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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
the video 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 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 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.
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