% of the population)
in the first 24 hours of life: 38 infants had moderate hypogly-
cemia (25-45 mg/dL), and 2 (0.2% of the population) had
severe hypoglycemia (< 25 mg/dL). Thirty out of 40 (75%)
hypoglycemic infants had a weight loss < 8%, 9 had a weight
loss of 8%-10% (22.5%), and 1 had a weight loss > 10%
(2.5%). Weight loss distribution in hypoglycemic infants was
almost identical to the distribution in the general population.
Re-hospitalization within the first month of life occurred
in 2.7% of infants (27/1003). Seventeen out of 27 (1.7% of
the whole population) were admitted for jaundice requiring
phototherapy; the remaining 10 (1% of the whole popula-
tion) were admitted because of excessive weight loss with
dehydration, but only 3 presented with hypernatremia. The
highest serum Na concentration found was 156 mEq/L.
In multivariate logistic regression, 5 variables were inde-
pendently associated with neonatal weight loss ≥ 8% before
discharge: (1) delivery by CS versus vaginal; (2) hot season
versus cold season; (3) any FF versus EBF or PBF; (4) jaun-
dice not requiring phototherapy versus no jaundice; and (5)
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appropriate and large for gestational age versus SGA (Table 3).
Hypernatremia was not included in the multivariate logistic
regression, as the hypernatremic infants were all in the
weight loss ≥ 8% group. Sex of the child, hypoglycemia,
birth weight, and gestational age were not included in the
final multivariate analysis, as they were associated with
weight loss ≥ 8% with a P > .1.
Considering the possibility that CS caused infants to lose
weight and, for this reason, infants were changed to FF, we
carried out a multivariate logistic regression with the same
variables as in Table 3, but restricting only to vaginal deliv-
eries. Results are presented in Table 4. There is no relevant
change in the adjusted ORs and in the confidence intervals
with respect to Table 3.
Discussion
Our data suggest that breastfeeding could be associated with
a weight loss lower than that reported for formula-fed new-
borns, contradicting a concept widely accepted by health
care staff experience and knowledge.16-23 In our infant popu-
lation weight loss in the FF was higher than in the BF group
(7.5% vs 6.3%). All16-23 but one24 previous study docu-
mented higher mean weight loss in breastfed than in for-
mula-fed infants (Table 5). In such studies, mean neonatal
weight loss in breastfed infants ranged from 5.5%-7.4% and
in formula-fed infants, from 2.4%-4.9%.16,21 This variability
may be the consequence of different feeding protocols and
practices. Considering that exclusively breastfed babies
depend on the volume of breast milk after lactogenesis II
and may lose more weight during the first days after birth,
the association between weight loss and FF is probably
because infants with greater weight loss are more likely to
receive formula supplements.
It is surprising that the documentation of a phenomenon
that affects the entire human population is relatively limited
in the scientific literature. The weight loss observed in the
early days after childbirth depends on changes in body com-
position, mainly a loss of total body water and fat in a pro-
portion of weight loss of approximately 80% and 20%,
respectively.18,25 As recently demonstrated, greater weight
loss after birth could also result from positive maternal intra-
partum fluid balance and fetal volume expansion.26 We
found a mean percentage neonatal weight loss of 6.7% and
an association of increased weight loss with non-SGA status,
FF, CS, hot season, and jaundice.
In our infants, being SGA seemed to be a protective factor
against weight loss. This association may simply be explained
by greater attention paid, by health professionals and moth-
ers, to the feeding of this category of neonates, deemed at
increased risk of hypoglycemia.27,28 Our results are probably
a result of a more liberal policy in breast milk substitutes
applied to SGA infants. Limited scientific literature specifi-
cally addresses the relationship between weight/age ratio
and neonatal weight loss.29
Davanzo et al. 49

Table 3. Multivariate Analysis of Factors Possibly Influencing Neonatal Weight Loss (N = 1003)

Variable N (%) Crude OR (95% CI) AOR (95% CI)

Season  
  Cold season 88/383 (23.0) 1 1
 Mid-season 74/273 (27.1) 1.25 (0.87-1.78) 1.41 (0.96-2.08)
  Hot season 110/347 (31.7) 1.56 (1.12-2.16) 1.49 (1.04-2.12)
Small for gestational age  
 No 266/952 (27.9) 1 1
 Yes 6/51 (11.8) 0.34 (0.14 - 0.82) 0.18 (0.07 - 0.45)
Type of delivery  
 Vaginal 179/795 (22.5) 1 1
  Cesarean section 93/208 (44.7) 2.78 (2.02 - 3.83) 2.29 (1.61 - 3.26)
Feeding at discharge  
  Exclusive breastfeeding or predominant breastfeeding 118/667 (17.7) 1 1
  Complementary feeding or no breastfeeding 154/336 (45.8) 3.94 (2.94 - 5.27) 3.65 (2.67 – 4.99)
Jaundice  
 No 199/802 (24.8) 1 1
  Yes, not treated with phototherapy 54/142 (38.0) 1.86 (1.28 - 2.70) 1.67 (1.11 - 2.52)
  Yes, treated with phototherapy 19/59 (32.2) 1.44 (0.81 - 2.54) 1.19 (0.64 - 2.22)
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio.

