The Importance of Newborn Stool Counts
From LEAVEN, Vol. 33 No. 6, December 1997-January 1998, pp. 123-6
We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.
"Hello. I got your number from (hospital, hot-line, friend, etc.) and I have some questions about breastfeeding......"
And so starts another tentative call for help and reassurance from a breastfeeding mother. Her concerns may involve a complex situation or simply be a request for meeting information. Whatever the purpose of a mother's call there is one area of basic information I routinely share. Regardless of why a mother calls or what questions she asks, if her baby is younger than six to eight weeks, I take an extra minute to discuss the importance of frequent stooling for breastfed babies in this age group. Here is why.
The frequency and consistency of the breastfed baby's stool has long been a misunderstood aspect of breastfeeding. By mid-20th century when infants were often raised on simple recipes of cow's milk and early solids, formed, infrequent stools became common. In contrast, the frequency and loose consistency of the breast milk stool was at times mistaken for diarrhea and treated as such, even by such measures as weaning. Older breastfed babies with normal patterns of delayed stooling were also unnecessarily treated in various ways for constipation.
For decades, La Leche League and other breastfeeding advocates have disseminated information on healthy breastfed babies' stool patterns to alleviate worries and spare babies from unneeded interventions. Unfortunately, this work is far from complete. Some new mothers are still not expecting loose, frequent stools. Some breastfed babies are still mistakenly treated for constipation. A more disturbing consequence of misunderstanding breastfed babies' stooling continues to occur: undetected impending failure-to-thrive.
In the past, publications focused on educating mothers to expect frequent, loose bowel movements from the breastfed baby as well as the common possibility that baby may skip several days between bowel movements. Since both frequent and infrequent stooling can fall within the range of normal, the criteria for adequate intake focused solely on urination. In the 1980s this standard was modified for breastfed babies within a specific age group. The normal stooling pattern of an exclusively breastfed newborn under the age of six to eight weeks has more recently been recognized to be multiple daily bowel movements.
Why can't urination alone be used to assess newborn breastfeeding? It has long been known that the composition and quantity of human milk changes both during the weeks following birth and during a single feeding. The first milk, colostrum, provides the baby with many invaluable health benefits and is also a natural laxative ensuring the early evacuation of meconium. Though a mother's milk supply will greatly increase or "come in" within a few days of birth, the transition from colostrum to mature milk takes several weeks to complete. Transitional and mature milk are also responsible for increased stooling. As stated in Lactation Consultant Series Unit 8, page 7, "Newborns commonly stool at least five times a day after day three as the additional fat of transitional and mature milk causes the formation of bulk."
Two Kinds of Milk
The terms "foremilk" and "hindmilk" are used to refer to the differences in human milk during a single feeding. Foremilk, the first milk taken at a feeding, is the more plentiful, yet it has a relatively lower percentage of fats and calories. As suckling continues at the first breast the percentage of fats in the milk increases until baby receives the higher calorie hindmilk. A combined intake of both foremilk and hindmilk is the optimum result.
In answer to the question, "Is baby getting enough?" a second question could be posed, "Enough of which?" In the early weeks wet diaper counts give only part of the answer. Because the nursing newborn takes in plenty of foremilk before receiving the richer hindmilk, it would be difficult for an infant to produce several bowel movements per day without being adequately hydrated.
However, the opposite can easily occur. Since feeding practices, ineffective sucking or other problems may diminish the mother's milk supply or prevent the baby from receiving an adequate portion of hindmilk, it is possible for a baby to be adequately hydrated yet have an inadequate calorie intake. Frequent urination remains one valid indicator of adequate newborn hydration from foremilk intake. Multiple daily stooling is an indicator of adequate newborn calorie intake from hindmilk. Both factors are needed to fully assess neonatal breastfeeding.
Since a lack of daily stooling may be associated with inadequate newborn calorie intake, it is also a predictor of poor infant weight gain. Early detection of this symptom can be crucial for the baby's health and the continuation of breastfeeding. In severe cases, an infant's low calorie intake may lead to weaker sucking, diminished milk supply and critical dehydration. While less serious conditions may be improved at various stages of breastfeeding, it is much more effective to establish a generous milk supply and hearty weight gain in the early weeks than to have to work to achieve them in later months.
