In the critical first days of a newborn's life, monitoring weight loss is essential, particularly for exclusively breastfed infants. Recognizing the challenges faced by pediatricians and parents in determining healthy weight loss, researchers have developed an innovative online tool called the Newborn Weight Tool, or Newt. This tool is designed to help healthcare providers assess whether exclusively breastfed newborns have lost too much weight in their initial days, offering crucial support in preventing complications and hospital readmissions.
Understanding Newborn Weight Loss
Women don't immediately produce high volumes of breast milk after childbirth. Instead, mothers at first secrete small amounts of colostrum, which contains high concentrations of nutrients and antibodies for the baby. Most newborns tolerate this initial period of weight loss. However, some do develop complications such as dehydration and hyperbilirubinemia - jaundice caused by too much bilirubin in the blood - which are the two most common causes of newborn hospital readmission. Previously, in the absence of an hour-by-hour newborn weight loss nomogram, pediatricians have evaluated sufficient nutrition for newborns based on primarily anecdotal experience, using the figure of “over 10 percent of birth weight” during the first several days as a marker of concern.
Weight loss is normal for healthy newborns in the first few days, especially for those exclusively breastfed, until mothers begin to produce copious amounts of milk about two to five days after giving birth.
The Newborn Weight Tool (Newt): A Breakthrough Innovation
Newt® is the first tool created that allows pediatric healthcare providers and parents to see how a newborn’s weight during the first month following childbirth compares with a large sample of newborns. The Newborn Weight Tool, or NEWT, is an interactive weight loss chart using data from more than 100,000 exclusively breastfed babies born between 2009 and 2013. It was developed by Ian Paul, M.D., Penn State Hershey Children’s Hospital, in collaboration with Eric Schaefer, a statistician at Penn State College of Medicine, and researchers at the University of California, San Francisco, and Kaiser Permanente. Using a research sample of birth weights from more than 160,000 newborns, the tool uses a nomogram to plot a baby’s weight percentile at any given time in the first month following birth compared with the research population.
The tool was developed by Dr. Ian Paul, M.D., M.Sc. at Penn State Hershey Children’s Hospital, Dr. Valerie Flaherman, MD, MPH at University of California San Francisco, Pediatrics, and Eric W.
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How Newt Works
NEWT enables health care professionals to compare an individual newborn’s weight loss with a large sample size - similar to the way in which growth charts are used - to start interventions early, when needed. To learn if a newborn who is being exclusively breastfed has better than average, average or above average weight loss, health care providers simply go to www.newbornweight.org, enter in the baby’s birth weight, birth date and time, whether the baby was born vaginally or by cesarean section, and the baby’s most recent weight and the date and time for that weighing. Ian Paul, M.D., accesses the Newborn Weight Tool via newbornweight.org, and enters the baby’s birth weight, birth date and time, mode of delivery, and most recent weight (with date and time).
“For parents who are concerned about their newborn’s weight loss, they can be shown how their baby compares to the study sample, and whether they fall into a dangerous zone,” said Dr. Valerie Flaherman, a pediatrician at UCSF Benioff Children’s Hospital San Francisco and lead author of the study.
The Study Behind Newt
The Newborn Weight Tool, or Newt, was developed using a sample of hourly birth weights from more than 100,000 breastfed newborns at Northern California Kaiser Permanente hospitals between 2009 and 2013. A cohort of 161,471 healthy, singleton newborns born at ≥36 weeks gestation at 14 Northern California Kaiser Permanente hospitals between 2009 and 2013 were included in the research that generated the Newt nomograms. Data were extracted from the birth hospitalization regarding delivery mode, feeding type, and weights from electronic records. A total of 108,932 newborns had weights recorded while exclusively breastfeeding with 83,446 delivered vaginally and 25,486 delivered by Cesarean. An additional 7,075 were exclusively formula fed and had weights recorded with 4,525 delivered vaginally and 2,550 delivered by Cesarean section. Weights obtained after a newborn had been fed both breast milk and formula during the birth hospitalization were not included in this research. For each exclusive feeding type, quantile regression was used separately for each delivery mode to estimate the 50th (median), 75th, 90th and 95th percentiles of weight loss as a function of time after birth. For newborns fed breast milk, percentiles were estimated from 6 through 72 and 96 hours of age for those delivered vaginally and via Cesarean section, respectively.
Benefits of Using Newt
- Early Intervention: NEWT enables health care professionals to compare an individual newborn’s weight loss with a large sample size - similar to the way in which growth charts are used - to start interventions early, when needed.
- Reduced Hospital Readmissions: NEWT provides a more nuanced assessment of weight loss following birth and can aid in highlighting newborns at risk for readmission due to hyperbilirubinemia.
