Because you are using a nipple shield and he has jaundice you need to keep a very close eye on his poop output. A nipple shield can prevent the baby from getting enough hindmilk/fat/caloires, so can being sleepy, not nursing well, etc. And its the pooping that gets rid of the bilirubin.
You should expect that between day 3-5 to see a change from meconium to normal poop.
Also you should be seeing a real lactation consultant. No qualified professional would have told you to use a nipple shield before your milk was in.
IS BABY GETTING ENOUGH? -- QUICK REFERENCE CARD
~~~ BIRTH to 6 WEEKS ~~~
If baby is gaining well on mom’s milk alone, then baby is getting enough. A 5-7% weight loss during the first 3-4 days after birth is normal. Baby should regain birth weight by 2 weeks. Once mom’s milk comes in, average weight gain is 6 oz/week. If these goals are not met, call your lactation consultant. More on weight gain.
WET DIAPERS: 5 - 6+ sopping wet diapers per day (after 1st week).
Expect one wet diaper on day one, increasing to 5-6 by one week. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper (if baby wets more often, then the amount of urine per diaper may be less). Urine should be pale and mild smelling.
DIRTY DIAPERS: 3 – 4+ dirty diapers per day (after day 4).
Stools should be yellow (no meconium) by day 5 and the size of a US quarter (2.5 cm) or larger. The normal stool of a breastfed baby is usually yellow and is loose (soft to watery, may be seedy or curdy). More on infant stooling.
OTHER POSITIVE SIGNS: After a feeding, mom’s breast feels softer and baby seems reasonably content. Baby is alert, active and meeting developmental milestones.
A nipple shield started before the mother’s milk becomes abundant (day 4 to 5) is bad practice. Starting a nipple shield before the mother’s milk “comes in” is not giving time a chance to work. Furthermore, used improperly (as I see it often being used), a nipple shield may result in severe depletion of the milk supply.
Potential causes of low milk supply
Nipple shields can lead to nipple confusion. They can also reduce the stimulation to your nipple or interfere with milk transfer, which can interfere with the supply-demand cycle.
Reverse Pressure Softening
... a technique to aid latching when a mother is engorged
In answer to the question, "Is baby getting enough?" a second question could be posed, "Enough of which?" In the early weeks wet diaper counts give only part of the answer. Because the nursing newborn takes in plenty of foremilk before receiving the richer hindmilk, it would be difficult for an infant to produce several bowel movements per day without being adequately hydrated.
However, the opposite can easily occur. Since feeding practices, ineffective sucking or other problems may diminish the mother's milk supply or prevent the baby from receiving an adequate portion of hindmilk, it is possible for a baby to be adequately hydrated yet have an inadequate calorie intake. Frequent urination remains one valid indicator of adequate newborn hydration from foremilk intake. Multiple daily stooling is an indicator of adequate newborn calorie intake from hindmilk. Both factors are needed to fully assess neonatal breastfeeding.
Since a lack of daily stooling may be associated with inadequate newborn calorie intake, it is also a predictor of poor infant weight gain. Early detection of this symptom can be crucial for the baby's health and the continuation of breastfeeding. In severe cases, an infant's low calorie intake may lead to weaker sucking, diminished milk supply and critical dehydration. While less serious conditions may be improved at various stages of breastfeeding, it is much more effective to establish a generous milk supply and hearty weight gain in the early weeks than to have to work to achieve them in later months.
Two Types of Jaundice
The liver changes bilirubin so that it can be eliminated from the body (the changed bilirubin is now called conjugated, direct reacting, or water soluble bilirubin--all three terms mean essentially the same thing). If, however, the liver is functioning poorly, as occurs during some infections, or the tubes that transport the bilirubin to the gut are blocked, this changed bilirubin may accumulate in the blood and also cause jaundice. When this occurs, the changed bilirubin appears in the urine and turns the urine brown. This brown urine is an important clue that the jaundice is not "ordinary". Jaundice due to conjugated bilirubin is always abnormal, frequently serious and needs to be investigated thoroughly and immediately. Except in the case of a few extremely rare metabolic diseases, breastfeeding can and should continue.
