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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. See
our 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)
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-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 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 five 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
1. 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.
2. 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? (416) 813-5757
(option 3) or drjacknewman@sympatico.ca
or 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
1. Breastfeeding:
Starting out right
a) The
importance of Skin-to-Skin contact
2. Colic in the Breastfed Baby
3. a) Sore Nipples
b) Treatments
for Sore Nipple and Sore Breasts
4. Is my baby getting enough?
5. Using a Lactation Aid
6. Using Gentian Violet
7. Breastfeeding and Jaundice
8. Finger Feeding
9. a) You should continue breastfeeding
(Medications and breastfeeding)
b) You
should continue breastfeeding (Illness in the mother or baby)
10. Breastfeeding and other foods
11. Some breastfeeding myths
12. More breastfeeding myths
13. Still more breastfeeding
myths
14. More and more breastfeeding
myths
15. Breast compression
16. Starting solid foods
17. What to feed the baby when
the mother is working outside the home
18. How to know a health professional
is not supportive of breastfeeding
19. a) Domperidone 1
b) Domperidone
2
20. Fluconazole
21. Breastfeed a toddler –
Why on earth?
22. Blocked ducts and
mastitis
23. Breastfeeding your adopted baby
24. Miscellaneous treatments for problems
25. Slow weight gain after
the first few months
26. When the Baby refuses to
latch on
27. Expressing Milk
28. Toxins and Infant Feeding
How breastmilk protects Newborns
Risks of formula feeding
Breastfeeding and guilt
Candida protocol
Protocol to increase the intake
of Breastmilk by the Baby ("Not enough milk")
When latching
Protocols for Induced Lactation
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