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Is My Baby Getting Enough Milk?
by Jack Newman, MD, FRCPC
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
- 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.
- 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.
- 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:
- 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.
- 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.
- 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.
- 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).
- "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.
- 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.
- 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
- 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.
- 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
This article may be copied and
distributed without further permission
Please view the copyright information and warning about the material contained in this article.
| Jack Newman, MD, FRCPC, graduated from
the University of Toronto medical school as a pediatrician in
1970. He started the first hospital-based breastfeeding clinic in
Canada in 1984 at Toronto's Hospital for Sick Children and,
more recently, established similar clinics at Toronto's Doctors
Hospital and St Michael's Hospital. He has been a consultant
with UNICEF for the Baby Friendly Hospital Initiative in Africa,
and has published articles on the subject of breastfeeding in
Scientific American and several medical journals. |
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if you have any questions or comments!