Is my breastfed baby getting enough? (and things you can do if not)
Now, perhaps with the increasing popularity of Internet support, things seem to have veered in entirely the opposite direction - and I read a worrying amount of forum posts where babies are clearly not taking enough milk and gaining well below expected levels of weight, but are told by other mums to "ignore the midwife or health visitor'" and follow their instincts. "As long as he's weeing and pooing, he's fine" one mum stated recently, with no mention of the amount of poo or wee we expect to see in a baby consuming enough. These posts are often backed up with anecdotal evidence from other mums of low gaining babies - how their baby didn't gain well, took six weeks to regain birth weight and was fine! they are all different! Some mums wrongly feel if a newborn isn't getting enough they would be "unsettled" - some newborns will be, others wont. Some also feel that baby wouldn't have long awake periods if not taking enough - again, this is not reliable as some infants need to be really struggling before this happens. Some believe breastfed babies don't poo regularly - in fact they should stool at least several times per day before 5-6 weeks, after which it is quite common for them to become more infrequent.
Output and weight together, are by far the most reliable indication of whether a newborn is receiving enough.
I have no doubt mothers sharing the advice mentioned genuinely believe it to be true - they have perhaps read something pertaining to the first scenario and applied it to a younger infant. But in reality reassurance is short lived if things continue to go downhill day after day and pressure mounts from those caring for mum. Even if things pick up a little and don't appear quite as dire, if intake isn't up where it should be, it can really hit again at around 4 months - because not enough prolactin receptors were developed in the early weeks ready for when prolactin levels drop.
Unfortunately poor breastfeeding support from health professionals also plays a massive part - the midwife or health visitor sees a baby ticking a "red flag" box or two and because many are simply not equipped to help, threaten formula will be required if weight doesn't improve soon. The mother then posts upset online, confused and unsure of what to do and those that reply are trying to support her, and trying to protect breastfeeding.
What should happen is that if a midwife or health visitor is supporting a mum whose baby isn't gaining weight or giving output as expected, a full feeding evaluation should be done - observing a feed, asking lots of questions and supporting mum with techniques she can use to ensure her baby is receiving enough ie nipping any potential issues in the bud early. Feedback from mums online suggests this doesn't happen far more often than it does. There is absolutely no reason why any infant should need readmitting to hospital with dehydration - this only happens when vital signs have either not been recognised, or have been ignored.
There will always be babies who lose slightly more weight than normal, but are stooling and urinating as expected, and appear alert and hydrated - for example many midwives suggest those born at the later end of typical ie 42 weeks plus often lose more weight than others, or if mother and baby are retaining water/fluids for any reason (some state this is more common following an epidural). Then there will be those who gain weight fantastically but poo slightly less often and when they do a larger amount - if urine and all other signs are fine this may be the norm for a small group of infants. When both weight and output is suffering, further checks should take place - if urine suffers parents should seek medical assistance straight away.
So what should happen weight wise?
It is normal for infants to lose weight in the first 3/4 days postpartum: once milk "comes in" this should start to turn around, and so any baby who continues loosing is a red flag for further checks to ensure feeding is going well. For this reason many recommend a weight check on day 3, followed by weekly until six weeks and then monthly until six months. Once breastfeeding is shown to be established and baby gaining well, more frequent weighing can result in unnecessary concern.
Losing more than 10% of birth weight : there seems to be some confusion over this guideline with some believing loss or slow gain going on beyond day 5 is ok providing it is less than 10%. This is not the case! a loss of more than 10% indicates baby and breastfeeding should be evaluated immediately as one study published in the European Journal of Paediatrics, found 60% of these infants had some degree of hypernatraemic dehydration which can be extremely serious - this does not mean as discussed that a smaller but sustained loss is therefore ok.
By 10 days - 2 weeks baby should be back at birth weight : if not this is another sign feeding should be evaluated. There are exceptions to this guideline, perhaps mum has had a lot of problems in the first week and so the loss period was greater or longer than standard - which may mean even if these issues have now been resolved with support and baby is gaining well, they may run behind with catching up. Similarly if baby has been ill or is prem, gain can be slower to take off; but on the whole the vast majority of infants where mum isn't experiencing problems should be back at birth weight, or well on the way by around 2 weeks. Weight gain should always be measured from the lowest point.
