Newish research on counting diapers

[@llli*auderey]

Hi - not sure where the best place to put this is, but I've been poring over the 2010 Breastfeeding Answers Made Simple, and the data on counting diapers is not quite as clear as it seemed.

Here's what it says:

"There are several ways to gauge whether the baby needs a supplement. The most reliable is the baby's weight gain. ....

A less reliable gauge of milk intake - but one that can be helpful in combination with weight checks - is diaper output. In the first week of life, some aspects of diaper output can provide good clues about whether the baby is receiving the milk he needs. A transition to yellow stools by Day 6 or earlier was associated with acceptable levels of weight loss and earlier weight gain (Shrago, Reifsnider & Insel 2006). Day 4 breastfeeding inadequacy was predicted by less than three stools per day along wtih the mother's perception that her milk had not yet increased within 72 hours postpartum (Nommsen-Rivers, Heinig, Cohen & Dewey 2008). However, breastfeeidng was actually going well with 41% of the mothers with these indicators.

Although diaper output is not as accurate as weight gain in determining wehther a baby is getting enough milk, it can be used as a rough gauge between weight checks. During the first 6 weeks or so, daily stool output can be a helpful sign of whether milk intake is adequate. An average is at least four stools the diameter of a US quarter (2.5 cm) or larger (Shrago et al 2006). If the baby is having fewer stools but gaining weight well, this is not a problem. After 6 weeks of age, stool count is no longer reliable because many breastfeeding babies have fewer stools, even when getting plenty of milk." (p108)

"Two US studies examined whether diaper output accurately reflects adequate milk intake. Both found that there was much room for error. One study of 73 exclusively breastfeeding mother-baby couples monitored the babies' weight loss and gain, breastfeeding patterns, and diaper output for the first 14 days (Shrago, Reifsnider & Insel 2006). Th researchers found that more stools during the first 5 days were associated with positive infant outcomes. More stools during the first 14 days were associated with the lowest weight loss and early transition to yellow stools. (Mean number of stools per day was four, but some babies had as many as eight.) The first day of yellow stools was a significant predictor of percentage of weight loss (the earlier the babies' stools turned yellow, the less weight was lost.) The average number of daily stools was not an accurate predictor of initial weight loss, but the more stools passed during the entire 14-day study period, the earlier birthweight was regained.

Because some newborns breastfed ineffectively, number of daily feedings at the breast were not related to initial weight loss, start of weight gain, regainin of birthweight, or weight at Day 14. (Mean number of daily feedings at the breats was 8.5, with a range of 6 to 11.) In fact, the researchers considered unusally frequent feeding with low stool output a red flag to check baby's weight, as the study baby who breastfed the most times per day had the poorest weight outcomes. They found that frequent feedins with good stool output was a sign of effective breastfeeding, but frequent feedings without much stooling should be considered a red flag of breastfeeding ineffectiveness.

The second US study followed 242 exclusively breastfeeidng mother-baby couples, also for the first 14 days of life. These reserachers found that "diaper output measures, when applied in the home setting, show too much overlap between infants with adequate versus inadequate breastmilk intake to serve as stand-alone indicators of breastfeeding adequacy" (Nommsen-Rivers, Heinig, Cohen & Dewey 2008 p32). The most reliable predictor of poor milk intake was fewer than four stools on Day 4, but only when paired with the mothers' perception that her milk had not yet increased. But even when both of these criteria were true, there were many false positives, meaning that many of these babies' weight was in the normal range.

So at best, diaper output can be considered a rough indicator of milk intake. While it can be helfpul to track diaper output on a daily basis between regular weight checks, diaper output alone cannoe substitute for an accurate weight. Regular weight checks during the first weeks are vital to identifying breastfeeding babies at risk of low milk intake.

Also, diaper output patterns change over time. Four stools per day are average during the early weeks, but after 6 weeks of age stooling frequency often decreases, sometimes dramatically. Some breastfed babies older than 6 weeks may go as long as a week between stools, which is not a cause for concern from a breastfeeding perspective as lon as the baby is gaining weight well." (p215-216).

[@llli*lllmeg]

A less reliable gauge of milk intake - but one that can be helpful in combination with weight checks - is diaper output

.

So at best, diaper output can be considered a rough indicator of milk intake. While it can be helfpul to track diaper output on a daily basis between regular weight checks, diaper output alone cannot substitute for an accurate weight. Regular weight checks during the first weeks are vital to identifying breastfeeding babies at risk of low milk intake.

Also, diaper output patterns change over time. Four stools per day are average during the early weeks, but after 6 weeks of age stooling frequency often decreases, sometimes dramatically. Some breastfed babies older than 6 weeks may go as long as a week between stools, which is not a cause for concern from a breastfeeding perspective as lon as the baby is gaining weight well."

I don't see the discrepancy...who has said that poops ALONE should be considered the indicator of healthy growth? It is assumed (perhaps it should not be but it is) that newborn babies are under the care of a pediatrician and thus, are weighed frequently in the early weeks. Where I live, it is typical with hospital born babies to take a 1) birth weight 2) at least one more weight check before leaving hospital, with more weight checks if baby is in hospital longer than a day after being born, 3)another weight check done shortly after leaving the hospital (IF there is weight gain concern or any other concern, such as jaundice, while in the hospital) and then a 4) 2 week weight check and then a 5) 4 week. I am not sure what happens after that, but by then most issues with a newborn not gaining correctly would have been caught.
What is not discussed above is how inaccurate weight checks can be, due to the fact they are done on different scales, (sometimes several different ones) or not done with baby either naked or in a dry diaper, or just plain off due to human error. So weight checks alone are not the answer either, imo. But doctors will often use weight checks alone to suggest supplementing despite these possible discrepancies.

