4 month old dropping centiles

[Eastwiththem]

DS is EBF and has been following just above the 9th centile since birth. Last month he dropped below the 9th (although still put on weight overall) and dropped to just above 2nd centile this week (again still putting on weight, just not enough to keep up with the centiles).

The health visitor has suggested we top up with formula which I don't want to do. DS is a happy little boy who is hitting his milestones. He feeds on demand including two night feeds and I offer him the breast at every opportunity - he will refuse on occasion and is getting through lots of wet and dirty nappies so I don't think he is hungry. If he wasn't weighed and placed on the "wrong" part of the chart we would have no concerns at all.

So far there seem to be 3 possibilities:

1. His social/mental skills seem to be really coming along recently; he is also very active and rolling about. All his energy is going on these skills and his physical size will catch up soon.
2. My milk is poor quality so it's filling him up but not actually providing the energy he needs to grow.
3. He has a digestive or growth disorder that is stopping him growing despite having enough to eat.

From what I've read about BF it seems unlikely that my milk isn't good enough, and it also seems unlikely that he has an underlying medical issue when he's otherwise happy and alert. My instinct is that he is just putting his energy in to other things at the moment and will catch up later on, but is this even a thing? The HV has said some things about BF that I know aren't true so I really don't trust her to have the latest info on how weight gain works.

Should I continue EBF, see a lactation consultant or ask for a referral to a paediatrician to check for growth disorders? I'm knackered and just need someone to tell me what to do!

I am not sure what the issue is, OP. Seems to be that your Hv is concerned. If all she is concerned about is that your baby has dropped below the ninth centile to just above the second, then she needs to be asked why she is raising this as a problem. It is within normal.

If she thinks your baby needs more calories then the easiest way to address this would be to offer more breastmilk.

A healthy baby would take this, if needed.

Seems like you have already offered, and your baby seems not to want it.

Your Hv needs to explain why all this means he needs formula.

It's normal for bf babies at about 4 months. As you say they're gearing up for a huge developmental spurt.

We went through similar with dc1. Fortunately the hv was nearly sensible and didn't mention formula, just referred us to the gp once she crossed 2 centiles. Gp as protocol referred us to paeds, asked us if we were worried or the hv. When we said hv rolled their eyes, examined her thoroughly, and took blood just to rule anything out. It all came back normal, and at 5 months she started gaining again.

Thing is, formula won't actually change anything. It may artificially cause a weight gain, but consequently if he has a real issue it may mask it. If he has a real issue too he needs diagnosing, formula top ups won't help or cure it.

I'd ask the hv exactly what difference she expects formula to make. Your milk will be absolutely fine. It doesn't sound like you need to top up. Normal threshold anyway is crossing 2 centiles, which he hasn't reached. It sounds like your instincts are spot on.

Rather than muck about with formula against your will ask for a paed referral if she's that worried.

If I'm very honest though, the easiest and quickest way to solve this issue and the hv worry is to stop weighing. I never weighed dd2, and never had a problem, although I suspect she also dropped the centiles after a few months. If you can trust your instinct that he's clinically fine, stop. The numbers won't tell you anything anyway, without clinical signs to accompany.

I have a baby of the same age growing at the same rate. It's horrible when hv worry us!!
What Tiktok says, basically! It's also is what my HV said to me last visit: offer regularly, she is a slow grower but within the norm. She looked at dd's strength etc and was satisfied that she was healthy, just short! She kept telling me not to offer formula, not that I would, and said if I was still worried at 6 months they would review things as 100% bf before then was best.

I wonder if the HV suggested top ups sooner than 2 centiles is because dropping two centile would take him to about the 0.4th, which really is tiny.

Don't flame me, just suggesting. Healthy baby is the most important thing here. Healthy baby is far, far more important than feeding method.

That said, you've not got to a paeds referral yet so you can just carry on as you are with offering the breast often. If baby starts losing weight or drops 2 centiles, you can face that if it happens. But you are not there yet.

I finally would like to add that the physical symptoms of my DC3 malnourishment for the first three weeks of his life (he never put any weight on breastfeeding, just different degrees of weight loss) were the same characteristics you may describe in a very contented baby. A malnourished baby is a very sleepy and quiet baby.

• Well spaced breastfeeds
• Sleeps well
• Cries at times but not prolonged
• Easily settled
• Wide bright eyes can actually be wide-starry eyes

I do not aim to be controversial in this post. I am a Mum who breastfed DC1, DC2 and DC4. Some babies just do not take to breastfeeding and whilst breastfeeding support is very important when times are hard, realistic acknowledgment that breastfeeding is not more important than baby's health.

Mine dropped to below the 0.4th centile. She's just small and very active.

However I agree if he's not putting on any weight. Mine did gain consistently, albeit very small amounts, or stayed the same. Never lost.

The op does say he's recently become very active and is rolling about. I do agree that sometimes bf doesn't work, but I'd say ask for a paeds referral first rather than go straight to formula.

Thanks everyone. If it was up to me I wouldn't bother getting him weighed but the HV is involved with us for PND so she's visiting every few weeks and notices that his weight chart hasn't been updated so whips out the scales. I have to keep her onboard for accessing PND help so I can't even tell her to sod off with the scales.

Tiktok - I suppose my issue is that I don't think there is an issue but someone is coming round my house every few weeks and telling me I'm not feeding my baby properly. I suppose I just wanted a bit of reassurance that centile drops aren't a huge problem if the baby seems otherwise happy. My instinct tells me not but I don't feel particularly confident in that at the moment.