- Support for Breastfeeding Mothers: Paul emphasizes, however, that the major strength of the tool is in providing evidence-based support to mothers that their babies are receiving sufficient nutrition from breast milk alone, and therefore, do not need to supplement with formula. As breast milk is the optimal source of nourishment for newborns, this reassurance is crucial.
- Normalization of Weight Loss Patterns: “With NeWT, we can normalize what the expected patterns of weight loss are on an hour-by-hour basis, which has never been possible before,” Dr. Paul said.
- Improved Understanding of Newborn Weight Loss: “This tool has better enabled us to understand just how frequent newborn weight loss is, and makes it easier for us to identify the statistical ‘outliers’ who need additional breastfeeding support from lactation consultants,” says Paul.
Availability and Accessibility
The tool is available for free at www.newbornweight.org, and healthcare providers can bookmark it on their computers, smartphones and tablet devices.
Clinical Decision Support and Newt
Many micro clinical decisions are made daily in a newborn nursery. The Newborn Weight Tool (NEWT) can inform newborn feeding decisions and might reduce health care utilization by preventing excess weight loss. Clinical decision support (CDS) displaying NEWT might facilitate its use. At an hospital involved in NEWT development, we randomly assigned 2682 healthy infants born ≥36 weeks gestation in 2018-2019 either to CDS displaying NEWT with an electronic flag if most recent weight was ≥75th weight loss centile or to a control of usual care with NEWT accessed at clinician discretion. Our primary outcome was feeding type concordant with weight loss, defined as exclusive breastfeeding for those not flagged, exclusive breastfeeding or supplementation for those flagged once, and supplementation for those flagged more than once. Secondary outcomes included inpatient and outpatient utilization in the first 30 days. Feeding was concordant with for 1854 (74.5%) trial infants and did not differ between randomized groups (P = .65); concordant feeding was higher for all trial infants than for infants born in 2017 (64.4%; P < .0005). Readmission occurred for 51 (3.8%) CDS infants and 45 (3.4%) control infants (P = .56).
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Research Validating Newt's Effectiveness
Objective: The aim of this study was to determine if the Newborn Weight Loss Tool (NEWT) can predict hospital readmission due to hyperbilirubinemia.
Study Design: This is a case-control study of 93 newborns and 186 controls ≥35 weeks' gestation. All were discharged from the Mother-Baby unit of an urban academic center and subsequently readmitted for hyperbilirubinemia. Controls were matched for date of birth, gestational age, and Bhutani risk zone. All infants were screened for hyperbilirubinemia prior to discharge and managed according to American Academy of Pediatrics guidelines in place at the time. Chi-square, Fisher's exact test, and multivariate analysis were utilized as appropriate.
Results: There was no significant difference between the groups for a NEWT < 50% at discharge. More cases than controls breastfed. A significantly greater percentage of cases had NEWT > 50% at readmission than discharge. NEWT > 90% was moderately associated with readmission for hyperbilirubinemia (p = 0.081).
Conclusion: NEWT provides a more nuanced assessment of weight loss following birth and can aid in highlighting newborns at risk for readmission due to hyperbilirubinemia.
The Team Behind Newt
The development of Newt was a collaborative effort involving experts from various institutions:
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- Ian M. Paul, M.D., M.Sc.: Ian M. Paul is the University Professor of Pediatrics and Public Health Sciences and Chief of the Division of Academic General Pediatrics at the Penn State College of Medicine. Dr. Paul is a pediatrician and clinical and health services researcher with principal interests in a) primary preventive interventions for newborns, infants, and families and b) clinical therapeutics for children. Dr. Paul is also an internationally recognized expert on the pediatric treatment of the common cold and its symptoms having led numerous investigations related to cough/cold medications and antipyretics.
- Valerie Flaherman, M.D., M.P.H.: Valerie Flaherman, MD, MPH, is Professor of Pediatrics and Epidemiology and Biostatistics at the University of California San Francisco (UCSF).
- Eric Schaefer, MS: Eric is a biostatistician in the Department of Public Health Sciences at the Penn State University College of Medicine (Hershey, PA). He is a statistical consultant for a wide range of biomedical researchers at Penn State and he collaborates with clinical and health services researchers primarily in the Departments of Pediatrics, Surgery, and Public Health Sciences.
Impact and Funding
“Funding from Children’s Miracle Network at Penn State Hershey was crucial to allow us to take our research findings regarding newborn weight loss and share them with pediatricians, lactation consultants, nurses, and even parents, around the world,” said Paul, a professor of pediatrics and public health sciences at Penn State College of Medicine and a pediatrician at Penn State Hershey Children’s Hospital.
The development of Newt was supported by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program and the National Institute of Child Health and Human Development.