EP 25: The “Are They Getting Enough?” Spiral: Newborn Feeding, Weight Checks, and When to Get Support

Is your newborn getting enough milk, or are you stuck watching every feed, diaper, and sleepy stretch with worry? In this episode of Nutrition for the Early Years, Dr. Liz Daniels shares clear, caring guidance for parents in the first days and weeks of newborn feeding. She explains why advice can change from day to day, what normal newborn weight loss looks like, when milk usually comes in, and why very sleepy babies may need extra support. You’ll hear how jaundice, latch, wet diapers, poop, weight checks, and supplementation all fit together. Dr. Liz also talks about triple feeding, why it should have an exit plan, and how breastfeeding, formula, or combo feeding can all support a growing baby.

Dr. Liz Daniels is a nutrition-focused pediatrician and host of Nutrition for the Early Years. She helps parents feel more confident feeding their babies and kids without shame, guilt, or fear.

What You’ll Learn:

• Why one feeding does not tell the whole story
• What newborn weight loss can look like in the first week
• How to know if milk is coming in
• Why jaundice and sleepiness can affect feeding
• When supplementation or lactation support may help
• How to think about triple feeding without burning out
• Why your feeding goal can still change with love and care

Episode highlights:
(2:47) Why newborn feeding advice changes day by day
(4:55) Normal newborn weight loss and early growth patterns
(6:18) Jaundice, sleepiness, and feeding concerns
(7:00) How to know if milk is coming in
(9:51) When supplementation may help protect feeding and growth
(11:33) Weight trends, follow-up visits, and lactation support
(13:02) Wet diapers, poop, and what output really means
(15:52) Triple feeding and why it should not be a forever plan
(18:30) Setting your personal feeding goal
(20:00) Stories of breastfeeding, combo feeding, and letting go of guilt
(26:34) How to feel more grounded when feeding feels uncertain

NEW COURSE! "Read the Pattern: Feeding Your Baby 0–4 Months" — because a healthy relationship with food starts earlier than most people think. Course Link!

Disclaimer: This podcast is for educational purposes only, not medical advice.