FATE - Thanks for your input. I get where you are coming from and the symptoms you list definitely don't apply to DS - he's not overly sleepy or passive so he does seem to be getting energy, just not spending it on getting bigger. You're right that the next line is the 0.4th centile which is very small but that translates as 4 in 1000 children would naturally fall here, so unusual but not impossible.

Hopefully he will have had a growth spurt by the next HV visit but if not I feel happier about pushing for a paed referral rather than being bullied in to giving formula top ups.

Thanks again :)

Just to clarify as cross-posted with Micah, he is putting on weight each time, just not enough to keep pace with his original centile. If he was staying the same or losing then I would definitely be more concerned than I am.

Fate I raised this and was told in no uncertain terms "the shortest girl in the class has to be someone. She could be the next Kylie!" ... ie no, because if they're born small they can end up small. The HV looked me up and down and declared me "below tge 9th percentile" (ie short) so was not worried as it could be genetic.
My DD puts on about 1 lb a month like clockwork. Can't get more, rarely less

Oh and age is vital here: the signs of malnourishment in a 4 month old differ from a new baby. By 4 months their level of communication is such you can tell listless easily apart from calm - which is harder in the first weeks.

squizita

I meant nothing personal to parents of small babies. It is just a very important point to be made that while breastfeeding support is important, it should never be more important than a child's health if the child's health starts to be effected.

I mentioned in my post that the OP is not there yet.

This does not remove from the important point I was making.

Fate I wasn't taking it personally. I was reporting what HCP say on the matter in my case (on a whole clinic scale, 0.4 percentile won't be that unusual, they'll probably have a couple on their books just as they have on the 99th). As you can see from my PP I am speaking as someone with a 4 month old who drifts down the percentiles who specifically asked about whether ranking affects medical treatment at 4 months. I was just reporting that it doesn't as you asked I wonder if the HV suggested top ups sooner than 2 centiles is because dropping two centile would take him to about the 0.4th, which really is tiny ... I was just answering your question with what my HV/GP said.

It has nothing to do with BF v FF and I wholeheartedly agree if there's a medical issue formula should be given.

However I was even told that going purely by ranked size of baby is actually potentially risky.
My HV, MW, GP and a local nurse were all very clear that it's the speed and age of children falling percentiles that usually indicates ill health. A 99th percentile baby who rapidly falls to the 25th is much more likely to be unwell or underfed than a 9th percentile baby slowly drifting to the 2nd percentile: their place in the 'rank' seemed to be of little interest to all those HCP.
Age is also very important: a young baby without a good feeding history is 'at risk'. An older baby with communication and development markers anyone can test is easier to identify as healthy or not (i.e. if they are starving and can usually roll, cry real tears, babble etc' these things will be weakened. As you say, a young baby can't do these things so it's harder to tell). The OP has a 4 month old.
You're speaking from your experience with a baby who was malnourished for the first three weeks of their life. New born babies are different from 4 month olds who have been developing well even if the 'look' tiny.

I still wonder if the HV suggested top ups sooner than 2 centiles is because dropping two centile would take him to about the 0.4th which is tiny.

I'm not the HV in question so cannot answer why she suggested it. She did though. I was just thinking out loud.

Eastwiththem - For what it's worth I have only had my nearly 4 month old daughter weighed twice (three times if you include birth weight). DC3 was never weighed again after 4 weeks old because I was so anti HV interference.

Having baby weighed is not compulsory, especially if the HV is being unhelpful. If you have happy with your baby's weight, they you can choose not to put yourself through it.

Fate my baby dropped to below the 0.4 th. At 4 months it was either because she was just small, or she had some underlying disorder. In either case formula wouldn't make a difference, and might even mask something temporarily by forcing a weight gain.

If 0.4 isn't abnormal, it's just the bottom end of normal. If it's as worryingly tiny as you say, there should be automatic referral to paeds for growth disorder investigations. The paeds in my case certainly weren't worried.

If bf has been going well, at 4 months there's no reason for it to suddenly fail. Especially if the baby is otherwise clinically well (no dehydration, meeting milestones).

Formula is not the magic cure some hv seem to think it is. It's basically packing more calories in- if a baby needed more calories, they'd drink more breastmilk.

My below 0.4 centile baby is now 10. Still the smallest in her class, but is on a talented athlete scheme and comes out top on strength and fitness tests, even against boys two years older.

Purely from experience... DS was a sicky baby and very active. A lot of the small ones tend to be more active too. He was rolling around from 3 months and crawling at 5.5 months etc.

He dropped down the centiles from 50th to the 9th until 6 months but was hitting milestones and was still gaining. He did really well on solids however and although he is still slender (like little children should be) he is now back up to the 50th centile.

You have to look at height as well.... this is sometimes ignored.

I'd go to your GP and keep an eye on things. It is probably fine but no harm in being aware of it. He may just not like milk very much or not be a hungry baby.

I just checked myself on the adult size chart in the red book. I am 2nd percentile and dh is 9th. Makes me feel more secure dd is just wee!

Micah yes my HV did say if something was wrong with dd iit wasn't food quantity (based on nappies and number of - observed ok- breastfeeds) so formula would not be the answer. A check up would be needed. But as her poo is normal and there's no pain or colic they call her a "drifter" floating down a bit, up a bit, always gaining albeit slow.

Nottheop out of interest how did you wean (ie timings/blw). Relatives have mentioned babies weaning well after being skinny little things.