What Goes in Must Come Out

Linda J. Smith, BSE, FACCE, IBCLC

When faced with a young (under 6 weeks) breastfeeding baby who is not stooling, rule out "not getting enough milk" first. It's the most straightforward answer. Confirm milk intake with several methods, including pre-and post-feed weights, naked weights several days in a row, etc. Don't rely on subjective measures - weigh the baby. Stooling is a more reliable indicator of caloric intake than urination, because it's possible to have a well-hydrated but starving baby. If you have only one question to ask, ask about stools. The second question should be about urination patterns.

The most common reasons for "not getting enough," in order, are:

1. not enough time at breast - 140 minutes over 24 hours is a minimum. 2. poor positioning so baby can't get the milk that's there. 3. sub-optimum sucking pattern due to birth insults or labor medications.

First, get baby and mother together constantly. Then help her hold her baby with a deep attachment at breast. Carefully evaluate whether the baby is swallowing effectively and consistently for at least 5-10 minutes per feed with self-detachment before about 30 minutes per side. If you're not sure, get another LC to help evaluate the situation. Low supply is usually a result of poor milk transfer.

Once you're absolutely certain that the baby IS taking in enough milk, then ask "Where is it going if there's nothing coming out?" Occasionally a bowel obstruction or other anatomic problem is missed during early examinations, and the first sign is lack of stooling. Get the baby to a primary health provider immediately.

After about 6 weeks, an obviously thriving breastfed baby will sometimes retain and accumulate breastmilk stools for a week or more. This is fine, as long as when it comes out it's normal in consistency and there's a lot of it. The keys here are "older," and "obviously thriving" with earlier weight checks verifying weight gain, and "lots of it" when the baby does let loose.

What comes out must have gone in. Be sure something went in before you try to find out why it didn't come out.