Gauging Milk Intake and Weight Gain during Coronavirus Lockdown

We’ve entered a strange new phase for all of us - coronavirus lockdown.  Baby groups and breastfeeding support groups are shut down - a few might have moved online.  Health visitor and midwife visits have moved to largely telephone support as far as I know and weight checks are less frequent than they would have been.  This can be concerning if you have a newborn and aren’t confident yet in how feeding is going, or you have a baby who has had low weight gain up until now.  On top of that we know that anyone who has been supplementing might feel more anxious about the availability of formula right now because of empty shop shelves.  This means we have a lot of people who are trying to increase their milk supply to wean off formula, or at least to reduce their dependence on it.  Others are trying to relactate so that their baby gets the immunological protection of breastmilk with it’s anti-viral components, or so that they can give some of their milk to their toddler in their food.  When weaning off formula and working on low weight gain usually regular weight checks are an important part of that - so without the frequency of weight checks we have been used to, what can we do to estimate how things are going instead?

What should be happening with weight gain?

This previous blog explains how weight charts were created and what is normal weight gain for a baby.  Essentially what we expect is that after a baby is born they will lose some weight.  We want that loss to be within 10% of birthweight.  Once your milk “comes in” (around day 3-4) and the baby starts getting larger amounts of milk your baby should then start to gain weight.  Average weight gain is 30g a day.  Anything over 20g a day is considered normal.  So that’s a gain of at least 5-7oz a week for normal gain.  Under 5 oz a week is considered outside of normal range and needs some kind of intervention.

After 12 weeks weight gain slows - at that stage we expect more like 4-5oz gain a week.  After 6 months we expect 3-4oz a week.  After 9 months it’s 2-3 oz a week.  It slows again as a baby gets older.

Weight gain is most rapid in the first 3 months and that’s what we want to see.  So if you aren’t having HV /midwife visits to confirm weight, how can you gauge how things are going?

Scales

Scales are absolutely the most accurate way of gauging whether a baby is getting enough milk - which is why your midwife/HV weighs during visits.  I am aware that some mums have ordered baby scales from Amazon, but Amazon have also now prioritised essential deliveries, so they may not receive them for a while.  I don’t think you need to order specialist baby scales, but I understand why some mums who are particularly worried have gone for this option.  When you baby is not gaining as you expect it can create a lot of anxiety.  Having your own scales can be useful in some circumstances, but please also have a look in the back of your red book where you will see that it suggests that weighing a baby too often can also cause anxiety - this is why HVs usually weigh at particular times only.  If however you are one of the people who feel that this is something you need to do - please make sure you have scales which are accurate to at least 20g.

Another option if you want to use scales is to check what other scales are in your house.  If you have adult scales you can weigh yourself, then pick up baby and weigh again, and just subtract the 2 to get your baby’s weight.  If you have a scale for luggage this is also an option.  Get creative.  Just remember that the accuracy will be different depending on different scales.  If your baby is very young and you are tracking weight it can help to wait at least a couple of days between checking weight because if your scales aren’t accurate to at least 20g you won’t get a good picture of what is happening if you weigh daily.

Nappy Output

It can’t come out if it’s not going in, so looking at nappies can give you a very rough idea of how much milk your baby is getting.  A very rough idea of what we would expect would be that on day 1 of life you should have at least 1 dirty nappy (meconium).  Day 2, at least 2 dirty nappies. Day 3, at least 3 dirty nappies and changing in colour.  Day 4, at least 4 dirty yellow nappies. After this dirty nappies should become frequent.  By the end of the first week it would be normal for a baby to have a dirty nappy for each feed.  If you are getting multiple dirty nappies a day this is a very good sign of milk intake.

If you are only having 1-2 dirty nappies a day in your 2 week old, it may be normal for your  baby, but it may be a sign that your baby is not getting enough milk.  It could also be a sign of another issue going on, like allergy for example.  Read through my blog here on what is normal stooling pattern and what might be normal and abnormal variations.  Either way it’s a sign that you should seek some help so that you can talk through the feeding pattern and stooling pattern and see if any changes might be helpful.

Dirty nappies should have plenty of poo in them.  If your baby has 4 dirty nappies, but in each there is really not much more than a stain on the nappy, then this would be an indicator that feeding should be looked at carefully, to see if your baby could benefit from some changes around feeding.  

Wet nappies should also be very wet after the first few days.  Sopping wet.  Heavy.  Just having a blue indicator line but not feeling obviously heavy and wet might be an indication to have a closer look at feeding.  After your milk is well in you’d like to see 6 heavy wet nappies a day.  The pee should be nice and pale, not concentrated and very dark coloured - similar to what you would notice for yourself if considering if you had been drinking enough water.

Breast changes & Feeding Behaviour

Learn to identify when your baby is sucking and when they are swallowing.  This is a great video by Dr Jack Newman which helps you to identity swallowing.  Also learn to identify when you have a milk ejection / “a letdown”.  This will become more obvious once your milk comes in.  Many people feel when they have a milk ejection.  They will describe it as different things, but the most common ways I’ve heard it described are as a tingle in the breast / tingle in the opposite nipple, pins & needles feeling in the breast, feeling of heat or relaxation.  Immediately afterwards you notice the sucking pattern change from the quick sucks, to long slow sucks and swallows.  Not everyone feels a letdown, but you should notice the feeding pattern change.  It will only last a couple of mins and then go back to the faster sucking pattern for a while.

