Is my baby getting enough breast milk in the first week?

Most babies are getting enough milk, even when the family worries there is "no milk". You can tell by counting wet and dirty nappies, by checking weight on day 3 to 5, and by watching a feed. Colostrum comes in small amounts on purpose, and the bigger flow of milk usually arrives on day 2 to 4.

How do I know if my baby is getting enough breast milk?

The best signs are what comes out, how the baby gains weight, and how a feed looks. You cannot see what goes in at the breast, but you can count nappies.

A baby who is feeding well usually:

• Has more wet nappies each day in the first week, and pale urine by day 5
• Changes from black stools to yellow stools by day 4 or 5
• Wakes for feeds and seems content afterwards
• Stops losing weight by about day 4 or 5 and then gains

If these signs are present, top-ups are rarely needed. If they are not, see your paediatrician early. Feeding problems in the first week are easy to fix when caught on time.

Is colostrum enough for my newborn?

Yes. Colostrum is the thick yellow milk of the first days, and a healthy term baby needs only small amounts of it.

In one careful study, healthy breastfed babies took about 15 grams of colostrum in the whole first day, with a wide range between babies.¹ That is only a few teaspoons. The newborn stomach is tiny, so this is normal.

Colostrum is rich in antibodies that protect the gut from infection. It also works as a mild laxative and helps the baby pass meconium (the first black stool), which carries bilirubin out of the body. A worried grandmother may say the baby is hungry because the breasts feel soft. Soft breasts on day 1 and 2 are expected.

When does breast milk come in after delivery?

For most mothers the larger flow of milk comes in around day 2 to 4. You may feel the breasts become fuller, heavier and warmer.

In a study of first-time mothers, the middle time for milk to come in was about 69 hours after birth.² Many first-time mothers took longer than 72 hours.² This is common and does not mean you cannot breastfeed. It means the first days need extra support and frequent feeds.

What can delay my milk coming in?

Some mothers have a later start. In first-time mothers, milk came in later when the mother was 30 or older, overweight, had a baby over 3.6 kg, or when the baby did not feed well in the first day.²

You cannot change most of these. You can help by:

• Feeding early, ideally within the first hour³
• Keeping the baby skin-to-skin and in your room day and night³
• Feeding whenever the baby shows hunger signs
• Hand expressing a little colostrum if the baby is too sleepy, and giving it by spoon

How often should a newborn breastfeed?

Most newborns feed at least 8 times in 24 hours, and some feed far more. American guidance encourages breastfeeding at least 8 times every 24 hours.⁴ WHO advises feeding in response to your baby's hunger signs, not by the clock.³

In an Indian study, healthy breastfed babies fed about 9 times a day.⁵ Babies who became dehydrated had fed only about 6 or 7 times a day.⁵

Early hunger signs include turning the head, opening the mouth, sucking the hands and stirring. Crying is a late sign. Some babies want to feed every hour for a few hours, often in the evening. This is called cluster feeding. It is the baby's way of telling your body to make more milk.

Should I wake my sleepy newborn to feed?

Yes, in the first week a very sleepy baby should be woken for feeds. My practical rule: if your baby has gone about 3 hours without waking, gently wake them.

Sleepy babies are common after a long labour, after medicines in labour, and in babies with jaundice. Sleepiness and poor feeding can feed each other: less milk can mean more jaundice, and more jaundice can mean more sleep.

To wake a baby, undress them down to the nappy, change the nappy, hold them skin-to-skin, and stroke the feet. If you cannot wake your baby enough to feed, that is a reason to see a doctor the same day.

How many wet nappies should a newborn have?

The number of wet nappies rises day by day in the first week. As a practical rule, by day 5 or so Dr Dutta expects 6 or more heavy wet nappies a day with pale urine.

In a study of exclusively breastfed babies, the typical baby had 2 wet nappies on day 1, 5 on day 4 and 7 on day 7.⁶ Disposable nappies hide urine well. To learn what a wet one feels like, pour 3 to 4 tablespoons of water into a dry nappy.

Orange or brick-red powder in the nappy on day 1 or 2 is common. These are urate crystals. If you still see them after day 3, your baby may not be getting enough milk.

What should newborn poop look like in the first week?

Stools change colour in a set order. Black and sticky on day 1 and 2, greenish brown on day 3, and yellow and seedy by day 4 or 5.

In the same study, the typical baby passed 4 stools on day 4 and 6 stools on day 7.⁶ Three or fewer stools on day 4 was one of the best warning signs of poor feeding.⁶

Yellow, runny, seedy stools are normal for a breastfed baby. They are not diarrhoea. If your baby is still passing black meconium on day 5, please see your paediatrician.

How much weight loss is normal for a newborn?

