Breastfeeding mothers frequently are concerned 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. And this is a good thing!! We are not supposed to know how much the baby is getting but rather whether the baby getting enough. 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 can be a good indication whether the baby is getting enough, but rules about weight gain appropriate for bottle fed babies may not be appropriate for breastfed babies. In the short term, weighing babies is fraught with errors or misreading or writing down of numbers.
There are ways of knowing if baby is receiving ample amounts of milk by looking at how the baby is sucking at the breast, combined observing the baby after a feeding – is the baby content, satisfied, or is he rooting or sucking his hand or crying? The most common reason for healthy babies to exhibit the previously mentioned behaviours is that the babies are still hungry.
Ways of Knowing
Baby’s sucking at the breast is characteristic. A baby who is obtaining goodly amounts of milk at the breast sucks in a very characteristic way.. When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide > pause > close mouth type of sucking). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This same pause that is visible at the baby’s chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more milk the baby received. Once you can recognize this pause you will realize that so much of what women are told about timing the baby on the breast is meaningless. For example, it is meaningless to suggest to mothers to feed the baby twenty minutes on each side. Twenty minutes of what? Sucking without drinking? Sucking and drinking (some pausing in the movement of the chin)? All long pause-types of sucks? A baby who does this type of sucking (with the pauses) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn’t drink) for 20 hours will come off the breast hungry. Our website nbci.ca shows video clips of drinking at the breast. If the baby comes off the breast while doing this kind of drinking with long pauses, then baby is probably saying, I have had enough. If baby is continually just sucking without drinking (therefore little or no pausing) baby will still be hungry. Play detective, what is baby’s chin doing as he seems to “finish”? If the milk is flowing well the baby can either choose to drink it or take a little break (in fact the baby does not need to suck continuously and most babies do not). If the milk is not flowing well, then baby will be ‘forced’ to just suck without drinking. If this is the case, use compression to help more milk to flow (see the blog on Breast Compression).
In this video, the baby is drinking very well (long pauses, sustained)
In this video, the baby is not drinking at all (no pauses at all).
In this video, the baby is in between. He might be getting enough, but it is not definite. In the video, we have already had the mother latch him on with an asymmetric latch, we taught the mother breast compressions, and to switch sides, offering the baby both breasts at each feeding, when breast compressions no longer resulted in the baby getting milk.
Baby’s bowel movements (stools, poops). For the first few days after birth, the baby passes meconium, a dark green, almost black, substance which has collected in his intestines during pregnancy. It is passed during the first few days, and by the third day, sometimes even the second, the bowel movements start becoming lighter, as the baby drinks more milk.
Usually by the fourth 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 (full of air bubbles). The variations in colour do not mean something is wrong. A baby who is getting only breastmilk, and is starting to have bowel movements that are becoming lighter by day 3 of life, is doing well. Without becoming obsessive about it, monitoring the frequency and quantity of bowel movements is one of the best ways, next to observing the baby’s drinking. After the first three to four days, the baby should have increasing bowel movements so that by the end of the first week he should be passing at least two to three 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 a very reliable sign. Some breastfed babies, after the first three to four weeks of life, may suddenly change their stool pattern from many each day, to one every three days or even less.
We used to think that the infrequent bowel movements (without any bowel movements at all every few days or even longer) did not mean that there was a problem. But we have realized that probably, infrequent bowel movements, actually mean the mother has had a decrease in milk supply and flow of milk. We used to explain the baby’s fussiness as being due to the infrequent bowel movements, but no, they are fussy because they want more milk flow. Please note that “decreased” does not mean “not enough”, only less than the baby has been used to.
Urination (pees). If, after about 4 or 5 days of age, the baby is soaking six diapers in a 24 hour period, (the diapers should be soaking, not just damp or just wet) you can be reasonably sure that the baby is getting a lot of milk (if he is breastfeeding only). 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 almost colourless after the first few days, though occasional darker urine is not of concern. During the first two to three 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 the breastfeeding baby. 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 (see the video clip links, above).
During the first few days of life, only if the baby is well latched on can he get his mother’s milk well. Giving water by bottle or cup or finger feeding at this point does not fix the problem of the baby not getting enough. However. It only gets the baby out of hospital with urine that is not red. Fixing the latch and using compression will usually fix the problem (See information sheet Protocol to Increase Breastmilk Intake). If fixing the latch and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly (see the information sheetLactation Aid). Limiting the duration or frequency of feedings can also contribute to decreased intake of milk.
The following are NOT good ways of judging
1. Your breasts do not feel full. After the first few days or first weeks, it is usual for most mothers not to feel full. Your body adjusts to your baby’s requirements and how well the baby feeds. This change may occur rapidly. Some mothers who are breastfeeding perfectly well never feel engorged or full. In fact, feeling “full” after a feeding suggests that the baby is not latching on well and that the breasts have not drained well.
