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

Linda C. Shrago; Elizabeth Reifsnider; Kathleen Insel

Disclosures

Pediatr Nurs. 2006;32(3):195-201. 

In This Article

Literature Review

Mothers seek an answer to the question, "How do I know my infant is receiving enough breast milk?" Because the exact intake of milk from the breast is unknown unless performing pre and post feed weights with an accurate scale, mothers have in the past been advised to assume that their infants are receiving adequate nourishment if they breastfeed frequently (eight or more times a day) and if their infant has wet diapers (at least 6 a day) (Lawrence & Lawrence, 1999). In recent years, some authors have suggested that bowel output may indicate caloric consumption from breast milk more accurately than wet diapers, which may indicate adequate fluid consumption but not adequate caloric intake (Biancuzzo, 1999; Lawrence & Lawrence, 1999; Gotsch, 1994; Huggins, 1990; La Leche League International, 1987; La Leche League International, 1997; Neifert & Seacat, 1986; Pryor & Pryor, 1991; Sears & Sears, 1987). Clarke, Markarian, Griswold, and Mendoza (1979) cite a case in which an infant seen at two weeks of age had lost 27% of birth weight. He was voiding five to six times per day but had had only two or three bowel movements since discharge from the hospital. Neifert and Seacat (1986) report an association between bowel output fewer than four per day and insufficient lactation. Neifert and Seacat (1986, p. 28) identify infrequent passage of stools as "the earliest excretory clue of inadequate breast milk intake" and state that "infrequent urination is usually a later sign of poor intake...(as) an infant may remain hydrated while consuming inadequate calories for growth." In a review of case reports of breastfed infants readmitted to hospitals with a diagnosis of hypernatremic dehydration (see Table 1 ), the authors found that low bowel output is frequently associated with the diagnosis, as is extreme weight loss.

A validation study of the nursing diagnosis of "ineffective breastfeeding" included inadequate weight gain and inadequate infant elimination patterns as major defining characteristics of the diagnosis, without quantification of what an inadequate pattern is (Lethbridge, McClurg, Henrikson, & Wall, 1993). Although many authors have suggested that bowel output is an indicator of adequate breast milk intake, only one research study (Nyhan, 1951) has been located that investigated the actual bowel output of breastfed infants. Nyhan's classic study of breastfed infants documented the number of bowel movements recorded during the 7 days the infants were in the hospital following birth. He found the mean number of daily bowel movements of infants who were rooming-in and breastfeeding ad lib to be 3.77 bowel movements per day.

Published studies have identified that breastfed infants' initial weight loss ranged from 3%-7% (Avoa & Fischer, 1990; DeMarzo, Seacat, & Neifert, 1991; Maisels, Giford, Antle, & Leib, 1988; Tjon, Ten, Kusin, & Dewith, 1986). The Guidelines for Perinatal Care (AAP & American College of Obstetricians and Gynecologists [ACOG], 2002) cite 7% as the expected initial weight loss for a healthy term breastfed infant. These guidelines recommend that a breastfed infant with a weight loss of more than 7% of birth weight should be evaluated by a physician. Lawrence and Lawrence (1999) suggest that a breastfed infant with a weight loss of more than 5% of birth weight should be evaluated. Neifert and Seacat (1985) suggest that a breastfed infant with a weight loss of more than 10% of birth weight should be evaluated by a physician. DeMarzo, Seacat, and Neifert (1991) found in a prospective study of 236 healthy, term, exclusively breastfed infants that 88.7% were above their birth weight at 10 days of age. Therefore, the expectation for this study was that well nourished infants would have an initial weight loss not greater than 7% following birth, and would regain birth weight no later than 14 days after birth.

Because mothers' milk "comes in" at 72 to 96 hours post birth (Lawrence & Lawrence, 1999), the time when the least amount of milk is available to the infant is the first 4 days post birth. This is therefore the time that the lowest bowel output would be expected. This study gathered information about bowel output during the first 5 days post birth.

The Neonatal Bowel Output Study was undertaken to (a) describe the bowel output, weight loss, and weight gain of exclusively breastfed infants during the first 14 days following birth, (b) determine whether there is a relationship between the frequency of bowel output and adequacy of breast milk intake during this time frame, and (c) determine whether there is a relationship between bowel transition to yellow color and adequate breast milk intake.

Based on the objectives of the study, the following hypotheses were tested:

  1. A greater number of daily bowel movements during the first 5 days following birth will be associated with less initial weight loss.

  2. A greater number of daily bowel movements during the first 5 days following birth will be associated with earlier transition to yellow bowel movements.

  3. A greater number of daily bowel movements during the first 5 days following birth will be associated with regaining birth weight earlier.

  4. Earlier transition to yellow bowel movements will be associated with less initial weight loss.

  5. Earlier transition to yellow bowel movements will be associated with regaining birth weight earlier.

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