Table 4. Multivariate Analysis of Factors Possibly Influencing Neonatal Weight Loss, Restricted to Vaginal Deliveries (n = 795)

Variable N (%) Crude OR (95% IC) AOR (95% IC)

Season  
  Cold season 57/304 (18.8) 1 1
 Mid-season 49/218 (22.5) 1.26 (0.82 – 1.93) 1.51 (0.95 – 2.41)
  Hot season 73/273 (26.7) 1.58 (1.07 - 2.34) 1.56 (1.02 - 2.38)
Small for gestational age  
 No 266/952 (27.9) 1 1
 Yes 6/51 (11.8) 0.48 (0.17 - 1.39) 0.32 (0.11 - 0.97)
Feeding at discharge  
  Exclusive breastfeeding or predominant breastfeeding 118/667 (17.7) 1 1
  Complementary feeding or no breastfeeding 154/336 (45.8) 4.54 (3.19 - 6.47) 4.81 (3.32 – 6.98)
Jaundice  
 No 199/802 (24.8) 1 1
  Yes, not treated with phototherapy 54/142 (38.0) 2.32 (1.49 - 3.59) 2.06 (1.29 - 3.29)
  Yes, treated with phototherapy 19/59 (32.2) 1.68 (0.91 - 3.11) 1.05 (0.53 - 2.05)
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio.

In agreement with other authors,30,31 we demonstrated that
neonatal weight loss, apart from diet, is associated with type
of delivery. Suboptimal feeding after CS may lead to greater
weight loss. In fact, despite efforts to promote a “natural”
CS32 and a specific breastfeeding education program,33 CS
still adversely affects both initiation34-36 and duration of
breastfeeding,34,37 especially after an emergency procedure.38
Lower breastfeeding rates may be a result of maternal impair-
ments after surgery. Additional factors involved may be
limited effective compensatory aid by health professionals
and delay in feeding after birth.39 The latter is independently
associated with breastfeeding failure.40
Our study also shows that in the hot season, infants tend
to lose more weight. Our maternity ward is provided with air
conditioning; nevertheless, some mothers prefer to switch it
off. We did not record data on the hydration status of mothers
in the maternity ward, and therefore we cannot infer that
greater weight loss in the hot season is associated with a

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50 Journal of Human Lactation 29(1)

Table 5. Neonatal Weight Loss: Data from the Literature

Author, Year of Publication Country Type of Feeding Mean Weight Loss (%)
Podratz 198626 USA BF 7.4
  FF 4.9
Yamauchi 199027 Japan BF 6.6
Rodriguez 200016 Spain BF 5.7
Macdonald 200328 Scotland EBF 6.6
  No BF 3.5
Anctil 200629 Canada EBF 6.7
  CF+No BF 6.2
Martens 200730 Canada EBF 5.5
  FF 2.4
Crossland 200831 UK BF 6.4
  FF 3.7
Volta 200833 Italy EBF 6.2
  CF+No BF 6.9
Flaherman 201032 USA Mostly EBF 6.0
Present study Italy EBF+PBF 6.3
  CF+No BF 7.5
Abbreviations: BF, breastfeeding; CF, complementary feeding; EBF, exclusive breastfeeding; FF, formula feeding; No BF, no breastfeeding; PBF, predominant
breastfeeding.

