The Neonatal Bowel Output Study: Indicators of Adequate Breast Milk Intake in Neonates

Linda C. Shrago; Elizabeth Reifsnider; Kathleen Insel


Pediatr Nurs. 2006;32(3):195-201. 

In This Article

Abstract and Introduction

Purpose: This study describes the bowel habits of neonates who were exclusively breastfed during the first 14 days following birth to determine whether bowel output (frequency and character) could be used as a proxy measure for adequate breast milk intake.
Study Design: A prospective, descriptive study was conducted. During the 14-day study period, mothers kept a log of their infants' daily naked weight, number of feedings, number of daily bowel movements, and color of all bowel movements.
Participants: One hundred thirty-one participants were enrolled in the study; 73 participants completed the study.
Findings: Findings indicate that more bowel movements per day during the first 5 days following birth were significantly associated with less initial weight loss, earlier transition to yellow bowel movements, earlier return to birth weight, and heavier weight at 14 days.
Conclusions: These findings suggest that scant bowel output during the first 5 days following birth, or delayed transition of bowel movements to yellow, warrant weighing the infant in a health care professional's office.

The American Academy of Pediatrics' (AAP) Work Group on Breastfeeding (1997) has recommended research-based practices that support successful initiation of breastfeeding. These recommendations include breastfeeding when infants "show signs of hunger," breastfeeding "approximately 8 to 12 times every 24 hours until satiety," and that "formal evaluation of breastfeeding performance should be undertaken by trained observers and fully documented in the record during the first 24 to 48 hours after delivery and again at the early follow-up visit, which should occur 48 to 72 hours after discharge" (p. 1036). Additional recommendations are made for those infants discharged from the birth setting less than 48 hours after delivery. Despite these recommendations, hospital readmission of breastfeeding infants for problems due to inadequate feeding such as dehydration, hypernatremia, and hyperbilirubinemia, has occurred in recent years (Hall & Smith, 2000; Trotman, Lord, Barton, & Antoine, 2004; Tyler & Hellings, 2005). Cases of dehydration and excessive weight loss in breastfed neonates have been reported in professional journals (Escobar et al., 2002; Neifert, 2001; Rand & Kolberg, 2001; Roddey, Martin, & Swetenburg, 1981; Rowland, Zori, Lafleur, & Reiter, 1982; Rushton, Lambert, Avrum, & Frangakis, 1982; Scott, Raghunath Gnananayagam, & Simon, 2003) and the lay press (Helliker, 1994; Chase, 1994; Park, 1994), some with tragic sequelae including stroke, convulsions, brain damage, dehydration-induced blood clots, and limb amputation (Cooper, Atherton, Kahana, & Kotagal,1989). An eight-day-old infant was admitted to the primary author's practice site in 1992 with hypernatremic dehydration, thrombocytopenia, seizures, sagittal sinus thrombosis with intraventricular hemorrhage, a weight loss of 25%, and a history of no bowel output for the 5 days prior to hospital admission (Shrago, 1996).

Common factors in most of the reported cases of excessive weight loss attributed to inadequate breastfeeding, when other medical factors such as sepsis had been ruled out, were term healthy infants at birth and parental lack of awareness that there was a breastfeeding problem until the development of alarming symptoms and examination by a physician. There is potential for serious sequelae if inadequate nutritional intake exists in a neonate and the deficit is not identified and treated promptly. Because parents are unable to measure the precise amount of breast milk received by their infant, an objective and easy to use criterion is needed to help parents determine the adequacy of their infant's intake of breast milk.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.