There are many benefits to discussing normal stool patterns with each new mother. When a fully breastfed newborn baby is having several yellow or tan, seedy stools each day, Leaders can emphasize this is a reassuring sign that breastfeeding is off to a good start. What a wonderfully observable proof allaying a new mother's fear of inadequate milk supply!
While new parents often have difficulty deciding if a baby's diaper/nappy is truly wet, there's little doubt when one is soiled. For the mother who is worried—even without saying so—that frequent stooling is diarrhea, hearing the expected frequency and significance of the normal newborn pattern is again a great relief and confidence builder. Beginning a call with this positive interaction sets a supportive tone as the conversation moves on to other topics of interest to the mother.
On occasion a mother calling with a deceptively simple or unrelated question will describe notably infrequent newborn stooling when asked. Sometimes it has been overlooked or, using the criteria for older babies, labeled normal. Sometimes, under the advice of family, friends or health workers, this has already been treated as constipation. During the 1990s mothers have related such treatments as: changes made in the mother's diet; various supplements for baby including glucose or corn syrup water, fruit juices, or pureed fruits; various types of anal stimulation, anal dilation and enemas of vegetable oil. In cases of infrequent newborn stooling, babies are often known to have or are later found to have poor weight gain.
When a mother describes infrequent newborn stooling the Leader will want to carefully discuss adequate urination. Well hydrated infants are expected to have pale yellow, clear urine significantly wetting 6-8 cloth or 5-6 disposable diapers/nappies every 24 hours starting the third day after birth. A new mother can learn how a minimally wet diaper would feel by pouring one to two ounces (30 - 60 ml) of water onto a dry diaper. Even though disposable diapers may not feel wet, they will feel recognizably heavier.
If an infant's urine output also seems low, immediate referral to medical care is warranted. Even if urination seems consistent with the above guidelines, the absence of daily newborn stooling remains a cause for concern. According to Ruth A. Lawrence, MD in her book Breastfeeding: A Guide for the Medical Profession, Fourth Edition, page 273.
When...[daily newborn stooling]...does not happen, the physician needs to confirm that all is really well. This means a check of urine output...and urine specific gravity as well as a review of breastfeeding patterns. The purpose is to identify the potential failure-to-thrive situation before it becomes serious.
Dr. Lawrence continues to explain that minor adjustments to breastfeeding may be needed to increase the amount of high-fat hindmilk the baby receives.
Leaders may need to be especially sensitive during a discussion about the importance of newborn stooling. A mother calling for breastfeeding support will be concerned to hear nursing may not be going as well as it could. Using Human Relations Enrichment (HRE) skills and suggestions from the BREASTFEEDING ANSWER BOOK sections on "Asking Questions" and "Giving Information" (pages 3-7) helps keep the conversation positive. It can be reassuring to explain that simple adjustments in the mother's or baby's nursing style may quickly improve the situation. Many newborns with infrequent stooling will begin to produce several stools per day within 24-48 hours of improved breastfeeding techniques. Most mothers will be eager to discuss this further.
Leaders can begin by briefly explaining basic breastfeeding management including the typical number of feedings newborns require each day (10-12), the way foremilk changes to hindmilk during a feeding and the importance of allowing/encouraging baby to sustain active nursing long enough on the first breast to take in plenty of total milk and therefore more hindmilk. Often the mother herself will be quick to realize and mention several ways this process has not occurred for her baby. See sidebar of "Possible Hindrances" [below] to further assist the mother in this process.
Once a mother understands her own situation, she will usually request (or the Leader can offer) strategies to increase baby's intake of hindmilk to achieve multiple daily stooling and optimal weight gain for her newborn. Concise resources for these discussions are LLLI's tear-off sheets Is Baby Getting Enough? (No.457) and Establishing Your Milk Supply (No.469).
If the baby's weight gain is not yet known, Leaders can suggest that the baby's weight be checked with a health care provider. In many communities such weight checks are provided free of charge by the doctor's office or the public health department. Some mothers request a weight check immediately; others may choose to wait for an upcoming, previously scheduled appointment. In either case, the mother is prepared for the possibility of poor weight gain. At the health visit the mother can explain that breastfeeding difficulties may have affected the baby's weight, however, she has contacted La Leche League for assistance and has implemented changes. If the weight gain is then shown to be low, the mother is in an especially strong position to request a probationary period of weight checks while she continues working to improve breastfeeding.