poorer maternal hydration status. Although supported by
common sense, our finding is not in agreement with the sci-
entific literature.41,42 In his review paper, Sachdev docu-
mented that, based on breast milk intakes, urine output, and
urinary specific gravity or osmolarity, breastfed infants do
not need fluid supplementation.43 However, this finding does
not imply that weight loss should be identical in the hot and
in the cold seasons, as long as weight loss remains within
“normal,” acceptable limits.
In accordance with previous studies, our data show that
jaundiced infants lose more weight than non-jaundiced
infants.44-46 However, need for phototherapy does not signifi-
cantly alter weight loss, possibly because of a wider use of
breast milk supplements. In our study, we found no signifi-
cant difference in the proportion of weight loss ≥ 8% between
those subjected to phototherapy (33%; 20/61) and not sub-
jected (27%; 252/942; P = .30), even if this finding might be
partially a result of the insufficient size of the sample. The
hypothesis that jaundiced neonates might lose more weight
secondarily to altered sucking behavior has been rejected by
Alexander and Roberts,47 as bilirubin levels showed no cor-
relation with milk consumption. Although a recent report
underlines that breastfed newborns have higher rates of sig-
nificant hyperbilirubinemia,48 there is sufficient consensus
that jaundice does not appear to be associated with breast-
feeding per se, but with increased weight loss in dehydrated
breastfed newborns.46
In the present study, we recorded the maximum neonatal
weight loss measured during the hospital stay. We have docu-
mented that only a minority of neonates lose ≥ 10% birth
weight. In clinical practice, some uncertainty exists concern-
ing the definition of the upper limit of safe weight loss in
neonates. According to main reference textbooks,6-9 an infant
should not lose more than 7%-12% of birth weight. Ten per-
cent is the most frequently cited upper normal percentage
limit of neonatal weight loss. However, the reported percent-
age of infants with a weight loss > 10% varies considerably,
ranging from less than 1% to 12%.49,50 These differences are
likely to result from variables that are difficult to control,
such as characteristics of the mother-baby dyad, breastfeed-
ing management, hospital feeding protocols, and attitudes
and skills of health care workers in maternity wards. Dewey
reports that excessive weight loss is generally associated with
suboptimal breastfeeding and is influenced by many factors
such as primiparity, long duration of labor, use of medica-
tions, CS, neonatal conditions at birth, delayed onset of lacta-
tion, and infant feeding behavior on the first day of life.50
Hospital-based as well as community-based health ser-
vices of Trieste province recommend and support EBF for
the first 6 months of life. In 2007, the rate of EBF at the aver-
age age of 17 weeks in Trieste province was 52%.51
We believe that breastfeeding support prior to lactogene-
sis II and during the very first weeks of lactation, careful
monitoring of infant weight loss, and following a strict
weight loss protocol as part of the infant feeding policy led
to low rates of: (a) weight loss ≥ 8% (27%) and in particular, ≥
10% (6%); (b) hypernatremia before discharge (0.2%); and
(c) admission for hypernatremia (0.3%).
Hypernatremia is the most feared complication of neona-
tal weight loss, and its incidence reported in the literature

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Davanzo et al. 51
appears to be increasing as a consequence of the promotion
of exclusive breastfeeding.52-56 Our data on readmissions for
dehydration after discharge are in line with data available in
the literature.57-60
Our study has obvious limitations. First, we studied a
limited number of variables related to weight loss, which
hinders the value of multivariate analysis. In particular, we
did not control for relevant maternal factors, both clinical—
such as body mass index61 and intrapartum fluid balance26—
and sociodemographic. Second, as this was a retrospective
cohort study, we have not been able to establish direct cau-
sation between some of the variables considered and weight
loss as outcome; that is, the decision to formula feed might
be made after weight loss occurs, thereby generating a prob-
lem of reverse causality, with weight loss being the potential
cause of FF and not vice versa. Third, regarding the use of a
weight loss protocol, previous studies were designed as
audit and re-audit studies following the implementation of
guidelines.60,62,63 We did not make any comparison with a
control group before and after the implementation of our
neonatal weight loss protocol, and consequently we cannot
attribute any proven clinical effectiveness to our protocol.
Nevertheless, we evaluated some clinically meaningful neo-
natal outcomes and compared our results with those avail-
able in the scientific literature. In our study, hypernatremia
(a serum Na level > 150 mEq/l) appeared to be a rare event
both during the first days of life (0.2%) and after discharge
(0.3%). Moreover, the rate of re-hospitalization for dehy-
dration after birth appears to be rather low (1%). Finally, we
realize Risk Ratios would be more appropriate than ORs for
incidence measures such as weight loss ≥ 8%, which is not
a rate outcome. However, both the problem of temporality
already mentioned and the use of the logistic regression
made us opt for reporting the ORs.
Conclusion
In conclusion, breastfeeding is not necessarily a risk fac-
tor for higher early neonatal weight loss, as previously
documented in the scientific literature. The promotion
and support of breastfeeding is compatible with other
good neonatological practices, including postnatal moni-
toring, breastfeeding assessment, and careful formula
supplementation.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: The study was approved by the Research Commission of
the IRCCS “Burlo Garofolo,” Trieste, and funded by the grant RC
18/09 of the same Institute.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
Downloaded from jhl.sagepub.com at PENNSYLVANIA STATE UNIV on February 22, 2013
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