Transcript

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Just this week, I had a family come in for a newborn visit, seven days old. And in that time frame, they'd seen probably 25 different medical providers, all with a different answer to their question. Is she getting enough? Some said yes. Some said no. Some said, try this. At the end of the day, they were exhausted. And it wasn't just because they were tired of sleep. They didn't know where to go or who to believe. And today we're going to talk about the spiral of is my baby getting enough? And how to get out of it? Because I think there are a few key things that help us feel confident that a baby is growing and feeding really well. And I want you to know. Welcome back to the Nutrition for the Earliers podcast with me, your host, Dr. Liz Daniels. I'm a nutrition first kind of pediatrician, and this podcast is for the parent who's second-guessing their grocery cart, worrying if their kid is going to end up with the same food struggles that they once had. I love getting into the weeds of what kids actually need and then putting it into context of where they're at in growth and development so you can let go of the shame and guilt and focus on what actually moves the needle together. Let's get into it. Welcome back to the Nutrition for the Earliers podcast. I'm your host, Dr. Liz Daniels, nutrition-focused pediatrician, who is ready to give you guilt-free guidance in feeding your family well so that you can be confident along the way. Now, today I want to talk to you about the common questions that I get in the very beginning when you have a new little newborn. And it doesn't matter if it's your first kid or your tenth kid, these questions come up because every baby is unique and every delivery is a little unique. So even with the most seasoned of parents, I hope that you can walk away from this episode feeling confident and encouraged and knowing what signs to really look for and what might not be enough information to worry about. Okay, like let's go back to the room where I was with this amazing family and their beautiful newborn baby. The key here is that, you know, they were born in the hospital and they left day two to three. Pregnancy and delivery was pretty great for the most part, you know, expected, and baby was doing okay latching. They had a lactation consultant helping a lot. Mom is a new mom, so it is her first baby, but she had taken breastfeeding classes, knew kind of what to expect, and was latching what she thought was pretty comfortable by the time she was leaving the hospital and felt really good that, like, baby's waking up to feed, we're queuing, things are going really well. And in the hospital, the family kind of warned Mama, like, if you need a supplement, go ahead, just do a little bit because their bellies are so teeny tiny. And then I saw the family on day of life four, and the baby had lost a fair amount of weight. We knew that would happen. That wasn't a big surprise. But I want to talk to you today about what to do in that like really first week of life where things are sort of shifting a lot, and how the advice you're given from day one to day two and day three and day seven are going to differ, and they actually should, because your baby changes a lot. And as people are giving you guidance along the way, they're able to look at that point in time retrospectively and put it all together. And there's no one person that can give you the right answer every time without having that whole pattern, because no one feeding can give you enough information to see the whole picture. So the encouragement here is not to feel like you're being led astray or that you're not being given good advice or that people don't know how to help you, but more so that as your baby grows and you take a direction, you test it out, you see what happens, each day that that baby is actually pretty different developmentally. I mean, truly, baby on day one versus day three are quite different, in my opinion. And on day five and day six, I'm expecting very different things. And so my advice would be really different. We're gonna talk about that and how the fear of overfeeding a baby is kind of a misleading cue. And really the one that we want to understand is why our baby is so sleepy. Because usually a really hungry baby is actually overly sleepy. And then we're gonna talk a little bit about triple feeding because it is a trap that can start out really well and be very helpful for a lot of people, but it is not our forever plan. You know, these parents, like a lot of parents, especially when it's not their first baby, they're well read. They're smart, they've read the books, they know what to expect, and yet they still find themselves in this feeling of like, I don't know if I'm doing it right. And that's okay. It's really okay to be there. I know I was there with my first kids too. And and what I want you to know is a couple basics, and you probably already have heard this, but it's nice to hear it again, okay? Full-term babies, for what it's worth, is kind of the primary caveat for this conversation. Preterm babies have a little bit different numbers that we follow, but the general rule of thumb is that at least full-term babies were expecting to lose weight after birth. Um, and we're expecting to lose up to 10 to 12% of their birth weight by day of life five. It's a steady decline on their weight. And then once we hit around day of life five, it starts to come back up and we start regaining that birth weight at about an ounce a day on average. And that's a really great sign that we're moving in the right direction. I had one baby who left the hospital at a higher weight than his birth weight. Not normal. And so when I see that happen, it's always this like, wow, we're really, really growing well. But in this particular situation, I want you to know that the families who get worried about the spiral of if my baby's getting enough are often the ones who are having our physiologic drop in their weight. And they'll kind of steadily decline day one, day two, day three, day four, despite feeding. So you're breastfeeding and you think things are going really well because latch is okay, we're comfortable, they seem sleepy and relaxed, and they go back to sleep. And we did our job. So they sleep, eat, poop, that's kind of it. You're done. And that's true. Now, a couple of caveats. The first week of life is especially tricky because jaundice happens. And I'm not talking scary jaundice. You'll know before you leave the hospital for the most part, if your baby has scary jaundice. And if you're not, because you're leaving the hospital, things are usually going to be pretty good. We are not completely out of the woods, though. What happens is that as the first