A concern for all parents with a newborn and one of the questions that I am asked most frequently as a midwife and IBCLC lactation consultant- ‘how do I know that my baby is getting enough milk?’.
It is a valid question, particularly with breastfed babies as there is no way to know exactly how much milk they are consuming at the breast. As a new parent, there are so many unknowns; despite well meaning friends and family telling you to ‘trust your gut’, this can be hard when you are in the depths of birth recovery, sleep deprivation and hormonal chaos. Those first few weeks are daunting and all parents want their baby to be well nourished and growing.
So how can we understand if a baby is getting enough? I have been lucky enough to support women with this question for over a decade. In this article, I will firstly explain why some measures are not valid and then I will explain the evidenced based ways which can reassure that your baby is growing and thriving on your breast milk.
It is important to note here the considerate design of your baby’s digestive system- their stomach is the size of a marble and evidence suggests its maximum capacity at birth is just 5-7mls. This increases rapidly, and is able to expand to hold 30-60mls at a week of age. Hold this physiology in your mind as we explore the subsequent points.
How not to assess whether your baby is getting enough:
Pumping to see volumes
Lots of new mums that I have been lucky enough to care for understandably think that if they pump instead of breastfeed, this will tell you how much milk the baby would have taken from the breast. It is a very logical plan and might give some indication as to the rough amount of milk available at that time. However, it is not a true indicator. Why? Firstly, with a deep effective latch, your baby will stimulate the breast more than any pump can ever do. This means your baby will likely receive more milk during the feed compared to the amount you have pumped. In addition, more stimulation and effective drainage of milk will increase and sustain your milk supply.
Secondly, we know that milk supply fluctuates throughout the day. For example the volume you pump in the morning could be very different to the amount pumped later on in the day. This is completely normal and is due to many factors such as how much your baby has fed that day, gap between feeds, hormones etc. Milk supply can also vary across days so we cannot assume that whatever you pump would be the same everyday.
Whilst a baby receiving expressed breast milk (EBM) is amazing as they still receive many of the nutritional benefits of breast milk, it is important to note here that EBM may have a different microbiome compared to milk received directly from the breast. The latter allows for more transfer of antibodies, resulting in increased protection against infection. It should also be noted that when a mother is exposed to a potential bacteria/virus, she will secrete antibodies against these into her breastmilk, promoting immediate protection for her baby. EBM which has been previously expressed and given later on will not have such benefits.
Testing how much your baby takes with a bottle
Another way in which some families attempt to gain reassurance is by giving their baby a bottle of EBM or formula and seeing how much they take. Some parents assume for example if a baby takes 60mls from the bottle and settles, they must need this amount from the breast in order to do the same. Unfortunately, this is not evidence based and may lead to confusion. Firstly, as noted before, your baby will take different volumes of milk from the breast (or bottle), at different times of day. This is normal- babies feed for food but also for comfort. They also have no internal clock or circadian rhythm so it is illogical to think they need the same amount of milk and specific times.
Secondly, introducing a bottle is not recommended until after breastfeeding is established after 6-8 weeks (unless there is any clinical indication, please consult with your paediatrician/midwife or lactation consultant on this). Even with a slow flow teat and one which claims to replicate a nipple (which can never be the case), the way your baby sucks is different when comparing a nipple to a teat. Although the research on nipple confusion (that a baby might develop a preference for an artificial teat over a nipple) is now weaker, avoiding a teat until later can help to reduce the chance of subsequent issues occurring.
Mistaking cluster feeding for not enough milk
All new mums have been there. It’s the middle of the night, your baby has been constantly feeding, seems to settle for what seems like minutes, only to wake again the moment you put them in their bassinet. Of course, the logical deduction here is that your baby must not be getting enough. Why would they want to feed again if they are full?
Let me start by reassuring you that cluster feeding in the first 6-8 weeks is normal. Here me out here. At night, your hormone prolactin levels are higher, meaning you produce more milk at this time. Your baby instinctively knows this and evidence shows that newborns may receive up to 30% of their daily milk intake in this time. It is also nature’s way of keeping your baby safe because you are awake together.
