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 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 cream 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 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 sure.
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 mean 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 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 which is not red. Fixing the
latch, using compression usually fix the problem. If relatching and breast compression do not result in better intake, there are ways of giving
extra fluid without giving a bottle directly (see 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
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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.
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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.
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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 Colic in the Breastfeeding Baby.
Do not limit feeding times.
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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 feeding (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. 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. (see using a lactation aid)
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"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.
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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.
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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 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 250 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 2000 Written by Jack Newman, MD, FRCPC
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