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Is
my Baby Getting Enough Milk?
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 milliliters
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.
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 several hundred grams (half a pound
or more), so babies should be weighed naked.
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.
Handout #4. Is My
Baby Getting Enough? Revised January 1998
Written by Jack
Newman, MD, FRCPC
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