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


An increased number of daily bowel movements during the first 5 days was significantly associated with positive infant outcomes, including less initial weight loss, earlier regaining of birth weight, and heavier weight at 14 days of age. Earlier transition to yellow bowel movements also demonstrated the same positive associations with the same positive outcomes. These findings suggest that parents and health care providers can use number of infant bowel movements per 24 hours during the first 5 days after birth and day of transition of bowel movements to yellow as a gross screening tool for adequacy of breast milk intake.

These findings provide compelling evidence of the appropriateness of education that encourages mothers to pay close attention to their infants' bowel movements during the first two weeks following birth. The professional providing lactation support can inquire from the breastfeeding mother how many bowel movements (larger than an American quarter or 2.5 cm diameter) typically occur each 24 hours. Asking which day the infant's bowel movements transitioned to yellow is an important part of the assessment. Infant behaviors (hunger and satiety cues) also contribute to the assessment of adequacy of breast milk intake; however, infant behaviors were not addressed in this study. Interpretation of infant behaviors may be difficult for inexperienced parents, who may misinterpret hunger cues as "fussiness" or "gas." Counting dirty diapers and noting the color of bowel movements is an objective assessment that can be performed even by inexperienced parents.

Mothers should be encouraged to breastfeed 8-12 times per 24 hours as recommended by the AAP (1997). However, the assumption by health care providers that adequate nourishment of a breastfed infant is assured if the infant is offered breastfeeding opportunities the recommended number of times cannot be supported by the current research study. A concerning number of infants in the study (18% of the sample) lost more than 10% of birth weight; and 16% were not back to birth weight by 14 days. These findings confirm that breastfeeding infants during the first 14 days following birth are at risk of excessive weight loss. Therefore, monitoring infants' weight during this period is indicated.

In the current research study, the infant who had the greatest number of breast feedings per 24 hours had the poorest weight performance. Newman (1996) reported an 11-day old infant who had lost 30% of birth weight, who was being breastfed 12 times a day for an hour each time. The infant had a small dark bowel movement every 3 days. The current study and Newman's case report suggest that unusually frequent feedings may be a symptom of an infant not getting enough milk at each feeding. This may occur if a mother has a low milk supply or if the baby is not capable of extracting the available milk efficiently. Because mothers may lack the skill to evaluate the actual transfer of milk from the breast to the infant, the health care provider must consider that a breastfeeding attempt does not guarantee milk intake. Feedings of unusual frequency, particularly when associated with low bowel output, strongly suggest the need for evaluation of the baby's weight, the mother's milk supply, and the baby's ability to remove milk from the breasts.

The sample size was small and the study was conducted at a single site using a homogenous population. Findings of this study cannot be extrapolated to other populations in other locations.


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