The normal rate of gain for a newborn is around 5-8 oz per week: much less than this and again, breastfeeding should be evaluated. At this age of course there is still a range of "normal", but it is a smaller range than for an older infant. In the early weeks gain should be 5-8oz or more per week - with many health professionals and breastfeeding supporters more comfortable when this is 6-7oz upwards. Whilst it may be normal for some infants to gain nearer 4oz (perhaps some Asian mothers with a very petite frame) the vast majority will gain within the range above in the earlier weeks.
There also seems to be a misconception that babies are either "thriving", or (to use a bit of an out of date term) "failing to thrive". In reality there are a whole host of shades of grey in between, and babies can limp along with minimal to moderate gain, without it ever becoming so serious they could be described as "failing to thrive". Similarly some can output as expected, develop as expected and still have much smaller than average growth which is why the term has been changed to "faltering growth" from "failure to thrive". The current charts are such that all babies should sit somewhere on here and follow that appropriate curve (note they will NOT all sit in the same place, nor should they! it is an average) sometimes a few tweaks can make a big difference to weight gain, and ensure baby fulfills their genetic potential.
Common causes of weight gain problems.
Not feeding frequently enough: A young baby needs to feed 10-12 times per 24 hours. This (obviously) equates to every two hours day and night at the latter end of the scale. A slightly longer sleep means even more frequent feeding when awake. In the first couple of days, some feed frequently whilst others are tired and less interested. If birth was unmedicated, baby is more likely to rouse when hungry - if baby was exposed to opiates such as pethidine, they are more likely to be unusually tired and perhaps need encouragement to feed. There is a fine line between ensuring baby has enough, and pushing the breast so much it potentially leads to breast refusal. Aiming for every couple of hours (more often if your baby's cues indicate), with a maximum gap of around four hours, and watching your baby and his output (ie whether nappies are transitioning as they should) can help.
Missing hunger cues: crying is a late sign of hunger, often by this point very young infants may then become too uncoordinated to milk the breast as well as they could. Early cues include smacking or licking lips, the "goldfish impression" (opening and closing mouth) and finger/hand sucking. If not offered the breast, this progresses to "rooting" (turning head looking for breast) fussing and squirming. Finally baby will begin frantic head turning, fast breathing and squeaking/crying.
Offering one breast: because there has been confusion over fore and hind milk, some mothers are advised to stick to one breast per feed, and feeding roughly every two hourly as described above. However, whilst we know women can produce the same mean amount of breastmilk per 24 hours, what is available at each sitting can vary enormously from women to women; some babies will thrive taking one breast every two hours, others won't - if only taking one breast they may need to feed hourly. I always suggest mums consider offering the second breast, because then baby can choose to not have any, have some or have all! Of course breastfeeding is also about convenience so if you just want to "push baby on" until you get somewhere, offer one and if happy offer the other when you get there!
Oral difference such as high palate or tongue tie: both can make it more difficult for baby to feed effectively, with an outcome the same as the point above - positioning and latch. Baby can simply tire before becoming truly satiated, resulting in smaller gain or static weight.
Scheduled feeding and clock watching: Limiting feeds to a clock or swapping baby after x minutes can cause some to receive insufficient fatty milk to gain weight well.
Pacifiers: some babies who are hungry will spit the dummy and object, others will happily suck the pacifier. Even if you want to introduce one, waiting until breastfeeding and weight gain are established is important. This not only ensures baby doesn't suck a replica when hungry, but also that mum's breasts receive enough stimulation to produce an adequate supply.
Tips to improve weight gain.
Ensure baby is latched & positioned well: Visit a breastfeeding group, breastfeeding counsellor or lactation consultant if you are unsure; this ensures all sucking efforts produce maximum milk.
Ensure milk is transferring well: whilst there is a lot of focus on latch, many mums are never shown how to tell if baby is actually drinking lots of milk! I think the best way to demonstrate this is using a couple of clips by Dr Jack Newman.
The first clip below shows "nibbling" or ineffective feeding: Baby is doing almost no drinking. A baby who breastfeeds only with this type of sucking could stay on the breast for hours and still not get enough milk. Something needs to be done here and if achieving a better latch, using compression doesn’t help, the baby almost certainly needs to be supplemented (Newman).
Now compare this to the clip below, where baby is doing some really good drinking: The pauses are very long (this is the mouth filling); this baby could spend a very short period of time on the breast and still be getting plenty of milk (Newman)
It's also worth noting the difference in positioning in these clips. In the first baby is meeting the breast almost vertically - with nose, mouth and chin meeting the breast at the same time. As you can see the baby's nose is pressed against the breast, potentially making it difficult for him to feed well and breathe easily In the second clip baby's head is flexed and the chin meets the breast first, the nose is then well clear from the breast tissue - allowing him to milk the breast easily.