Most breastfed babies lose some weight in the first 3 to 4 days. A loss of 10 percent or more of birth weight needs a careful feeding check.⁷

In a very large study of breastfed babies, about 5 percent of those born vaginally had lost 10 percent or more by 48 hours.⁷ After a caesarean, more than 1 in 4 babies had lost 10 percent or more by 72 hours.⁷

So a bigger loss after a caesarean is common. It still deserves attention. In an Indian study, babies admitted with dehydration and high blood salt had lost about 11 percent of their weight and came in around day 6.⁵ A weight check on day 3 to 5 picks this up early.

When should my baby be back to birth weight?

Most babies are back to birth weight by 10 to 14 days.⁸ Half of babies reach it by day 9 after a vaginal birth and by day 10 after a caesarean.⁸

Some take longer. In the same study, 14 percent of babies born vaginally and 24 percent born by caesarean were still below birth weight at 14 days.⁸ A baby who is not back to birth weight at 2 weeks needs a feeding review, not panic. After that, steady gain week by week is the best sign that feeding is going well.

How do I know my baby is latched on well?

A good latch is comfortable for you and shows deep, slow sucking with swallowing. Pain all through the feed usually means the latch is too shallow.

Signs of a good latch:

• The mouth is wide open, with lips turned out
• The chin touches the breast and the nose is clear
• More of the dark areola shows above the top lip than below
• Quick sucks change to slow, deep sucks with pauses and swallows
• The baby comes off by themselves and looks relaxed

In Dr Dutta's experience, a nipple that looks flattened, like a new lipstick, after a feed means the latch needs work. WHO advises that mothers get practical, hands-on help with breastfeeding difficulties.³ Ask for it before you leave hospital.

What is the best breastfeeding position for a newborn?

There is no single best position. The best one is the one where your baby latches deeply and you are comfortable.

Common positions are:

• Cradle hold: baby lies across your lap, head in the crook of your arm.
• Cross-cradle hold: you hold the baby with the opposite arm, which gives more control in the early days.
• Football or rugby hold: baby is tucked under your arm at your side. This is useful after a caesarean or with large breasts.
• Side-lying: you and your baby lie on your sides facing each other. Good for night feeds, if you stay awake.

In every position, keep the baby's ear, shoulder and hip in one line, tummy to tummy, and bring the baby to the breast rather than leaning over.

Is it normal for breastfeeding to hurt?

A little tenderness in the first few seconds of a feed is common. Pain that lasts through the feed, or cracked or bleeding nipples, is not normal.

The usual cause is a shallow latch. It can almost always be improved with help from a nurse or lactation counsellor. A few drops of your own milk rubbed on the nipple after feeds and letting it air dry can soothe sore skin. If pain persists, ask your doctor to check the baby's mouth and to look for thrush or a blocked duct.

Should I give formula top-ups if I think I have no milk?

Usually no. WHO advises against giving any food or drink other than breast milk unless there is a medical reason.³

A baby full of formula feeds less at the breast. The breast then gets less signal to make milk, and supply falls. That is how one bottle "just to be safe" can become many.

WHO says that when extra milk is medically needed, it can be given by cup, spoon or bottle.³ In Dr Dutta's practice, the usual reasons are large weight loss, low blood sugar or severe jaundice with poor feeding. Her first choice is always the mother's own expressed milk, by cup, spoon or paladai (the traditional small Indian feeding cup). In an Indian trial, babies took their feeds faster and stayed calmer with a paladai than with a cup or bottle.⁹

Does my breastfed baby need water in hot weather?

No. Exclusively breastfed babies do not need extra water, even in the Indian summer.

A study in Indian villages, at 35 to 40 degrees C with dry air, found that breastfed babies under 6 months stayed well hydrated on breast milk alone.¹⁰ Water fills a small stomach without giving any calories, and it can carry infection. If your baby seems thirsty in May in Kolkata, offer the breast more often. WHO advises only breast milk until 6 months of age.¹¹

Is breast milk better than formula?

Yes, for nearly every baby. Breastfeeding protects children against infections and is linked with higher intelligence scores later.¹² Mothers who breastfeed have a lower risk of breast cancer.¹²

The American Academy of Pediatrics advises exclusive breastfeeding for about 6 months, and says medical reasons not to breastfeed are rare.¹³ Formula is a safe choice when it is truly needed, and no mother should be made to feel guilty. But in the first week, most "not enough milk" worries are fixed with better latch and more frequent feeds, not with a tin.

When should I see a doctor about my baby's feeding?

Please see your paediatrician the same day if, in the first week, your baby:

• Has fewer wet nappies than expected, or dark urine after day 3
• Has 3 or fewer stools on day 4⁶
• Still passes black meconium on day 5
• Is too sleepy to feed, or you cannot wake them for feeds
• Looks more and more yellow, especially on the tummy, legs or feet
• Has a dry mouth, a sunken soft spot, or seems floppy
• Has a fever or feels cold
• Has lost 10 percent or more of birth weight⁷

Go also if feeding is so painful that you dread each feed. A weight check on day 3 to 5 is one of the most useful visits you will ever make.