Breast milk is quickly digested which is why you may have noticed that your baby might poo during or straight after a feed and go more than 8 times a day. So although they are feeding a lot, their stomach empties quickly too, meaning they need to go back to the breast to become full again. Again, this is nature’s clever way of bringing your baby back to the breast and keeping your milk supply up. So hang on tight with the cluster feeding- I know it is a killer and might make you question your life choices but it won’t last forever!
Evidenced based ways that show your baby is getting enough milk
Settled after feeds
Maybe your baby falls asleep at the end of a breastfeed. Or maybe they aren’t asleep but they are settled, meaning they are no longer showing us hunger cues and they are content. This is a great sign that they are satisfied by your breast milk! Maybe you are worrying because they don’t stay asleep or settle for a long period? Once again, the fast digestion of breast milk as explained above, applies here. Not only will your baby feed for food but also for comfort which is why breastfeeding is so important in helping with bonding and attachment. Sometimes they might just want 5 mins of feeding so soothe them and send them back off to sleep. That is ok too.
Expected number of wet and dirty nappies for their age
To put it simply, input=output. Lots of wet and dirty nappies is a great sign and one that should not be overlooked when it comes to assessing whether your baby is getting enough breast milk. We have already discussed how breast milk has a natural laxative in it- this is what makes their stool so loose. You will notice that as your colostrum changes to milk around day 3-5, so too does the stool change from meconium black to green to a dark yellow colour and often quite runny! This is a very reassuring sign that your baby is getting lots of milk. After day 5, breastfed babies should wee and poo at least 6 times every 24 hours. Don’t panic here if you count a lot more! Many breastfed babies might go up to 12 times in a 24 hour period- get those nappies ready!
Normal weight loss and weight gain
Whilst it is important to look at the bigger picture and all of the factors that help us to understand if your baby is drinking enough milk at the breast, parents understandably are keen to know their baby’s weight. Weighing the baby at appropriate time intervals on calibrated medical scales does help to offer reassurance and can help midwives and lactation consultants see the whole clinical picture.
All babies will lose some of their birth weight in the first few days of their life and firstly I want to reassure you that this is very normal! Your baby is adjusting to life outside the womb, they need to learn to breastfeed (which takes time) and so they burn their brown fat stores to use for energy. Although they may only receive small amounts of colostrum, it is extremely highly concentrated in proteins and energy needed to sustain your baby for those first few days.
Your baby should be reweighed following the birth on day 3-5 (often when you are discharged home from hospital). Try to not worry about their weight on day 1 or 2 of their life as often a drop can be due to your baby passing excess fluid in their urine. Ideally on day 5, your baby will have lost less than 10% of their birth weight. Close to 10% or over it? That is ok- thats why midwives and lactation consultants are here to help! We will be able to offer a holistic assessment, observe a feed, check the latch and make a plan that ensures your baby will thrive.
Evidence dictates that breastfed babies will regain their birth weight by day 10-14. Of course, once your baby surpasses their birth weight, we want them to keep growing! The most recent literature tells us that normal daily weight gain within the first 8 weeks is 25-30g a day. For a smaller baby, this figure will be a higher proportion of their body weight compared to a bigger baby. Your paediatrician, midwife and lactation consultant will be able to weigh your baby and ensure they are tracking their expected growth trajectory. When new parents are worried about their baby’s weight, understandably the first logical solution could be to have the baby weighed every day or even purchase a pair of scales at home- I say this in the kindest way possible but please try not to do this! As discussed, fixating on weight can lead to us ignoring other positive signs such as your baby’s behaviour and their nappies. It is better to see your midwife or lactation consultant once a week- your baby may gain more some days than others so weighing at longer intervals will enable us to see the general trend. Home scales are also not calibrated in the same way as hospital scales and are therefore unreliable in determining weight.
As midwives and lactation consultants, we know all too well the worries and anxieties that all new parents face- navigating breastfeeding is challenging and all new parents want the best for their baby. We are here to support you every step of the way, no matter what your journey looks like!