Skin to skin: this not only increases the levels of hormones involved with milk production, but also allows baby to find the breast the moment they are hungry! babies held skin to skin feed more frequently and gain weight better than those who are not.
Breast compression: when baby is sucking, but not actively feeding, compressing the breast can increase the amount of fat available to baby. Even with a less than brilliant latch, with breast compression and unrestricted access to the breast - baby can often do much better until things are resolved.
Switch nursing: when baby works for letdown on one side, the other side also lets down - meaning there is an instant reward for baby as soon as they swap. As mums have multiple letdowns per feed, switching baby to the other side as soon as baby stops effectively feeding, snoozes, or come off the breast, can help to increases intake. For babies that are sleepy at the breast, a combination of breast compression and switch nursing can dramatically increase intake.
Frequent offering: Not all newborns will always give hunger cues when hungry, therefore being proactive in offering either one breast hourly or both every couple of hours- can ensure not only that baby takes enough, but that mums breasts receive adequate stimulation to maximise supply. To boost supply offering both breasts hourly along with other techniques mentioned can also be very effective.
If baby needs milk NOW
The first rule when supporting a mum is to "feed the baby". If there are concerns over whether baby is adequately hydrated or loosing weight and is clearly very hungry even after a feed, ensuring baby gets milk is the first priority. If at all possible mums own milk should be used, so as to protect the infants gut - however, if baby is displaying as described and mum is struggling to express enough, or with support an effective feed can't be achieved - risks of formula are outweighed by the need for nourishment; not providing food is a far bigger risk.
If a breastmilk substitute is required, liquid formula is sterile (unlike powder) and so reduces risk of infection for the very young. Expressing alongside this is also important to ensure supply doesn't dip further and instead is boosted, so mum can progress to replacing the substitute supplement with breastmilk. Once baby is gaining and any problems are resolved, mum can then feel confident her body is already producing the right amount of milk to meet baby's needs, making the transition back to exclusive breastfeeding easier. Both breastfeeding and expressing boost supply.
In some cases where baby is gaining less than desired but isn't critical, supplementation may still be suggested - depending upon how long the problem has been ongoing and whether mums supply has suffered from baby not taking enough milk (this is the cue mum's body uses to know how much to produce) the individual situation the best course of action varies. For some it may be that whatever was causing the issue is easily resolved and so very frequent feeding for a few days to give supply a boost and transfer lots of milk is enough. For other mums expressing and giving a supplement may be needed - perhaps doing so every couple of hours during the day to provide a supplement before bed. If using a breastmilk substitute it is just as important not to over supplement! Giving a top up too big will result in baby feeding less frequently, again reducing supply further - your health professional should be able to help, if not contact a breastfeeding counsellor, group or lactation consultant.
Other things to consider:
Scales: Time, clothing, scales and floor surface can all make a big difference. If a clinical weight is required due to concern over growth digital scales that are regularly calibrated are essential. Always weigh the baby on the same scales.
If supply is low, consider a galactagogue to increase milk supply ie: fenugreek, fennel or domperidone
Diet: is mum eating and drinking enough? Some studies have linked consuming less than around 1700 calories per day with reduced supply. This seems to be particularly the case if calorie intake dips significantly from the norm. You can read more here.
Does baby sick up a lot? Could he have reflux?
If baby isn't interested in extra feeding, try something different – maybe feed lying down or in the bath.
Is baby feeding enough at night? Night feeds are very important for maintaining and increasing supply.
If a breast pump is required to boost supply, a hospital grade double breast pump is more effective than an ordinary hand pump. You can hire pumps from:
Sometimes your health visitor or midwife may be able to arrange for you to borrow one from your local hospital, or alternatively contact your local La Leche League, NCT or Association of Breastfeeding Mothers counsellor to enquire about pump hire.
Did the baby have a very difficult birth? perhaps long or resulting in intervention or csection. Some mums are also surprised to hear a very fast birth can also impact with both potentially resulting in a disorganised suck. If so exploring cranial osteopathy can often have amazing results.
Has tongue tie been ruled out?
Breastfeeding is about protecting your baby from allergies, illness, obesity, diabetes, childhood cancers, SIDS and normal oral and dental formation. It also protects mums from various cancers and osteoporosis. Formula feeding is about putting on weight and that’s it.