week of life goes on, their bilirubin levels, their jaundice levels naturally increase, especially with breast milk. That's not problematic if they're getting enough. The hard part is that sometimes it's hard to tell if they're getting enough. And so the fear of are they getting enough comes from a good place. Here's benchmark number one. Is your milk coming in? I'll ask moms that in the first newborn appointment, and they'll say, I don't, I don't know. The answer to that is no. The question is, are you is your milk coming in? And the answer is, oh my God, yes. You will know. If you've ever traveled and you've had like traveler's diarrhea and you're like, I gotta find a bathroom, it's that kind of urgency. Sorry to be grappling, but it's that kind of urgency that you feel the need to express breast milk when you are fully engorged and you're like, my milk is in, because it's really obvious. You physically look different, you feel different, and you can tell that your breasts need to be emptied or full. And so when your milk is in, that's a great sign. When milk is in by day of life three or four, usually a really good sign that things are going in the right direction. So immediately, if that's happening, I'm pretty happy for a family. I'm not worried. I just want to watch and see what goes on. Make sure latch is comfortable. If a family needs support, we want to make sure they get lactation support. Really, really key. If a mom is noticing that her breast milk's not there by day of life four, I start to say we probably want to think about supplementing and or pumping to make sure that we're able to get enough stimulation to the nipples to produce breast milk in the time and the trajectory that the baby's gonna need because their bellies are teeny tiny in the beginning, but they grow really quickly. And so the amount of volume that a baby wants and needs on day of life one versus seven are very different. A lot of families will maybe leave the hospital feeling like they wanted a supplement a little bit in the beginning. And that's fine, totally fine. However, um, they'll often be afraid to offer more formula while they're waiting for their milk to come in because they're either afraid that it's going to interrupt their milk supply, they're afraid that the um they'll overfeed the baby and it'll cause problems. And I want to offer you some reassurance that if your milk is not in by day of life four or even five, it is probably a really good idea to get in with your pediatrician, see if you need to get supplementation going just in those first few days, because here's a problem that I often see. If we're in that camp and we think our milk is in, but it's we're not really sure. That means it's not. And breastfeeding might not be as effective as we're hoping it is. Colostrum is amazing, and we want to make sure I'm clear in that like colostrum is gold and there is nothing like it on the planet for babies. Like that is the best thing. So it's not that we don't want to keep breastfeeding, it's that if there's not effective latching, then it will be more of a risk for your milk supply than offering formula. Here's the delicate thing to think about. By day of life four or five, and especially six, if our milk is not in yet, chances are bilirubin levels have climbed and we haven't been able to adequately flush them out. And so as a result, bilirubin, when it's at a higher level, makes babies even more sleepy. If they're really sleepy, then they don't cue for feedings. And when they do go to the breast, they are so tired they don't effectively transfer, which means that you don't effectively produce milk. And we get into this negative loop that's really hard to climb out of. And I don't want that to be you. So, and this family wasn't for what it's worth. They were actually doing everything right. It's just nice to see that weight check and see, like, oh, yep, we're doing great. However, they were afraid that they were gonna be overfeeding or oversupplementing with formula by increasing their volumes. And yes, I hear that. But if you are not producing enough milk or your baby is um, you know, not getting enough and their bilirum is creeping up, it's important to know where your weight is. So this is where we want to get seen. We want to get attention to make sure we have objective information to know what's going on. This is a big part of why we love to encourage quick follow-up after the hospital so that we have a chance to see how things are going. Lactation consultants are an incredibly useful friend to have in your back pocket if you are in this camp, because being able to see a good latch, make sure that transfer is going really well is the key to being able to help your milk supply as well as ensure that that latch is really effective. So kudos to them for that. So to put that together, because we know that baby's weight is going to drop to its lowest by day of life five, and their jaundice is likely to peak by day of life five. If our mom's milk is not in by then, it's important to make sure that we have good follow-up because these are babies who might really need more supplementation. And these are the ones that I will often hear from families, and to me, is a very like red flag where I hear they're just sleeping all the time and I can't get them to wake up, so I don't know if they're getting enough. And I'm like, mm, what I'm hearing is a baby who's too tired to effectively breastfeed. It doesn't mean it can't work forever. It just means that right now we need some more support. Don't be afraid to get that support. And I think sometimes parents are worried that they're gonna look like they're extra or they should know it all by now or have it all figured out. But again, you don't know unless you see that objective number. And it's not just one weight, it's the weight over time. So this is the main thing we're looking for is what are those data points saying and what is our rate of weight gain per day or rate of weight loss per day? Because those trends are really how we make decisions. It's not just one data point, it's the data points together that add up and give us enough information along with the symptoms you're experiencing to know how to guide you. And that's what your pediatrician wants to do for you. The other question I often get is well, I can't really tell if they're getting enough because we are having a ton of wet diapers, but I don't really know if we're pooping enough. And this one is a little bit funny because we usually tell parents, okay, at least one poopy diaper on day of life one, two on day two, three on day three, and then after that, I kind of don't care. I chuckle a little bit, but bear in mind that after they've evacuated the meconium, which is like dead skin cells and stuff that's