Catch-down growth involves a natural period of slow growth that is normal for some babies. It is often mistaken as poor growth. This mistake can lead to flawed feeding advice that has the potential to cause infant feeding and growth problems. Knowing the difference between catch-down growth and poor growth could benefit your baby’s health and spare you needless anxiety.
What is catch-down growth?
Most people are aware of catch-up growth, which involves a period of rapid growth that follows a time when baby’s growth was slow or delayed. (See catch-up growth for more). Catch-down growth is less well known.
Catch-down growth is the flip side to catch-up growth. Catch-down growth involves a period of slow growth that follows a phase where baby experienced rapid or extreme growth above normal range.
Catch up and catch-down both entail compensatory growth that realigns a child’s body size and shape in harmony with his genetically determined path (as programmed into his DNA due to inherited traits). Compensatory growth - slow in the case of catch-down growth or rapid in the case of catch-up growth - occurs once the reason or reasons that caused baby’s growth to deviate away from its natural course are resolved.
People are delighted when they observe baby undergoing catch-up growth. But most become needlessly worried when a baby’s growth slows as a result of catch-down growth, mistaking this as poor growth. Catch-down growth is as normal as catch-up growth. Both forms of healthy growth demonstrate baby’s growth is getting back on track.
To understand why catch-down growth occurs begins with understanding why a baby might grow so rapidly that it causes his growth deviates from its genetically determined path.
Preceding catch-down growth
Rapid or extreme growth - beyond that which is in keeping with the baby’s genetic endowment - can occur while a baby is in the womb. For example, due to maternal diet, gestational diabetes, certain medications given to the mother, or other factors. Baby could be born with generous rolls of body fat, or he could be large but well-proportioned, or he could be be average weight and size and yet be ‘large’ when considering his genetic potential based on his parents’ heights.
Alternatively, a baby could gain large amounts of weight and become chubby, overweight or obese in the early months following birth as a result of overfeeding. Overfeeding is a common problem for newborn babies. Bottle-fed babies are at greater risk of overfeeding compared to breastfed babies. Babies who are given steroid medications to treat certain conditions and tube-fed babies are also at risk of overfeeding. (See our Overfeeding article for other reasons that a baby might overfeed).
As a result of these intrauterine or external factors baby gains large amounts of weight and his growth heads in an upward trajectory on an infant growth chart in a way that is inconsistent with his genetic endowment.
Because a baby is born unexpectedly large or gains large amounts weight in the early months doesn’t mean his growth will continue at the same rate or follow the same percentile curves on an infant growth chart.
Why catch-down growth occurs
The strongest influence on a healthy baby’s growth following birth is his genetic endowment. Once factors that caused baby’s growth to deviate from its natural course have been remedied – e.g. baby is born and therefore his growth is no longer influenced by factors within the womb, or once overfeeding no longer occurs - his growth pattern will head back towards his genetically determined course.
The period of catch-down growth could last for days, weeks or months depending on how far baby’s growth deviated from its natural course and how his parents or caregivers respond once they’re aware of the decline in his rate of growth. How the parent responds will depend on whether they recognize this as catch-down growth or not.
What you will see
If your baby is undergoing a period of catch-down growth you can expect to see the following:
Weight gain
Baby’s weekly or monthly weight gains will be less than average when compared against standard measurements, which are based on the median (average) weekly or monthly weight gain figures for babies of the same age.
Infant growth chart
An overweight or obese baby - whose weight is higher on an infant growth chart compared to length - may convert excess stores of body fat into energy (calories). His weight will slowly drop to lower percentile curves and over time he will appear slimmer.
A baby who is large but proportionate won’t necessarily become slimmer. Both weight and length will drop to lower percentile curves and he may remain proportionate.
After realigning to his natural growth course, baby’s growth then follows growth curves that harmonize with his inherited body shape and size. That is, provided there are no barriers, such as infant feeding or sleeping problems that hamper his ability to feed effectively.
Baby’s appetite
Baby’s appetite may appear to be small because you and/or his healthcare professional might be expecting him to eat more. Or may be small in comparison to the time when he was overfeeding.
If he’s breastfed he might go for unusually long periods of time before demanding feeds, refuse offers to feed at times, feed quickly and appear to eat very little.
If he’s bottle-fed he will eat less than standard for babies of his age and size. Note: Standard milk estimations do not take into account the numerous reasons for appetite variances between individual babies. See How much milk baby needs for reasons.
While your baby might gain less and drink less than you or his healthcare professional expect, he will display other signs that indicate he’s well fed.
Signs that indicate a baby is well fed
- He has a healthy layer of body fat;
- He’s outgrowing his clothes;
- He displays hunger. (This will depend on how often you offer feeds. A baby with an easy-going temperament may be content to wait until food is offered.);
- He appears satisfied by the amount he’s willing to drink;
- He’s energetic and active;
- He’s generally content between feeds (except when bored or tired);
- He sleeps well. (A well-fed baby could experience broken sleep due to a sleep association problem and hence be irritable at times due to sleep deprivation.)
