Blog 3 : How To Know If There Really is a problem with your infant

Before tackling the question of why your baby is not getting enough milk or deciding what to do about it, you have to know for sure that there really is a problem. This includes finding out approximately how much milk your baby is getting and whether it is enough for good growth, because the amount each baby needs to grow appropriately can vary. When you have the facts, you can build the best strategy for your specific situation.

Determining if your baby is getting enough milk

Doctors look at many factors, but baby’s weight gain usually is the bottom line. Between doctor visits, monitoring diaper output is normally sufficient because what is coming out is usually an indication of what is going in. If baby is gaining well, he should be having adequate diaper output; if he isn’t, he won’t. If his diaper output is high but his weight gain is low, then there is reason for further medical investigation. Beyond the few days of birth, diaper output and weight gain or loss usually go hand in hand.

Adequate Milk Intake Criteria for Exclusively Breastfed Babies

This BLOG explains the fine points of measuring intake by weight gain and diaper output. The preceding checklist provides the minimum benchmarks of both weight gain and diaper output for an exclusively breastfed baby to grow adequately according to his age. Read through them and decide whether or not each statement is true for your baby.

Weight Gain to Gauge Milk Intake

When accurately measured, weight gain is the best indicator that your baby is getting enough milk. For this reason, obtaining an accurate weight each time is crucial when baby’s intake is in question Pay attention to these five factors:

1. Accurate Readings. Human error in taking weights is surprisingly common. The scale can be used incorrectly, the weight reading can be misread, the numbers can be transposed, the wrong weight can be recorded, or the percentile can be plotted incorrectly. To minimize errors, watch the reading being taken and double-check the figure yourself against what is written and plotted in your baby’s chart

 2. Scale Accuracy. Weighings on different scales can yield different results because all scales are calibrated differently. Scale type also matters; electronic scales are more accurate than spring-loaded scales. Whichever is used comparing weights taken on the exact same scale gives the most accurate results. The instant feed- back of a home scale can be empowering because you’ll know sooner if baby isn’t gaining enough, avoiding the need for frequent doctor visits. Just remember that readings on your scale and your doctor’s scale may not match

3. Clothing Removal. Be sure to remove all clothing, including hat, socks, booties, and mittens. Don’t forget to take off the diaper, too.

4. Consistent Time Intervals. The interval between readings should be as consistent as possible, even down to the time of day 5. Baby’s Stomach and 5.Colon Contents. Accuracy can be further increased by timing the weights for after a bowel movement and before a feed.

Newborns may lose up to 7 percent of their birth weight in the first days after birth before they begin gaining. Occasionally, excessive weight loss (more than 10 percent) occurs rapidly even though baby appears to be nursing well. In some of these cases, it is believed that baby’s birth weight may have been artificially inflated by extra water acquired during labor as the result of mother’s IV fluids or medications. After birth baby urinates the extra fluid. When excessive weight loss occurs together with multiple wet diapers in the first days after birth, this noncritical cause should be considered.

If your baby appears to be feeding well and is healthy, alert, and passing black, tarry meconium stools, chances are good that everything is fine and he will start gaining once milk production kicks into high gear. This means that if your milk “comes in” on the second day, he’ll probably start gaining very early. But if it doesn’t come in right away, he may lose a little more until milk production picks up. When milk is slow to come in and low intake becomes a problem, temporary supplementation may be needed.

Breastfed babies who are doing well often regain birth weight by the end of the first week. But because some mothers and babies may get a slower start, doctors usually are satisfied if baby regains his birth weight by the end of two weeks Weighing him every few days or once a week is usually enough, but daily weighing may be necessary in critical cases But what if baby was gaining well in the early weeks or months and faltered only later on? It’s OK for him to be on the lower end of the growth chart, but a significant drop in percentiles (such as having been in the seventieth percentile then dropping to the fiftieth) is cause for concern and further investigation.

Diaper Output to Gauge Milk Intake

In the first forty-eight hours (days one to two) after birth, an exclusively breastfed newborn will pass meconium stools and wet one or two diapers with pale yellow urine per day. Stools will lighten and turn greenish around day three. Reddish “brick dust” urine from uric acid crystals occasionally occurs before the milk comes in well but should be gone by the fourth to fifth day.

By day four (the fourth twenty-four-hour period), the milk is usually in, and meconium should transition to brownish-green and then yellow, while the urine should be nearly color- less and odorless. If your baby is still passing black or brown stools after the fourth day, this indicates low intake.

After the first six to eight weeks, the frequency of wet diapers may decrease, but they are heavier as baby’s bladder grows. Bowel movements may continue to be frequent, or they may slow down to once a day or once every two or three days.

A few babies may go once a week or even longer. You’ll know if this is nor- mal or not by the size and consistency of the stool. When a thriving baby’s stooling pattern changes, the stools are still loose but proportionally larger. If you find yourself changing “blow- out” diapers every few days, chances are he’s doing just fine.

In most cases, stool output is more important than urine output because babies who are not getting enough milk may be taking in enough to urinate frequently but not enough to gain weight and produce enough stools. When in doubt, baby’s weight can be checked to verify if there is any cause for concern.

In most cases, stool output is more important than urine output because babies who are not getting enough milk may be taking in enough to urinate frequently but not enough to gain weight and produce enough stools. When in doubt, baby’s weight can be checked to verify if there is any cause for concern.

How Wet Is “Very Wet”?