accumulated in the GI tract before they've had any nourishment coming in, once that's kind of out, and sometimes babies will either lose some of that even during delivery, or they'll do it on the first day of life and have like eight poopy diapers on day of life one, and then not again for like a week or even 10 days. And that can be really scary to the parent because they're afraid that that sign of not having poop yet means that they're not getting enough. And that's not necessarily true. This one is tricky because again, the weight and what's coming in really matters. If I have a baby whose mom's milk not in and we're not pooping, and we're really sleepy, I'm gonna be worried about that baby. But if we are cueing for all of our feeds by day of life five and six, latching is going great, mom's milk is in, or we know we're bottle feeding and we're getting plenty of volume in, I'm not really worried about no poopy diapers on day of life four or five or six or seven. You catch the drift, right? It's how they all add up together that really drives our worry level and consequently what your worry level should be too. So, so the most reassuring sign is a baby who is calm but not overly sleepy and is waking for feeds on their own without having to be totally undressed, totally diaper changed, made mad, flicked their heels, rubbed their back, just to get them to take an ounce. Now, here's how to like hold all this together and to know when to do something about this. Okay, so we want to read those cues sort of like across a full day or even two days, not just one feeding, because inevitably you're breastfeeding and things are going really well. And then all of a sudden you have like one weird off feeding where they like cluster a whole bunch or don't really eat anything, and that can be really confusing. So, my encouragement to you is that if you're in the first week of life, um, then you can truly just take a step back and say, how did the last 24 hours go? Like, is there a pattern I'm seeing? If there's not a pattern yet, then you probably need more time. Keep going, don't give up. If you're seeing a consistent pattern where we aren't latching every single time or we're refusing the bottle, we're struggling to um, you know, see any output, those are some worrisome things over a trend. Now let's talk a little bit about triple feeding. If you're not familiar, triple feeding is where you breastfeed and then you pump the leftovers, if there are any, and then you offer that to the baby in a bottle. So normally, if you're gonna put the baby to the breast in the beginning, we're gonna do probably 10 to 15 minutes per side. That's a 30-minute event, and then pumping another 15 minutes and then feed the baby the bottle another 15 to 20 minutes. You're looking at an hour and then you're back at it another hour later. That's incredibly exhausting. And it's not a long-term strategy. So if you're in the triple feeding category because you're struggling to, you know, make enough milk in the beginning, or you feel like your milk supply is not adequate. This is where I love to say we want to get our lactation consultants involved. In my community, we're fortunate to have them even in our practice as well, which is wonderful. But the support from a lactation consultant can be key in helping you get out of that triple feeding trap because it is a good way to help bridge the supplemental formula to exclusive breast milk. But if we are still in that camp at like week two to three of life, I usually am encouraging families to really ask themselves, what is our primary goal? And what are we trying to achieve? Because at the end of the day, you as a mama need sleep in order to be able to recover and have, you know, enough milk and enough wherewithal to be able to feed your baby and take care of yourself. So it is okay to sleep at night. If you are triple feeding and you're like, I'm at my wit's end and I can't do this anymore, like it's okay to give yourself a break, give yourself a couple of nights to catch up a little bit and wake up in the middle of the night just to express. But maybe somebody else can feed the baby in the middle of the night, just for those couple of days. And then see where you're at and start to transition away from that. Now, if you have regained your birth weight, like in this situation, this family had actually regained birth weight by like day 10, 11. And so things were going really well. And to me, that's our sign like it's time to back down from triple feeding at that point. We should have an exit strategy. And the first place to exit on triple feeding is usually the nighttime. Because babies are sleepy and they're not going to be doing their best breastfeeding at nighttime anyway. They're just not. So give yourself the break. And if you need a supplement with formula to do that, to get like a supply built up, that's okay. It's not a forever game, but it's something to consider. The question I like families to ask themselves is what is my eventual goal? Like, what do I want to see myself doing at month three or month four? And I'm not saying you have to know the how. I'm just saying know the what. Like what is most important to you? Is it most important that you exclusively breastfeed or have exclusive breast milk? Does it have to all be yours? The other question is, what's our end point? Like at what point are we saying we're wanting to wean? For some mamas, that's month two or three when I'm ready to go back to work. For some mamas, that's, you know, six months or not until we're three and a half. Like, I mean, it really varies. And so I think you have to ask yourself what your end goal is. And this is one where you really need sleep to make a good decision because it can be an emotionally charged one. And I want to tell you two stories that I feel like highlight this in a little unique way. Okay, if you listened so far, thank you. I just want to give you a quick PSA. Okay, if you have a little baby and you are struggling with these kinds of things, I wrote a course called Read the Pattern, Feeding Zero to Four Months. And in this course, it's about like six modules, two and a half hours of support for you. And it is a workbook along with really like clear frameworks to help you think through some of these things. And this podcast is kind of an example of some of the stuff that's in the modules. So if this kind of information is helpful and you want to get more, link is in the show notes and you can find it also on my website. Okay, back to the stories. One mama, who happens to be my mama, had a really challenging first pregnancy with my sister. And that three and a half pound sweet little baby, my sister, had to stay in the NICU for a while, growing until she was big enough to be able to come home. And