- He has 5 or more wet diapers in a 24-hour period;
- He has regular bowel motions.
Catch-down growth versus poor growth
While its important to not mistake catch-down growth as poor growth, the reverse is equally important. If a baby is experiencing poor growth the cause needs to be rectified as soon as possible. The following table compares catch-down growth to poor growth.
Misdiagnosis
Catch-down growth is commonly mistaken as poor growth.
Some health professionals simplistically base their assessment of a baby’s growth on average weight gain figures without consideration of the individual baby’s genetic endowment, birth size or prior growth pattern. Many fail to ask parents questions about their baby’s behavior in order to assess whether he displays signs indicating he’s well fed.
In a nutshell, they fail to consider the many variances of growth that can be perfectly normal for individual babies, and instead make the assumption that slow growth = poor growth. And that poor growth means baby is not eating enough.
Catch-down growth might not be ‘typical’ growth, but this doesn’t mean it’s not 'normal' growth.
Standard weight gain figures based on average growth, and standard milk estimations based on average milk intake do not apply to a baby undergoing catch-down growth. A baby experiencing catch-down growth will not gain average weight nor will he drink average amounts of milk based on his current weight. Weight dropping to lower percentile curves needs to be considered within the context of the individual baby’s circumstances and not automatically assumed to be evidence of poor growth.
For reassurance that your baby’s growth is fine you need to look beyond the scales, past average figures and infant growth charts. Look at your baby! Look for signs that indicate he is well fed. If he displays these signs, there’s probably little worry about in regards to his appetite or growth.
Problems linked to misdiagnosis
Unaware of what is normal and what’s not regarding infant growth, parents in general rely on guidance from health professionals. The health professional’s assessment of the reason for baby’s decline in rate of growth and the advice they provide regarding infant feeding will influence the parents actions, and in turn what happens to baby.
When health professionals or parents mistake catch-down growth as poor growth this can trigger a chain of events that leads to infant feeding and growth problems. The following can occur when catch-up growth is mistaken as poor growth.
- Because baby’s growth is less than average, it's assumed that he’s experiencing poor growth.
- Because baby is not drinking as much milk as recommended using standard milk calculations, it’s erroneously assumed that the reason for ‘poor growth’ is because baby is not drinking enough.
- When a baby’s milk requirements are estimated based solely on age and weight alone – i.e. without consideration that he’s larger than genetically inclined to be or that he’s currently undergoing a period of catch-down growth and therefore expected to drink less - its likely to be an overestimation of his actual needs.
- These common errors in judgment needlessly cause parental anxiety.
- The parent then tries to pressure their baby to drink an overly inflated amount of milk, beyond what baby needs.
- Baby understandably objects to being pressured into drinking more than he needs.
- The more baby resists the greater the lengths parents go to try to make their baby drink the amount that has been recommended, unbeknown to them that it's an overestimation.
- Being pressured to feed makes for an unpleasant, or in some cases stressful, experience for baby.
- Baby develops a feeding aversion as a result of being repeatedly pressured to feed against his will.
- Because baby has become averse to feeding, he now consumes less milk than what he needs during catch-down growth and instead growth is now poor.
- Eventually baby’s weight drops below his genetically determined path.
- Baby becomes underweight.
A misdiagnosis of poor growth can become a self-fulfilled prophecy. And the health professional and parents remain unaware that an erroneous assessment of baby’s growth and overestimation of milk needs caused this unfortunate situation to develop. The case study below provides is an example of how bad things can get.
Case study
Caden was born weighing 9 lbs 12 oz (4.42 kg). This placed his weight above the 97th percentile on an infant growth chart. His length was 19.5 in (48 cm), which meant his length was around the 25th percentile. His mother Michelle was 5’3” (160 cm) and father Brett 5’8” (173 cm). So Caden’s length was in keeping with his genetic endowment, but his weight was a surprise to his family.
From the time of his birth Caden was exclusively breastfed. His weight at three weeks of age indicated he was 3.5 ounces (100 g) above his birth weight, which is well below average. The health nurse told Michelle that she had low milk supply and advised her to supplement Caden’s breastfeeds with infant formula. This created doubts in Michelle’s mind about her ability to successfully breastfeed and by the time Caden was five weeks old he was completely formula-fed.
Caden initially fed well from a bottle and gained close to average weight each week. However, the situation changed around the age of two months. He started to drink less than the recommended amount of formula based on his age and weight, and his weight gain slowed. Michelle found she needed to use pressure to try to get him drink the recommended amount, but never quite succeeded. By three months of age his weight was around the 60th percentile. Caden would become quite distressed at feeding times. He would cry as soon as Michelle held him in a feeding position, buck and scream and turn his head into Michelle’s chest, and try to bat the bottle away.
The child health nurse suspected acid reflux and advised Michelle to have Caden medically assessed. Her GP prescribed ranitidine (an acid suppressing medication). But this didn’t help. Caden was then referred to a pediatrician who prescribed omeprazole (an even stronger acid suppressing medication) and Neocate (a hypoallergenic formula). Despite these treatments, there was no improvement in his feeding behavior.
