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Is my baby getting enough milk?
Handout #4. Is My Baby Getting Enough Milk? Revised
January 2005
Written by Jack Newman, MD, FRCPC. © 2005
Breastfeeding mothers frequently ask how to know their
babies are getting enough milk. The breast is not the bottle, and
it is not possible to hold the breast up to the light to see how
many ounces or millilitres of milk the baby drank. Our number obsessed
society makes it difficult for some mothers to accept not seeing
exactly how much milk the baby receives. However, there are ways
of knowing that the baby is getting enough. In the long run, weight
gain is the best indication whether the baby is getting enough,
but rules about weight gain appropriate for bottle fed babies may
not be appropriate for breastfed babies.
Ways of Knowing
1. Baby's nursing is characteristic. A baby
who is obtaining good amounts of milk at the breast sucks in a very
characteristic way. When a baby is getting milk (he is not
getting milk just because he has the breast in his mouth and is
making sucking movements), you will see a pause at the point of
his chin after he opens to the maximum and before he closes his
mouth, so that one suck is (open mouth wide-->pause-->close
mouth). If you wish to demonstrate this to yourself, put your index
or other finger in your mouth and suck as if you were sucking on
a straw. As you draw in, your chin drops and stays down as long
as you are drawing in. When you stop drawing in, your chin comes
back up. This same pause that is visible at the baby's chin represents
a mouthful of milk when the baby does it at the breast. The longer
the pause, the more the baby got. Once you know
about the pause you can cut through so much of the nonsense breastfeeding
mothers are being told—like feed the baby twenty
minutes on each side. A baby who does this type of sucking (with
the pauses) for twenty minutes straight might not even take the
second side. A baby who nibbles (doesn't drink) for 20 hours will
come off the breast hungry. The website www.thebirthden.com/Newman.html
has videos that show this pause in the baby’s chin.
2. Baby's bowel movements. For the first few
days after delivery, the baby passes meconium, a dark green, almost
black, substance. Meconium accumulates in the baby's gut during
pregnancy. It is passed during the first few days, and by the third
day, the bowel movements start becoming lighter, as more breastmilk
is taken. Usually by the fifth day, the bowel movements have taken
on the appearance of the normal breastmilk stool. The normal breastmilk
stool is pasty to watery, mustard coloured, and usually has little
odour. However, bowel movements may vary considerably from this
description. They may be green or orange, may contain curds or mucus,
or may resemble shaving cream in consistency (from air bubbles).
The variations in colour do not mean something is wrong. A baby
who is breastfeeding only, and is starting to have bowel
movements that are becoming lighter by day 3 of life, is doing well.
Without becoming obsessive about it, monitoring the
frequency and quantity of bowel motions is one of the best ways,
next to observing the baby’s drinking, (see above, and videos
at www.thebirthden.com/Newman.html)
of knowing if the baby is getting enough milk. After the first three
to four days, the baby should have increasing bowel movements so
that by the end of the first week he should be passing at least
two to three substantial yellow stools each day. In addition,
many infants have a stained diaper with almost each feeding. A
baby who is still passing meconium on the fourth or fifth day
of life, should be seen at the clinic the same day. A baby who is
passing only brown bowel movements is probably not getting enough,
but this is not very reliable.
Some breastfed babies, after the first three to four
weeks of life, may suddenly change their stool pattern from many
each day, to one every three days or even less. Some babies have
gone as long as 15 days or more without a bowel movement.
As long as the baby is otherwise well, and the stool is the usual
pasty or soft, yellow movement, this is not constipation and is
of no concern. No treatment is necessary or desirable,
because no treatment is necessary or desirable for something that
is normal.
Any baby between five and 21 days of age who does
not pass at least one substantial bowel movement within a 24 hour
period should be seen at the breastfeeding clinic the same day.
Generally, small, infrequent bowel movements during this time period
mean insufficient intake. There are definitely some exceptions and
everything may be fine, but it is better to check.
3. Urination. With six soaking wet
(not just wet) diapers in a 24 hours hour period, after about 4-5
days of life, you can be reasonably sure that the baby is getting
a lot of milk (if he is breastfeeding only). Unfortunately,
the new super dry "disposable" diapers often do indeed
feel dry even when full of urine, but when soaked with urine they
are heavy. It should be obvious that this indication of milk intake
does not apply if you are giving the baby extra water (which, in
any case, is unnecessary for breastfed babies, and if given by bottle,
may interfere with breastfeeding). The baby's urine should be almost
colourless after the first few days, though occasional darker urine
is not of concern.