my mom felt so much guilt and shame. So much guilt and shame. Still, she's in her 70s and she still feels this like it was yesterday. And my mamas, who either had a traumatic delivery, traumatic birth, often will clutch on to breastfeeding like it is their badge of honor. And because they didn't get to deliver the way they wanted to, it's like they have to pay penance for that, and they have to breastfeed. And I want to pause here because I want you to know that it's not that this is wrong or that you shouldn't, but I just want to call it out for what it is. Because when we carry that with us, it's actually grief that's totally misapplied. Now, in 1980, there were not a lot of the tools that we have today. Okay. And my mom was really committed. And in her love, like truly in her grieving and in her love, she wanted so deeply to breastfeed my sister. And so she pumped, they only had hand pumps back then, and would bring milk to the NICU, drop it off, couple get sometimes with like lactation support a little bit, but it wasn't like it is today. And so she was discharged home with this baby who everyone assumed was gonna stay on a bottle because effectively up until that time, most of the feeding had been all bottle feeding. And you guys, my mom was, she was really committed. She took like a regular rubber nipple from a bottle and covered her breast with it and would sort of hand express a little bit, try to get some in there, kind of like a nipple shield that we have today, and train my sister. This is just a mother's intuition. There was like nobody taught her how to do this. Okay. Like this was her saying, I want to get to the place where I can breastfeed her. Um, part of that was convenience in life. Again, there wasn't some of the same pumping and supplies that we have today. And she knew that that was going to be the best nutrition for her. Um, and so, you know, it and by the way, formulas have come a long way too. But again, just picture that like this was her realizing that she was she was really committed to this. And she still remembers what my sister was wearing, what it felt like, and where she was, who was around her the moment my sister latched truly for the first time without that rubber nipple. And that is the power of motherhood. She wanted to connect with her baby in that way, and she worked and she was patient, and it wasn't, it didn't happen right away. It didn't happen for quite a while. I think it was like two to three weeks after leaving the hospital of every single feeding. She was really trying that. And I'm not telling you that that's what you need to do. What I'm I'm using that story as an example of like she just in her mind, that goal was I just want her to get breast milk. And that was the only route she had. Now I want to pivot to another story that's equally beautiful. I have a mama that I care for, all of her babies, and her third, back up her second, actually, um, she came in and was like, I really want to breastfeed. I didn't get to breastfeed my first, and I just didn't have enough milk. Um, I really want that for her, for him. And um, it was a really slow go. Mom really just was struggling to produce enough milk and it was exhausting. She had another kid at home, you know, was getting closer to maternity to leave time, and baby was two and a half months old when she was still triple feeding. Still triple feeding. It was exhausting. And that was hard. Well, her third baby, she comes in and she says, okay, everybody knows this is gonna be different. I'm producing milk, milk latching is going well, but I'm gonna do it different. I know my goal this time, I know what I'm gonna do. And I was like, what do you mean? She's like, I'm gonna breastfeed, but it doesn't have to all be me. And it won't be triple feeding forever. I want to take care of myself and I know it's okay to do both. And she meant combo feeding. Now, in this particular situation, she actually, you know, had more milk each pregnancy. Um, so it was exciting to see that come through. And at month one, baby was getting about 25% direct breastfeeding. Um, and then um she at that point had said, I'm just gonna keep feeding her what I can produce and what she can transfer. The rest of it will be formula. I'm not gonna do triple feeding anymore. Like past a couple of weeks, I'm not doing it. It was too stressful for me. I have other kids. And I'm gonna be really grateful for that. Well, then month four, guess what? She's actually doing about 50% breast milk from direct feeding and 50% formula. This is not a normal scenario. I mean, often it kind of goes in other directions. It's really variable. But the purpose in telling you that is that she knew her goal too. Both of these women had a goal in mind. They had different ways of getting to that goal. They didn't have the how figured out. And that's my invitation for you. You don't have to have the how for every little detail to stop the spiral. You have to just know what do you rely on? Our growth, is growth happening? Is our baby queuing for feeds? Are we seeing the output? Is this consistent over time? And that's it. And in both of these situations, the babies grew beautifully. They both achieved amazing things. And I have to say, like, it was really amazing to see both of these mamas say, I want to be in charge, but here's how I'm gonna do that. And my invitation for you as a new mom is that I think a lot of the times we feel like we have all this time to prepare in pregnancy. And so we're supposed to know what to expect once motherhood is there. But the thing is, is that when you actually have the child, a lot of times things have to pivot. And that's okay. We have to grieve that too and recognize that if breastfeeding's not going well or we need more support, that's a grieving process that we want to create space for. And that's my invitation, right? So the invitation isn't to say that, you know, you need to give up on breastfeeding or this isn't gonna work, or if you're spiraling if your baby's not getting weight. That's not the goal. The goal is to say, if I'm spiraling, what can I anchor myself to to be confident that my baby is growing? And what is my goal for this growth? How do I want to connect with my baby? Because there are more than one way to do that. And you don't have to have the roadmap totally figured out right now. Just know that we take it day by day and we continue to follow up and see what that direction looks like to make the right decision. If you're in the spiral, I hope this has been encouraging to you. Give yourself a nap. It's gonna be okay. And know that after a good nap and good rest, you'll be able to think a little more clearly about what the next steps are. Don't be afraid to ask for support if you need it. Thanks so much for listening.