I think it is important that breastfeeding helpers do not just say "make sure baby poops enough" without explaining what "enough" is, not just in terms of frequency but in terms of what size poops "count" and, in the first days, the importance of seeing the poops transition from the dark tar merconium to the typical yellow runny breastmilk poop. And I personally do not like to even suggest tracking pees. There is just too much room for error, either of seeing too much or too little pee, and, when using output as a measure, poop frequency tells you all you need to know about output- if baby under 6 weeks is pooping enough, you do not have to worry about pees, and if baby is NOT pooping enough, it is probably best to get another weight check soon to make sure baby is getting enough.

How many times are moms told "it is normal for your 2 week old to not poop"-I have heard of doctors and nurses saying this, but never an LLL Leader or any mom on here. To my knowledge, we have always stressed that a healthy baby must be pooping frequently in the early weeks, but that after 6 weeks or so this pattern can change and become less frequent and all still be well.

Anyway, I do not find this info in BAMS to contradict what is in the latest WAB (2010) or on kellymom re: using output to measure input. There is some slight difference of opinion on what constitutes enough poop frequency, and whether or not it is helpful to count wets, but again I don’t see anyone suggesting that output be the ONLY measure of how much milk a breastfed baby is getting.

[@llli*auderey]

i think it's commonly understood, and suggested on this site, including by me, that if a baby is having 5-6+ wets per day, they're gaining well. and the BAMS clearly doesn't say that. i have noticed that you (meg) have been writing about poops pretty consistently, not wets, and i think your posts have been consistent with BAMS. but i know mine haven't!

ETA: you're totally right about the weight checks. i never knew how much of a problem this was because we've seen 3 different docs for DS in his first 6 months, so while he was often weighed on different scales, they all made a point of making sure he was naked, and with his first ped all his weight checks up til 1 month old were also explicitly on the same scale (they double checked with us that we were in the same exam room as they had written in the charts). so i thought everyone was on the same page about the proper way to do a weight check!

[@llli*lllmeg]

Ah, I see. OK. yes, I would not tell a mom with a baby under 6 weeks old that she can measure weight gain or even if output is appropriate by pees alone. I used to tell moms to look at poops and pees, like the kellymom article does, but I have had so many moms freak out that baby, for example "pooped big 6 times but only 2 pees" which I know is impossible, they are just not seeing the pee under all that poop. So now I usually go by what it says in the latest Womanly Art of Breastfeeding -to count poops and that gives the info you need about OUTPUT but, I would agree, probably not all the info needed about weight gain.

Where it gets frustrating for me is when a baby seems to not be gaining well according to the scale but has lots of good size poops. I have to admit I usually think the scale measurements are off in those cases because I cannot understand how a baby is pooping lots yet not getting enough.

so i thought everyone was on the same page about the proper way to do a weight check!

Oh how I wish. Jack Newman talks about scales and the outrageous mistakes he has seen-somewhere. his book maybe. It's scary! Then you also have the "smile syndrome"-where baby lost more in the initial days than was recorded, weight is now on the way back up, all normal, but it appears baby is still losing-Or else a "lowest" weight check was never taken, and everyone is measuring weight gain from birth weight...it's no wonder sometimes that parents are told to supplement unnecessarily. So I DO really think that watching output can be reassuring, for both parents and doctors, assuming the doctor is up on that. But I guess it's important to not overstate what output tells us.

[@llli*auderey]

when DS was born, he lost a little more than they were comfortable with, maybe 8%? he was born tuesday early morning, was still down thursday midday, but they let us go home with a weight check scheduled friday (he'd gained 1 oz but my milk still wasn't in) then another on monday (he gained 10 oz and surpassed birth weight). so everything was completely fine and normal but it FELT like a big rollercoaster. at the monday appt my DH said to the pedi that it could really mess a baby up if the original birth weight was measured incorrectly, since so much is gauged from that. and the pedi - whom i otherwise really liked - just couldn't wrap her head around what DH was saying. she couldn't even comprehend that a weight might be incorrect. which is all to say, yeah, this weight stuff is super important!!

[@llli*krystine]

It is important. I had to borrow a scale from my IBCLC and weigh my daughter daily for the first 4 months. I also kept track of diaper output but we were definitely looking for consistent gain on the scale (and also recording how much she nursed each side every time). I have 2 notebooks of pump output, nursing and how much breastmilk she took from a bottle. It's so awesome when a baby gets the hang of nursing from birth and gains well.

[@llli*jenna562]

Well I mention output to mothers because they most likely don't have a hospital scale at home, theyre desperate and needing reassurance, and they are between doctor appointments. I guess I didn't read why that's not still ok to say

[@llli*jenna562]

And the weight stuff is important but we see so much incorrect information about weight gain which sends moms into a supplementing tailspin. Like moms and babies Artifically plumped up during labor with fluids, people freaking about a less than 10% weight loss, using different scales, etc. This makes output a measure that moms can count and be sure of each day consistently.

[@llli*melissawoods]

I have seen (not here, but on other forums) people suggest that a newborn who is not pooping is fine. That irritates me to no end! Oh, breast milk is just better absorbed. He's fine, was what I was told by MANY people when my milk was seriously and truly delayed. I did not listen, we did follow the LC and pediatrician's advice to supplement. Fortunately, I did have a GREAT supply by 2 weeks postpartum. But I tell you, if we had not supplemented when we did, he would have been readmitted or worse.

Personally, I'd rather have a hundred moms needlessly concerned about baby getting enough than one mom who thinks her baby is FINE when they are not.

[@llli*jenna562]

Yes but it's not about being concerned, their concern drives them here, it's about providing solid advice and usually avoiding unnecessary supplementation.