If you aren’t sure what a “very wet” diaper feels like, take a fresh diaper and pour 2 tablespoons of water (1 ounce or 30 milliliters) on it; this is what a very wet diaper feels like. If baby weighs more than 8 pounds (3,636 grams), use 3 tablespoons of water (1.5 ounces or 4 milliliters). Save this sample in a sealed plastic bag to compare with baby’s wet diapers.

A simple diaper chart can be a useful tool when you’re not sure if your baby is getting enough. It helps you see at a glance if output is sufficient and sounds an early warning if things are not going well.You may find it convenient to put the chart on a clipboard above the baby’s changing table.

Feeding Test Weights

It is possible to determine fairly closely how much milk your baby receives at a given breastfeeding by performing a test weight.1 This technique is used by many lactation consultants and is especially useful in determining how much baby is getting at breast when he is also being supplemented, because diaper output and weight gain can’t give you the full picture. It can also help determine how much to supplement (see BLOG 4) .

To obtain a test weight, you’ll need to rent a high-accuracy scale such as the Medela Baby- Weigh orthe Tanita BLB-12 or BD-815U. Weigh your baby before feeding him and record the weight, and then feed your baby as you normally would. Don’t change baby’s diaper or clothing in any way. When the feeding is complete, weigh your baby again. Subtract the first weight reading from the second; the difference is the amount of milk your baby took. Some scales have special functions that automatically calculate the weight difference.

Weight Conversions

Ounces can be measured in both weight and liquid volume. One ounce (weight) – 28.3495231 grams, and 1 ounce (liquid volume) 29.5735297 milliliters. But for our purposes, it is easier and acceptable to use 1 ounce (weight) 30 grams and 1 ounce (liquid volume) 30 milliliters.

While test weights are an accurate way to measure how much milk is transferred during a feeding, the information must be interpreted cautiously. Babies vary the amounts taken at different feedings and times of the day, so a single test weight provides only a snapshot of one feeding. The best way to get a true and accurate picture, though not always practical, is to do test weights for twenty-four hours.

Measuring Production by Pumping

Although not often necessary, a pumping test can determine more precisely how much milk you are making. Until recently, the method most commonly recommended was to pump for twenty-four hours instead of breastfeeding and measure the amount. A better method that provides information in only four hours rather than twenty-four was recently developed by researchers Ching Tat Lai, Post Grad Dip, M.Sc.; Thomas Hale, Ph.D.; Peter Hartmann, Ph.D.; and colleagues. While some argue that a pump does not always remove milk as effectively as a baby does, this method was found to be a close approximation of a mother’s milk production when a hospital-grade pump is used. Because it interrupts breastfeeding, use this method only after exploring baby’s milk intake and when the information gained outweighs the risks and expense.

  • Four-Hour Test: Empty both breasts thoroughly once an hour for four hours with a high-grade pump (preferably hospital grade) Record the amounts of milk removed at hours three and four, then add them together and divide by two. The result is your average rate of milk production per hour. Multiply by twenty-four for your current daily milk production rate.

The Final Results

You now have all the important facts to begin the process of understanding what is happening and what can be done about it. If your baby has numerous diapers and adequate weight gain, he’s getting enough milk and all is well. Take a deep breath and go enjoy your baby. But if he still seems miserable or hungry, your doctor may need to rule out a physical problem. Don’t hesitate to seek a second opinion if you aren’t satisfied with the answer and your gut feeling is that something is wrong, even if that means asking the same doctor to reconsider. Once you both feel confident that there are no physical problems, there is the possibility that oversupply may be causing gassiness and pain (See BLOG_2 )

    If output and weight gain indicate that baby isn’t getting enough milk yet you seem to have plenty, he may be unable to remove milk effectively, he may be self-limiting his feedings, or you may be having difficulties with milk ejection. Your milk production might be at risk, so while you figure out the problem, it’s a good idea to pump, use breast compressions, or both. BLOG 7 discusses the types of difficulties that can prevent babies from feeding well despite an adequate milk supply. BLOG_8 addresses anatomical issues that can disrupt breastfeeding, and BLOG_10 describes ways milk ejection can be affected.

If your baby isn’t getting enough milk, don’t be discouraged. In many cases, milk production can be increased, depending on the reason that it’s low. If the problem is the result of how breastfeeding has been managed, you may be able to solve it yourself with the information provided in this book. If the problem stems from an issue with your breasts or hormones or is baby related, you will probably benefit from discussing what you learn with a lactation consultant, preferably one qualified to help mothers in challenging situations as an International Board Certified Lactation Consultant (IBCLC).

Developing a Milk Management Strategy

If you know for sure that your baby isn’t getting enough of your milk, you’ll need to develop a strategy for improving the situation. A good starting place are the three rules for solving breastfeeding problems taught by Kay Hoover, M.Ed., IBCLC, an author and lactation consultant in Pennsylvania:

Rule # 1- Feed the Baby: A baby who is well fed will feed better at breast.

Rule # 2 – Protect the Milk Supply Milk must be removed regularly and thoroughly to keep production as high as possible.

Rule # 3 – Find and Fix the Problem: When both baby and the milk supply are safe, you can then investigate the problem and develop a strategy to solve it.

Even though you may feel anxious to begin figuring out what the problem is and increasing your milk supply, your first priority is to make sure your baby is well fed. Supplementary feedings may be necessary, at least for a short time.

The next BLOG 4 will help you determine the best way to give them in a way that supports breastfeeding.