If baby's weight gain is so poor that temporary supplementation is recommended, the mother's own expressed milk is considered the first choice of supplement, especially the rich, high-calorie hindmilk which she can express after feedings. The BREASTFEEDING ANSWER BOOK, page 134, states:
The mother and her baby's doctor will need to discuss how much supplement to give. It may be helpful for the mother to know that babies need about 2 to 2 1/2 fluid ounces of nourishment per pound of body weight (60-75 ml per 454 grams) every 24 hours to maintain a normal weight. An additional 1 to 2 ounces (30-60 ml) per pound (454 grams) of body weight per day may be needed to compensate for a previous lack of weight gain.
The mother can use alternate feeding methods to avoid the risk of compounding a possible sucking problem with artificial nipples. A nursing supplementer used at the breast may encourage effective sucking and stimulate the mother's milk supply. Other choices include a medicine dropper, syringe, spoon or small cup. The mother may want to take special care to first give the baby the creamy milk off the top of expressed milk if it has been sitting long enough to separate.
If a mother has complications surrounding her efforts to breastfeed, the Leader may want to refer her for additional help (medical, lactation or social) while offering continued support for breastfeeding. Some mothers faced with the possibility of breastfeeding difficulties or changes prefer to discuss supplementation or weaning. While referring her to medical help for artificial feeding, the Leader can convey respect for the mother's choices and encouragement for her mothering efforts.
While multiple daily bowel movements are expected for thriving breastfed newborns, there are exceptions to be noted. Rarely, a healthy, well-nourished newborn with infrequent stooling will have weight gain within the acceptable range. The BREASTFEEDING ANSWER BOOK states newborns may have a 5% to 7% weight loss up to the fourth day after birth, then gain 4-8 oz (113-227 grams) or more per week. If a newborn is spacing bowel movements days apart rather than hours apart, each bowel movement would be very large. Since experts list infrequent newborn stooling as a "red flag" symptom requiring professional evaluation, confirming the infant's overall health and monitoring weight gain with the health care provider are prudent precautions.
Although breastfeeding provides infants with extensive protection against infections, illnesses do occur. Diarrhea symptoms include 12 to 16 bowel movements with offensive odor in a 24-hour time period. Infants with diarrhea need medical supervision and continued breastfeeding is especially beneficial.
Frequent bowel movements which are consistently green and watery may be caused by a sensitivity to food or medication that baby or mother is ingesting. Careful consideration of any medications, home remedies, foods or drinks may uncover a possible cause.
Consistently green, watery and foamy stools are also thought to be caused by a low intake of hindmilk, referred to as foremilk-hindmilk imbalance or "oversupply syndrome." Baby may act colicky, gain weight slowly and bowel movements may be very forceful. An overabundant milk supply or overactive let-down reflex may be involved. Breastfeeding techniques to improve the baby's control of the milk flow and intake of hindmilk may quickly reduce these symptoms.
For more than ten years LLLI publications have reflected the typical newborn pattern of multiple daily bowel movements. As breastfeeding supporters we realize change often comes slowly, and the public understanding of normal newborn stooling is no exception. Leaders can perform a valuable role in this area by sharing these guidelines with pregnant and new mothers. Early detection of infrequent newborn stooling and strategies to improve a baby's total milk/hindmilk intake may be deciding factors in a mother's continued breastfeeding.
How discouraged and frightened a new breastfeeding mother feels when she is told at a routine health visit that her baby is not gaining well. Grateful mothers have related how helpful it was to be forewarned of the possibility of weight problems and given immediate information and encouragement as well as criteria to observe baby's progress. Routinely explaining to mothers the importance of multiple daily stools for newborns is such a simple way to promote, protect and support breastfeeding, I have decided no mother who reaches out to me will go without this information.
Desmarias, L. and Brown, S. Inadequate Weight Gain in Breastfeeding Infants: Assessments and Resolutions. LLLI Lactation Consultant Series Unit 8. New York: Avery, 1990.
Eglash, A. Breastfeeding promotion in the community setting: managing the 24 hour discharge. ABM News and Views: The Newsletter of the Academy of Breastfeeding Medicine, Spring 1995.
Lawrence, R. Breastfeeding: A Guide for the Medical Profession. St. Louis, Missouri, USA: Mosby 1994, 272.
Mohrbacher, N., Stock, J. BREASTFEEDING ANSWER BOOK. Schaumburg, IL: LLLI, 1997.
Neifert, M. and Seacat, J. A guide to successful breastfeeding. Contemporary Pediatrics 3:6, 1986.