At four months of age Caden’s weight was around the 25th percentile. His milk intake had dropped to between 13 to 16 ounces (360 to 450 ml) a day. He was referred to a speech and language pathologist (SLP) who confirmed he had no underlying sucking problem. And also to a pediatric dietician who recommended increasing the calories he received by switching him to high-energy formula. But this resulted in him drinking even less. His pediatrician suggested that Michelle start feeding him solids. Caden initially enjoyed eating solids but within four weeks he was refusing to eat solids.
By six months his weight had dropped to the 7th percentile. His length stayed steady around the 25th. He was diagnosed as ‘failure to thrive’, referred to a pediatric gastroenterologist who admitted him to hospital for a series of diagnostic tests; all of which came back as negative. Out of options, his doctor recommended he be tube fed. Michelle and Brett reluctantly agreed. Caden remained in hospital for 10 days, during which time he gained over 10.5 ounces (300 grams).
When Caden was 8 months old, Michelle consulted me about the possibility of tube weaning. Caden’s growth was on track but he continued to reject bottle feeds and solids, and the situation didn’t look like improving any time soon. After taking a detailed history from Michelle, examining Caden’s growth charts, and the feeding app that Michelle had used to keep records of feeds and wet diapers since birth, I suspected that Caden’s catch-down growth had been overlooked. At birth he was 2.5 pounds (more than 1 kg) heavier than the average sized baby, and yet he was shorter than average. I didn’t need to see him at that time to know that he carried generous rolls of fat on his body.
Caden might have been born a chubby baby but this didn’t mean he was destined to remain that way. It would not be healthy if he did. He would be expected to go through a period of catch-down growth as his weight realigned with his genetically inherited body shape. His body started this process from birth but the process was halted temporarily when he was switched to bottle-feeding, which meant he could be pressured to drink for a time (until his sucking reflex disappeared and he was strong enough to resist).
Despite having gained less than average weight in the early weeks, according to the details recorded on Michelle’s app, all signs pointed to Caden being a well-fed baby. There was nothing wrong with Michelle’s milk supply at that time. What had been mistaken as poor growth due to low milk supply was catch-down growth. The consequence of the health nurse’s mistaken assessment of Caden’s growth and Michelle’s milk supply – which was assumed to be low without feeding observation or any other form of assessment – was feeding recommendations that led to Michelle ceasing breastfeeding long before she had planned to. (Michelle’s loss in confidence in her ability to breastfeed could also have a negative impact on any future babies she might have). But this was not the only time Michelle and Caden were let down.
Once Caden was fully formula fed, the nurse then overestimated his formula requirements. She used standard calculations based on age and weight, but did not take into account the fact that Caden was carrying excess stores of body fat, or that his requirements might be less and weight gains lower because he would be expected to through a period of catch-down growth. Caden should have been allowed to take the amount he wanted according to his hunger and satiety cues, which reflected his growth needs, but he was not. Thinking she was doing the right thing, Michelle forced him to take an overly inflated volume of milk until she could no longer do so when Caden was three months of age. By force-feeding, Michelle had caused Caden to develop a feeding aversion. As a result of his aversion his milk volumes dropped below his needs. He burned up fat reserves at a rapid rate until there was little left. What had initially been mistaken as poor growth became poor growth.
Michelle and Brett did everything they could to find answers to why Cade hated eating. The health nurse, GP, pediatrician, GI specialist, SLP and dietician all assumed his fierce rejection of feeding and poor growth was to due to acid reflux and milk protein allergy. Had his aversive feeding behavior been due to these reasons, acid reflux medications and hypoallergenic formula would have fixed the problem. According to Michelle none of the many health professionals she consulted asked about her feeding practices, or observed her feeding Caden. None considered the possibility of a behavioral feeding aversion due to being repeatedly pressured to feed. He had also been pressured to eat solids, because Michelle was desperate to improve his weight gain, and this caused him to become averse to eating solids as well.
Caden had no underlying physical cause preventing him from feeding orally, so over a period of three weeks, he successfully weaned from tube feeds onto oral feeds once his aversion to bottle-feeding was no longer reinforced. After weaning to bottle-feeds, which he enjoyed now he was no longer pressured to eat, he went on to relish eating solids as well, which were also offered without pressure. Caden was weaned off acid suppressing medications and returned to regular infant formula without ill effects. Michelle allowed him to decide how much he would eat and Caden continued to gain weight well. After 8 long months, the family were finally free to embrace life without the stress of constantly trying to make Caden eat. And Michelle would be better prepared in the future if she were to give birth to another large baby.
NOTE: this is a genuine case but the names have been changed.
Caden’s case may seem extreme, but it's not. I see similar scenarios all too often when assisting parents to resolve an infant feeding aversion. What I find so sad about these cases is that the situation could have been avoided had baby’s health professional identified catch-down growth and not mistaken this normal decline in growth rate as poor growth.
Written by Rowena Bennett.