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How to determine if the baby is getting enough ?

The first question every mother has in her mind is — “Is my baby getting enough?”, followed by the next question — “Am I making enough for my baby?”

To be clear, first, let’s understand that these two questions can have different answers. If the baby is not getting enough, it does not imply that the mother is not making enough. There could be problems in the latch and/or milk transfer that may limit the baby’s intake. There can be other, more physical problems like a tongue-tie or a lip tie that inhibits baby’s ability to latch and therefore get enough. There can be other conditions like reflux, CMPA (cow milk protein allergy), lactose intolerance etc. that may prevent the baby from reflecting his/her intake into sufficient weight gain. Sometimes certain illnesses like jaundice can result in low weight gain. So, a mother could be making more than enough milk and baby may still not be getting enough. Therefore, if the baby is not getting enough, don’t be quick to doubt your supply. Always check other factors as well.

Coming to – “is my baby getting enough?’; how is it determined? It is reflected through three things.

  • Urine output
  • Stool output
  • Weight gain

Also, the value/frequency/quality of these three things change according to the baby’s age.

Let’s discuss these three parameters individually.

1.Urine Output

Babies pass urine infrequently in the initial days. On the first day, once; second day, twice; third day, thrice and so on. By 5th day, babies usually start passing urine a minimum of 6 times in 24 hours. Urine output is what we popularly refer to as ‘pee count’. It’s counted over a period of any consecutive 24 hours. 6 is the minimum pee count a baby should have starting from day 5 till the age of 6 months in order to reflect that the baby is getting enough breast milk. There’s no upper limit for pee count. Some babies may pee more than 20 times and that’s perfectly ok too. The urine should be clear to pale yellow in colour and should not be foul smelling. If you’re using disposable diapers, you can weigh the diaper in order to guess the number of times the baby must’ve passed urine. On an average, the quantity of urine passed in one single urination is around 45 ml i.e. 3 tablespoons.

Some babies cry before passing urine. Some seem to be straining and that’s normal.

2. Stool Output
First stool should be passed within 24 hours after birth. On the first couple of days, the stool is black. This is called meconium. It’s the black substance collected in baby’s intestines during pregnancy. More efficient the breastfeeding, faster the meconium transforms into green and then mustard yellow stools. The frequency of stool, like that of urine, increases everyday. Once on day 1, twice on day 2 and so on. By day 5, the mature milk has come in, and the stools must become mustard yellow in colour. The consistency is often pasty to watery. Texture is seedy or curdy. Baby must now pass stools at least 3-4 times in 24 hours. And the size should be of a circle formed by joining our thumb and index finger. Some babies may pass stools up to 10-15 times in the first few weeks. It is normal and should not be mistaken as diarrhea. Diarrhea in exclusively breastfed babies is rare. After the age of 6 weeks, poop count comes down in many babies. Some babies may then poop only once in 7 days, which is normal. An exclusively breastfed baby can go up to 10 days without pooping as well, after the age of 6 weeks. And some babies may poop 7 times a day. Anything in this range is ok and normal. Crying while passing gas or stool is also a normal behavior amongst newborns.

3. Weight
Initial weight loss
All babies lose some weight after birth. By day 4, babies lose up to 5% to 7% of their birth weight. This is common and normal. Losing more than 10% of birth weight is routinely considered worthy of calling for medical attention. However, some babies are born with inflated weights as a result of IV fluids given to the mother during labour. Such babies may lose more weight but are still fine because they are only shedding the extra birth weight caused by IV fluids. There are differences of opinion about this amongst medical professionals though. In India, majority of doctors say that baby needs medical attention if baby loses more than 10% of his/her birth weight. A weight loss of 15% or more is considered risky.

Weight gain
Baby must stop losing weight by day 5 and start gaining. A full term healthy newborn usually gains 500 to 700 grams in a month. (18-24 grams per day) Some babies gain even more, and it’s perfectly ok too. As a thumb rule, if a baby gains minimum half kg i.e. 500 grams in a month, it can be said that baby is getting enough breast milk. It is important to note that, babies follow their unique pace in gaining weight. Some babies are fast gainers in the beginning. They may gain upto 1 kg per month in the initial 3 months and then slow down. There is no need to worry just because now the child is gaining around 700 grams as compared to 1000 grams. Baby is still gaining more than 500 grams and is only following his/her growth-curve.

Some babies may steadily gain 500-600 grams per month throughout the first 6 months. And some may start slow and then pace up later. As long as baby is getting enough as per the table given above, there is no reason to worry. Another thing to keep in mind while checking weight is to use the same scale throughout. For newborns, a difference of a few grams may also be a lot. Therefore, it’s important to maintain baby’s weight history recorded in the same weighing scale. Also, certain things need to be kept constant. E.g. if the baby is weighed without clothes, then baby needs to be weighed without clothes every time to record accurate weight gain. (Important to follow this in the initial days until baby has crossed birth weight)

Usually, babies double their weight by the age of 5 to 6 months. They triple it by the time they are one year old.

The following table is a handy tool to spot your baby’s age and accordingly find if the baby is meeting all the parameters that determine whether or not the baby is getting enough. This information given below applies to healthy, full-term born, exclusively breastfed babies.

It is important to understand that along with these parameters, the baby’s activity levels while the baby is awake and other milestones are to be monitored. Usually, a baby that is active, pees 6 or more times in 24 hours, passes sufficient stools, is gaining weight and is achieving milestones on time is doing well. Certain myths regarding whether or not baby is getting enough : 1.Baby is burping; so, baby is full. Or if the baby doesn’t burp, baby is not full. This is not true. Burping is letting out of the air baby swallows while nursing. While breastfeeding, a good latch creates a vacuum and hardly any air goes inside baby’s mouth. Therefore, a lot of breastfed babies don’t or hardly burp. Burping is not an indicator of baby’s intake. 2. Baby is sleeping through the night, so baby is drinking enough. This is not true. In fact, if a newborn is sleeping through the night, most likely he/she is not getting enough. Newborns and young babies are expected to nurse often. They are designed to wake up several to many times in the night to nurse. 3. Baby is demanding to nurse very often so, he/she may not be getting enough. This is not true. Babies are expected to be nursing at least 10-12 times in 24 hours or more. A lot of babies cluster feed in the evening and night hours. (Cluster feeding is nursing continuously for long hours or nursing very often at very very short intervals) This is normal newborn behavior. It does not indicate that baby is not getting enough and is remaining hungry. In fact, frequent nursing is good for the mother’s supply. 4. Baby is crying after feeding so, baby is not getting enough. This is not always true. Babies cry for a lot if reasons apart from hunger. Crying is their only means of communication. It should not be translated into only one thing viz hunger. Baby could be feeling cold/hot, could be in discomfort due to gas/colic, could be wanting warmth or security by skin to skin contact, could be wanting to sleep etc. If a baby cries immediately after nursing, it can be because the baby wants to continue to nurse not only to quench hunger or thirst but to be close to the mother. Perhaps baby wants to sleep while nursing. Probably baby wants to burp. Sometimes, baby can be hungry too, so, it’s always great to offer to nurse. But, it is important to remember – crying does not always indicate hunger. 5. Baby is sucking on his/her fist/fingers so, baby is hungry. This is true for babies under the age of 3 months. However, babies achieve a milestone of hand to mouth movement around the age of three months. That is when they learn to explore the world through their mouth by bringing whatever they can to their mouth. Starting with their own body parts like fist and finger, sometimes feet, to toys (if given in their hands). Once baby achieves this milestone, hand to mouth ceases to become an indicator of hunger. Sources : Child care : 2nd edition, BPNI-Maharashtra state branch