Margery Wilson and Elizabeth Puzar both posted with comments re quantifying
adequate output in the first four or five days following birth, expressing
concern that, if formula is used to stimulate voiding and/or stooling to meet
a predetermined standard, mothers will have their confidence undermined and
infants will suffer negative effect from the early, unnecessary introduction
of cow's milk.  I agree there's reason to consider these things, but I've
found poor output frequently is a marker for excessive weight loss.

I'm one of two LC's in a hospital with about 3500 deliveries / year.
 (Parenthetically, I did the stats for 1995 this week--our BF initiation rate
is up from 49.5% last year to 53.6%!!!  Hurrah!  All that overtime paid off!)
  All of our breastfeeding mothers are sent home with a list of indicators of
adequate intake--baby is alert, active, and responsive when awake, strong
cry, moist mucus membranes (we suggest the parents let the baby suck on a
clean parental finger to evaluate that), feeding at least eight times a day
after the first couple of days, seeming satisfied after most feedings, and
having the requisite number of voids and stools by day four or five, with
stools seedy yellow within 24 hours after milk is in.

We contact most of our breastfeeding mothers by phone a few days after
they're discharged from the hospital, and one of the things we ask about is
output.  If output seems borderline, I suggest the parents keep a written
record of stools and voids and call me the following day if output hasn't
increased or if stools aren't yellow.  If output is clearly low or stools are
still black by the fourth or fifth day, I'll ask the parents to come in for a
weight check, and, more often than not, I find that the kids have lost an
inordinate amount of weight.  Now, these are babies who seemed to be feeding
well (or as well as can be expected in the first 24 hours) when they left the
hospital, who gave no indication that there would be a problem with intake,
and who appeared to be nursing well at home.

Adopting a wait-and-see attitude can dangerous for some babies with low
output. We all know lack of stooIing can cause bilirubin levels to climb, as
bilirubin is reabsorbed back into the circulation, resulting in a sleepy baby
who feeds even more poorly. If the infant loses a lot of weight, with or
without elevated bili, he's often too weak to suckle effectively and must be
supplemented until he's recovered enough to feed well.  Then the parents are
frantic (or the physician is), so I'd rather supplement before they get to
that point, because it's necesssary for a shorter period of time and has less
impact on the mom's supply and her confidence.  Elizabeth points out that a
bottle of formula won't fix the problem, but it certainly will buy enough
time to fix the problem.

If we knew we were dealing with "normal" babies, I'd be much less inclined to
intervene so quickly.  But, given our invasive obstetric practices, I don't
think the great majority of our babies are "normal."  They're affected by
analgesic and anesthetic drugs and by maternal / infant separation
immediately after birth. They're affected by lack of "tribal support" (what
an appropriate term) for the family after discharge from the hospital.  And
they're affected by being born into a bottle feeding culture, which makes a
change to formula feeding much more common than trying to overcome a
breastfeeding problem.  They're also affected by the litigious nature of
American society, which causes nursing and medical practitioners to take
extreme steps to protect themselves from legal action in the event of a
negative outcome that may have had nothing to do with their actions.  (But I
truly think the primary motiviation of most nurses and doctors is to protect
the patient, rather then themselves, from a bad outcome, which often means
erring on the side of caution.)

Kathy Dettwyler, do you have any info on the normal stooling and voiding
patterns of infants in traditional societies?  It would be very helpful to
know what the physiological norms really are.

Judy Dunlap, RNC, IBCLC