Accumulation of bilirubin before it has been changed by the enzyme of the liver may be normal—"physiologic jaundice" (this bilirubin is called unconjugated, indirect reacting or fat soluble bilirubin). Physiologic jaundice begins about the second day of the baby's life, peaks on the third or fourth day and then begins to disappear. However, there may be other conditions that may require treatment that can cause an exaggeration of this type of jaundice. Because these conditions have no association with breastfeeding, breastfeeding should continue. If, for example, the baby has severe jaundice due to rapid breakdown of red blood cells, this is not a reason to take the baby off the breast. Breastfeeding should continue in such a circumstance.
So-called Breastmilk Jaundice
There is a condition commonly called breastmilk jaundice. No one knows what the cause of breastmilk jaundice is. In order to make this diagnosis, the baby should be at least a week old, though interestingly, many of the babies with breastmilk jaundice also have had exaggerated physiologic jaundice. The baby should be gaining well, with breastfeeding alone, having lots of bowel movements, passing plentiful, clear urine and be generally well (handout #4 Is My Baby Getting Enough Milk?). In such a setting, the baby has what some call breastmilk jaundice, though, on occasion, infections of the urine or an under functioning of the baby's thyroid gland, as well as a few other even rarer illnesses may cause the same picture. Breastmilk jaundice peaks at 10-21 days, but may last for two or three months. Breastmilk jaundice is normal. Rarely, if ever, does breastfeeding need to be discontinued even for a short time. Only very occasionally is any treatment, such as phototherapy, necessary. There is not one bit of evidence that this jaundice causes any problem at all for the baby. Breastfeeding should not be discontinued "in order to make a diagnosis". If the baby is truly doing well on breast only, there is no reason, none, to stop breastfeeding or supplement with a lactation aid, for that matter. The notion that there is something wrong with the baby being jaundiced comes from the assumption that the formula feeding baby is the standard by which we should determine how the breastfed baby should be. This manner of thinking, almost universal amongst health professionals, truly turns logic upside down. Thus, the formula feeding baby is rarely jaundiced after the first week of life, and when he is, there is usually something wrong. Therefore, the baby with so-called breastmilk jaundice is a concern and "something must be done". However, in our experience, most exclusively breastfed babies who are perfectly healthy and gaining weight well are still jaundiced at five to six weeks of life and even later. The question, in fact, should be whether or not it is normal not to be jaundiced and is this absence of jaundice something we should worry about? Do not stop breastfeeding for “breastmilk” jaundice.
Higher than usual levels of bilirubin or longer than usual jaundice may occur because the baby is not getting enough milk. This may be due to the fact that the mother's milk takes longer than average to "come in" (but if the baby feeds well in the first few days this should not be a problem), or because hospital routines limit breastfeeding or because, most likely, the baby is poorly latched on and thus not getting the milk which is available (handout #4 Is My Baby Getting Enough Milk?). When the baby is getting little milk, bowel movements tend to be scanty and infrequent so that the bilirubin that was in the baby's gut gets reabsorbed into the blood instead of leaving the body with the bowel movements. Obviously, the best way to avoid "not-enough-breastmilk jaundice" is to get breastfeeding started properly (handout #1 Breastfeeding—Starting Out Right). Definitely, however, the first approach to not-enough-breastmilk jaundice is not to take the baby off the breast or to give bottles (see Handout B: Protocol to Increase Breastmilk Intake by the Baby). If the baby is nursing well, more frequent feedings may be enough to bring the bilirubin down more quickly, though, in fact, nothing needs be done. If the baby is nursing poorly, helping the baby latch on better may allow him to nurse more effectively and thus receive more milk. Compressing the breast to get more milk into the baby may help (handout #15 Breast Compression). If latching and breast compression alone do not work, a lactation aid would be appropriate to supplement feedings (handout #5 Using a Lactation Aid). See also the handout: Protocol to Inc
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IBLCE - International Board of Lactation Consultants Examiners
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