Signs of underfeeding

What are the signs of a newborn baby not getting enough milk?

There are many signs that may indicate a newborn is underfed. There may be an abnormal feeding pattern, short or ineffective feeds when the baby is sleepy and weak at the breast, or an abnormal number of feeds (fewer than 7 a day or more than 10). There may be no audible swallowing or choking once the milk has come in. Other signs include hunger even after feeding on both breasts, and an inability to settle unless feeding, sleeping, using a pacifier, or getting a milk supplement. Some underfed newborns are always scowling or are jittery and irritable. They may be floppy and weak and very sleepy. Excessive weight loss is another sign of an underfed baby. Infrequent pees and stools (poops) are somewhat less helpful. 

A) Describing underfed breastfed newborns

Babies who are healthy and getting enough milk show signs of normal growth. There are four assessment tools that are used to ensure this:

  1. Feeding pattern
  2. Behaviour
  3. Appearance
  4. Weight gain

When babies are not getting enough milk, abnormal patterns appear with at least two of the four assessment tools.

For example, a baby’s feeding pattern and behaviour may be in the normal range but the baby is thin and not gaining. Another baby who is not getting enough milk may gain a little slowly and look lean but not thin but be irritable and feed all the time. Both babies are not taking in enough milk and need quick and effective treatment.

Underfed breastfed newborn babies may look and act a little differently from underfed older ones.

B) Abnormal newborn feeding patterns

Underfed babies may not have normal types of feeds or the normal number of breastfeeds in one day. 

1) Abnormal types of feeds

They may have abnormal feeds including those that are:   

  1. Short or ineffective in which the baby:
    1. Is very sleepy and weak at the breast.
    2. Is not sucking well on each side.
    3. Is angry at the breast and frequently tugs and pulls.
    4. Is not able to latch or stay latched.
  2. Long (more than 20 minutes per side).

If the mother has a low milk supply, she may notice:

  1. Fewer than expected swallows while breastfeeding.
  2. No choking at the breast once the milk has come in.

2) Abnormal number of feeds each day

Babies may have an abnormal number of feeds and may:

  1. Feed too often (more than 10 times a day).
  2. Not feed often enough (fewer than 7 times a day) (Hassan 2018).

C) Abnormal newborn behaviour

Underfed newborn babies tend to behave abnormally. These babies are generally not happy when fed and held and show abnormal behaviours. Some newborns are irritable and others may be very sleepy

1) Behaviour

a) Irritable underfed newborns

Some underfed newborn babies:

  1. Are still hungry after the second breast.
  2. Won’t settle unless:
    1. Feeding.
    2. Sleeping.
    3. Using a pacifier.
    4. Given a milk supplement.
  3. May need lots of rocking or “dancing” with a caregiver to stop crying.

b) Sleepy underfed newborns

Underfed newborns who become sleepy may:

  • Be unable to wake up to eat regularly.
  • Regularly sleep for more than 5 hours at one time.

 2) Low output

Underfed newborns may:

  1. Have infrequent or deep yellow or orange red pees.
  2. Have infrequent stools.
  3. Have stools that have not changed to yellow by the fifth day after birth.

However, output is not particularly reliable as a way of assessing a newborn baby’s milk intake (Feldman-Winter 2020). This is especially so before the mother's milk has come in.

D) Abnormal newborn appearance

Caregivers may notice that the baby is:

If not quickly fed, the baby will become thin

E) Poor newborn weight gain

The baby may lose too much weight or be gaining too slowly so that the baby:

  • Is under the 75th percentile for weight loss on the NEWT nomogram.
  • Has lost more than 3% of birth weight at 24 hours of age.
  • Has lost more than 7% of birth weight by 72 hours.
  • Takes more than two weeks to return to birth weight.

If not treated, the baby may continue to gain poorly and not follow the growth chart curves.

References

Feldman-Winter L, Kellams A, Peter-Wohl S, et al. Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infants ≥35 Weeks. Pediatrics. 2020 Apr;145(4):e20183696

Hassan B, Zakerihamidi M. The correlation between frequency and duration of breastfeeding and the severity of neonatal hyperbilirubinemia. J Matern Fetal Neonatal Med. 2018 Feb;31(4):457-463