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 lots of milk at the breast sucks in a very
characteristic way. The baby generally opens his mouth
fairly wide as he sucks and the rhythm is slow and steady.
His lips are turned out. At the maximum opening of his
mouth, there is a perceptible pause which you can see if you
watch his chin. Then, the baby closes his mouth again. This
pause does not refer to the pause between suckles, but
rather to the pause during one suckle as the baby opens his
mouth to its maximum. Each one of these pauses corresponds
to a mouthful of milk and the longer the pause, the more
milk the baby got. At times, the baby can even be heard to
be swallowing, and this is perhaps reassuring, but the baby
can be getting lots of milk without making noise. Usually,
the baby's suckle will change during the feeding, so that
the above type of suck will alternate with sucks that could
be described as "nibbling". This is normal. The baby who
suckles as described above, with several minutes of pausing
type sucks at each feeding, and then comes off the breast
satisfied, is getting enough. The baby who nibbles only, or
has the drinking type of suckle for a short period of time
only, is probably not. This is the best way of knowing the
baby is getting enough. This type of suckling can be seen on
the very first day of life, though it is not as obvious as
later when the mother has lots more milk.
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. Meconium is passed during the first
few days, and by the 3rd 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
lotion in consistency (from air bubbles). The variation in
colour does not mean something is wrong. A baby who is
breastfeeding only, and is starting to have bowel movements
which are becoming lighter by day 3 of life, is doing well.
Without your becoming obsessive about it, monitoring the
frequency and quantity of bowel motions is one of the best
ways of knowing if the baby is getting enough milk. After
the first 3-4 days, the baby should have increasing bowel
movements so that by the end of the first week he should be
passing at least 2-3 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
fifth day 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 yet definite.
Some breastfed babies, after the first 3-4 weeks of life,
may suddenly change their stool pattern from many each day,
to one every 3 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 5 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 means insufficient intake. There are definite
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 sure that the baby is getting a lot of
milk. 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 clear as water after the first few days, though an
occasional darker urine is not of concern.
During the first 2-3 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 measure 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 which is not
red. 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.
4. The baby feeds often and/or for a long time. For
one mother every 3 hours or so feedings may be often; for
another, 3 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 2-3 substantial
yellow bowel movements each day. If that is the case,
feeding on one breast each feeding (or at least finishing on
one breast before switching over) will often lengthen the
time between feedings. Remember, a baby may be on the breast
for 2 hours, but if he is actually breastfeeding
(open—pause—close type of sucking) for only 2 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 there, 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 (4-6 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.
Please Note: On occasion, it may be necessary
to supplement a baby who is breastfeeding. If this is done
by bottle, a bad situation may become worse. A lactation aid
is a method of supplementing without giving a bottle and may
allow you to supplement temporarily and get back to
exclusive breastfeeding. It is generally easy to use. In an
"emergency" situation, extra fluid can be given by spoon,
cup or eyedropper until a lactation aid can be started.
Handout #4. Is My Baby Getting Enough? Revised January
1998 Written by Jack Newman, MD, FRCPC
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