In your baby who is a few days old you may notice one letdown and then the baby falls asleep.  This is very normal.  By the time your baby is a week old you should probably be noticing it happening at least twice in every feed.  By 2 weeks old a baby will probably be taking closer to 3 letdowns at each feed.  These are very rough ideas but if you are noticing that your 2 week old baby is getting several periods of good active swallowing in a feed it is a good sign.  If you are not noticing this then it might be an indicator to ask for some support.  

Paying attention to your breasts can tell you a lot.  If your breasts feel full before a feed and much emptier and softer after a feed, this is a good sign - but should be taken in combination with looking at nappy output and feeding behaviour.

Your baby’s feeding frequency and behaviour between feeds can also help tell you whether they are getting enough milk.  Feeding frequency can vary from baby to baby and from day to day.  Feeding every 90 mins can be common.  So can feeding every 2.5 hours, so it varies - but what we want to see is that a baby cues clearly that they are hungry, goes to the breast, swallows actively (see above about letdowns), comes off full and content and will be content for a period before cueing again.
What we don’t want to see is a baby who goes to the breast and immediately falls asleep.  We don’t want to see a baby who spends a long time at the breast but doesn’t seem to ever be satisfied.  They may feed for an hour, fall asleep and 10 mins after you unlatch them they cue to feed again.  This is a pattern that needs looking at more closely.  

Baby Behaviour Between Feeds 

As I said above we want a baby to be pretty content between feeds.  Now that doesn’t necessarily mean that baby is fine being put down in a cot / Moses basket between feeds.  Young babies generally want to be held in someone’s arms- this is normal.  What we want to see is that a baby settles well in someone’s arms between feeds, then wakes and cues for a feed.  We want that wakening and cueing to happen at least 3 hourly (i.e. no longer than 3 hours from the START of the previous feed).  A baby who is constantly crying and looking to get back to the breast even when in your arms might need feeding looked at more closely to see if there is an issue.  Likewise a baby who is very sleepy needs feeding looked at.  If your baby is hard to rouse and hard to get latched on at the 3 hour mark, or regularly sleeps longer than 3 hours after the START of the previous feed, then it might be a good idea just to talk it through with someone.

Baby Appearance & Signs of dehydration

Babies lose a bit of weight after birth, but once milk is in, they should feed well and should start to look a little more chubby.  It’s normal for babies to have chubby little wrists and ankles and can have little double chins.  Their fontanelle (the soft spot on the top of their head) should look reasonably in line with the rest of their head.  If you are noticing that your baby’s fontanelle is sunken, that can be a sign of not drinking enough.  Their skin should look nice and plump.  Their eyes and mouth should look moist.  Dry eyes or mouth can be a sign of dehydration, and that a baby needs more milk.  If you are seeing these signs, reach out for help.

Look at the whole picture

The best way to use these indicators are as part of a whole.  Look at them together.  A baby who wakes every 2 hours, feeds actively, you notice letdowns, and you are getting 6 full wet and dirty nappies a day is probably doing well and you can relax about not getting frequent weight checks.  Keep doing what you’re doing and relax into it.

A baby who is constantly unsettled, has a couple of smeared dirty nappies and although nappies are wet they aren’t heavy, and is pretty sleepy at the breast is not the same reassuring pattern and feeding should be looked at more carefully.  A baby showing signs of dehydration definitely should have feeding discussed more carefully.  A very "content" baby who is pretty sleepy, hard to rouse and isn't having the expected dirty nappies should also be an indicator to talk through feeding with someone.

So where do you get support at this strange time?  Well actually the same support structures are all still in place - they are probably just working a bit differently.  If you feel you need to see your GP, contact your GP.  Although GP surgeries are often locked down right now, they are still seeing essential patients right now, so if your baby is unwell your GP should see you.  If you just want to discuss feeding and talk through whether there might be an issue with weight gain and what you can do to improve it you still have the NHS / Private / Volunteer options.  Although HVs are likely not doing the same visits they are often available by phone.  Volunteer groups still have their helplines running (like the LLL helpline in NI) and the online support groups are still available (I recommend Breastfeeding in Northern Ireland on Facebook for local mums).  If you are reading from abroad, look for your local groups too.  Private IBCLCs are still running their services, although most have moved to online options so they have their consultations via Skype / Zoom etc, and many will be happy to chat to you on the phone as well.  Many, like myself, will try to resolve your issue during a quick phone call if they can, and only if it is something that is going to take a bit more time or assessment will they suggest a consult.

These are strange times.  Hopefully this blog gives you some extra tools at your disposal.  Breastfeeding is a medicine for your baby at this time and you are doing an amazing thing by breastfeeding your baby.

Although we’re all sitting in our separate houses unable to physically touch, we’re reaching out to each other through cyberspace.  We’re all in this together.  Stay safe everyone and reach out if you need help.