During the first two to three days of life, some babies
pass pink or red urine. This is not a reason to panic and does not
mean the baby is dehydrated. No one knows what it means, or even
if it is abnormal. It is undoubtedly associated with the lesser
intake of the breastfed baby compared with the bottle fed baby during
this time, but the bottle feeding baby is not
the standard on which to judge breastfeeding. However, the appearance
of this colour urine should result in attention to getting the baby
well latched on and making sure the baby is drinking
at the breast. During the first few days of life,
only if the baby is well latched on can he get his mother's
milk. Giving water by bottle or cup or finger feeding at
this point does not fix the problem. It only gets the baby out of
hospital with urine that is not red. Fixing the latch and using
compression will usually fix the problem (See Handout B: Protocol
to Increase Breastmilk Intake by the Baby). If relatching
and breast compression do not result in better intake, there are
ways of giving extra fluid without giving a bottle directly (handout
#5 Using
a Lactation Aid). Limiting the duration or frequency of
feedings can also contribute to decreased intake of milk.
The following are NOT good ways of judging
1. Your breasts do not feel full. After the
first few days or weeks, it is usual for most mothers not to feel
full. Your body adjusts to your baby's requirements. This change
may occur quite suddenly. Some mothers breastfeeding perfectly well
never feel engorged or full.
2. The baby sleeps through the night. Not necessarily.
A baby who is sleeping through the night at 10 days of age, for
example, may, in fact, not be getting enough milk. A baby who is
too sleepy and has to be awakened for feeds or who is "too
good" may not be getting enough milk. There are many exceptions,
but get help quickly.
3. The baby cries after feeding. Although
the baby may cry after feeding because of hunger, there are also
many other reasons for crying. See also handout #2 Colic
in the Breastfeeding Baby. Do not limit feeding times. “Finish”
the first side before offering the other.
4. The baby feeds often and/or for a long time.
For one mother feeding every three hours or so may be often; for
another, three hours or so may be a long period between feeds. For
one, a feeding that lasts for 30 minutes is a long feeding; for
another, it is a short one. There are no rules how often or for
how long a baby should nurse. It is not true that the baby
gets 90% of the feed in the first 10 minutes. Let the baby determine
his own feeding schedule and things usually come right, if the baby
is suckling and drinking at the breast
and having at least two to three substantial yellow bowel movements
each day. Remember, a baby may be on the breast for two hours, but
if he is actually feeding or drinking (open wide—pause—close
mouth type of sucking) for only two minutes, he will come off the
breast hungry. If the baby falls asleep quickly at the breast, you
can compress the breast to continue the flow of milk (handout
#15, Breast
Compression). Contact the breastfeeding clinic with any
concerns, but wait to start supplementing. If supplementation is
truly necessary, there are ways of supplementing which do not use
an artificial nipple (handout #5, Using
a Lactation Aid).
5. "I can express only half an ounce of milk".
This means nothing and should not influence you. Therefore,
you should not pump your breasts "just to know". Most
mothers have plenty of milk. The problem usually is that the baby
is not getting the milk that is available, either because he is
latched on poorly, or the suckle is ineffective or both. These problems
can often be fixed easily.
6. The baby will take a bottle after feeding. This
does not necessarily mean that the baby is still hungry. This is
not a good test, as bottles may interfere with breastfeeding.
7. The 5 week old is suddenly pulling away from
the breast but still seems hungry. This does not mean your milk
has "dried up" or decreased. During the first few weeks
of life, babies often fall asleep at the breast when the flow of
milk slows down even if they have not had their fill. When they
are older (four to six weeks of age), they no longer are content
to fall asleep, but rather start to pull away or get upset. The
milk supply has not changed; the baby has. Compress the breast (handout
#15, Breast
Compression) to increase flow.
Notes on scales and weights
- Scales are all different. We have documented significant differences
from one scale to another. Weights have often been written down
wrong. A soaked cloth diaper may weigh 250 grams (half a pound)
or more, so babies should be weighed naked or with a brand new
dry diaper.
- Many rules about weight gain are taken from observations of
growth of formula feeding babies. They do not necessarily apply
to breastfeeding babies. A slow start may be compensated
for later, by fixing the breastfeeding. Growth charts
are guidelines only.
Questions?
see
my book Dr. Jack Newman's Guide to Breastfeeding (called
The
Ultimate Breastfeeding Book of Answers in the USA)
Handout #4. Is My Baby Getting Enough? Revised
January 2005
Written by Jack Newman, MD, FRCPC. © 2005
This
handout may be copied and distributed without further permission,
on
the condition that it is not used in any context in which
the WHO code on the marketing of breastmilk substitutes is violated