2. 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 woken for feeds or who is “too good” may not be getting enough milk. There may be exceptions, but we recommend you get good help without delay. Also, it is unusual for a 3 month old baby to sleep through the night. This should not be accepted as a “good thing”. See also this information on safe co-sleep by Dr. James McKenna.
3. The baby cries after feeding. Healthy babies usually cry after the feedings are “finished” because they are hungry. We do not believe that exclusively breastfed babies have colic, GERD (gastroesophageal reflux disease) or allergy to something in the milk.
Do not limit feeding times or feed by the clock. “Finish” the first side before offering the other. How do you know the baby is “finished”? Because the baby is not drinking at the breast. How do you know a baby is drinking at the breast? Click these links Really good drinking with English text, Twelve day old nibbling, English Text, “Borderline” drinking for video clips showing babies drinking well at the breast, or not. Watch the videos, read the texts and then watch the videos again. Use breast compressions to increase the baby’s intake of breastmilk.
4.The baby feeds often and/or for a long time. For one mother feeding every three hours or so may be too often; for another, three 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. It is time to put the watch/clock out of sight when you are breastfeeding.
It is time to accept that there are no timing rules that make sense. It is not true that the baby gets 90% of the feed in the first 10 minutes. Let the baby determine when he is ready to be fed and things usually come right, if the baby is sucking and drinking at the breast and having at least two to three substantial yellow bowel movements each day. Remember, a baby may be on the breast for two hours, but if he is actually drinking (open wide > pause > close mouth type of sucking) for only two minutes, say, he will likely come off the breast hungry. If the baby falls asleep quickly at the breast, you can use breast compressions to continue the flow of milk (see Breast Compression). 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 Lactation Aid). Get good help to use the lactation aid properly because it should not be frustrating to use. Unfortunately, too often mothers are given a tube and advised “go to it”. Do not cut off the end of the tube that goes into the baby’s mouth as a sharp end may injure the baby’s mouth.
5. “I can express only half an ounce of milk”. What you can pump or express should not influence you. Mothers are not always taught how to express milk properly including how to use a pump properly. Hand expression takes practice. It is not a good idea to pump your breasts “just to know” how much you are producing because you will not know. A baby well latched on can get more milk than you can pump. A baby poorly latched on may get less than you can pump.
Most mothers could have produced enough milk for their baby and even enough for twins. Why cannot they? A partial answer is discussed in birth practices 1 and 2.
In addition, it has been frequent for supplementation to occur in hospital even before the baby has been tried at the breast, based on the false notion that there is no milk in the first few days. The problem usually is that the baby is not getting the milk that is available, and this is usually because he is latched on poorly. And, of course, an important reason is the lack of proper training of staff in postpartum who can believe such nonsense. Milk started being produced in the breast by 16 weeks gestation and continues being produced until birth. See the photo of milk a mother expressed before the baby was born. She started expressing at about 35 weeks gestation. That is only one expression. The photo below shows what one mother expressed prenatally.
Breast Compressions can help the baby receive the milk. (see Breast Compressions). These problems could be prevented most of time if postpartum staff were properly trained in helping mothers breastfeed rather than trained to fear dehydration of the baby. Training in the first (helping mothers breastfeed) prevents the second (dehydration).
6. The baby will take a bottle after feeding. This does not necessarily mean that the baby is still hungry, and using this ‘test’ is not a good idea as milk pours into the baby from a bottle. Also, bottles may interfere with breastfeeding. Babies will often take more liquid from a bottle even if they are already full.
7. The 10 week old is suddenly pulling away from the breast but still seems hungry. This does not mean your milk has “dried up”. 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 (often by four to six weeks of age), they may no longer fall asleep but rather start to pull away or get upset. The milk supply may not have changed; the baby has changed. Get the best latch possible and use compression to help you increase flow to the baby (see the blog on breast compression).
However a 2 month old baby (for example) who starts becoming unsatisfied, or fussy at the breast and pulls at the breast is likely to be exhibiting a reaction to late onset decreasing milk supply and flow. We have found this to be a common problem. Parents and the baby’s doctor as well, as the baby often continues to gain weight well (at least for a while), so the parents are told the baby has “reflux” or “allergy to something in the mother’s milk”. If your baby shows fits the picture, get help early, because this problem continues to get worse. Typically, we see babies with this problem when the baby is about 3 months of age. Some babies are starting to refuse the breast, though they generally feed well at night, which may explain why they continue to gain weight well (at least for a while).
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.
The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.
This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!
©IBC, updated July 2009, 2021
Questions or concerns? Email Dr. Jack Newman (read the page carefully, and answer the listed questions).