DURING THE EARLY MONTHS
The special first milk, called colostrum, is a concentrated form of nutrition that also contains the specific immunities that a newborn needs. Colostrum alone is present in small amounts until the third or fourth day after birth, when most mothers notice that their milk becomes more plentiful. This is when the body begins to shift into the production of mature milk, a transition that takes about two weeks to complete.
After the first few weeks, a mother will notice her breasts feel softer and not as full. This softening of the breasts is a sign that the mother’s milk production is stabilizing to match her baby’s needs. It is normal for the engorged or full feeling of the early weeks to pass.
As long as her baby has at least six to eight wet cloth diapers per day (five to six disposable diapers) and at least two to five bowel movements per day, she can be sure that she has not “lost her milk.”
Most newborns need to nurse an average of eight to twelve times in 24 hours. Some babies nurse less frequently while others nurse more frequently. Less or more frequent nursing is not a problem unless the baby has fewer wet diapers or bowel movements than normal and the baby is not gaining well.
Daily nursing patterns will vary from baby to baby, and an individual baby’s nursing pattern may change from day to day and vary as he grows. A healthy baby with a good suck will naturally fall into the nursing pattern that is best suited for him. Ideally—to best meet her baby’s nutritional and sucking needs—the mother will “watch the baby and not the clock,” breastfeeding him on cue.
During the early months, many babies do what is called “cluster nursing,” spacing feedings closer together at certain times of the day (typically during the evening) and going longer between feedings at other times. Although most babies need to nurse eight to twelve times in 24 hours to grow and thrive, many babies are not content with the regular two-to-three hour feeding intervals some new parents expect. In areas where artificial feeding is the norm, many parents misinterpret their baby’s desire to nurse more often than every two to three hours as a sign that the mother doesn’t have enough milk, when cluster nursing is actually a common feeding pattern for most young breastfed babies.
Some babies do nurse at regular intervals early on, but the length of feedings and the intervals between feedings vary from baby to baby. Due to individual differences, healthy breastfed babies may nurse as often as every hour or as infrequently as every four hours and thrive. If the parents are concerned about their baby’s feeding pattern, suggest they focus on the number of feedings in 24 hours (see previous point) rather than the intervals between feedings and have their baby’s weight checked, as a healthy weight gain is proof that their baby is getting enough milk. See the next section, “Concerns about Milk Supply,” and “Normal Growth Patterns during the Baby’s First Year” in the chapter “Weight Gain.”
As babies grow—and their stomachs grow larger—babies who nursed irregularly may naturally begin to go longer between feedings and develop more regular feeding patterns.
Allowing the baby to finish the first breast first is preferable to switching the baby from the first breast to the second after a specified length of time. This is because the composition of the milk changes during a feeding and only the baby knows when he has received the right balance of fluid and calories.
The milk the baby receives when he begins breastfeeding is called the “foremilk,” which is high in volume but low in fat. As the feeding progresses, the fat content of the milk rises steadily as the volume decreases. The milk near the end of the feeding is low in volume but high in fat and is called the “hindmilk.”
By allowing the baby to decide when he is finished with the first breast, the mother can be sure he has received the proper balance of fluid and fat. Switching breasts too soon might mean the baby will receive only foremilk from each breast, filling him up with low-calorie milk. A baby who receives too much foremilk and not enough hindmilk may gain weight slowly, be fussy at the breast and between feedings, and may have a greenish, liquid stool (Woolridge 1988).
Studies have demonstrated that whether babies nurse from one or two breasts at a feeding they take in similar amounts of milk over twenty-four hours, although a baby may nurse slightly longer when he nurses from one breast at a feeding (Righard 1993; Woolridge 1990).
A mother will know when her baby has finished the first breast when he comes off the breast or falls asleep. Then she can burp him and offer him the other breast, which he may or may not take.
Exceptions to this general rule are the sleepy baby, the lazy nurser, and the baby with a weak suck, who may not nurse effectively at the breast and need the stimulation of being switched from breast to breast frequently in order to nurse actively. (See “Sucking Problems—Types and Suggestions” in the chapter “Positioning, Latch-On, and the Baby’s Suck.”)
Length of feedings vary with the baby’s personality and age. THE WOMANLY ART OF BREASTFEEDING describes common nursing styles such as “the leisurely diner,” “the nip and napper,” “the no-nonsense nurser,” and “the what-goes-down-tends-to- come-up tyke” to reflect the personality and physical differences among babies (La Leche League International, pp. 73-75). A baby’s nursing style also may change as he grows. The baby who is a slow nurser as a newborn may become faster and more efficient as he becomes practiced at breastfeeding.
Differences among mothers may be a factor in length of feedings, too. One study found that the fat content of milk varies among mothers and that babies whose mothers had lower-fat milk tended to nurse longer at feedings and take a greater percentage of the milk in the breast. Both groups of babies gained weight within the normal ranges, but die babies whose mothers had higher-fat milk gained more during their first six weeks. The researchers concluded that the longer feeding times helped the babies whose mothers had lower-fat milk to receive the calories they needed to gain and grow adequately (Tyson 1992).
A baby’s appetite is another factor that affects length of feedings. Because human milk becomes higher in fat as the feeding progresses, a baby who is slightly hungry may nurse for a shorter time at one feeding and longer at another feeding when he is hungrier.
When a baby suddenly wants to nurse more often, it is called a “growth spurt” or “frequency days.” More frequent nursing is the baby’s way of building his mother’s milk supply to meet his increasing needs.
Twenty minutes of vigorous nursing every hour or two is more effective in building up the mother’s milk supply than less frequent but longer sessions at the breast.
Human milk provides all the nourishment a baby needs until about the middle of his first year of life. Even in hot weather, bottles of water are unnecessary. Studies of babies living in hot, humid climates and hot, dry climates found that exclusive breastfeeding met the infant’s need for fluids (Brown 1986; Goldberg 1983).
Concerns about Milk Supply
Mothers often worry about their milk supply, especially if they began breastfeeding with definite expectations about how often or how long their babies would nurse. Babies’ nursing patterns vary, and a pattern that is right for one baby may not be right for another.
If the mother is concerned about her milk supply, review the following points so that she can judge for herself whether she has enough milk.
The amount of milk the mother produces depends on the frequency and effectiveness of the sucking her baby does at the breast. The baby’s effective sucking at the breast causes two hormones, oxytocin and prolactin, to be released by the mother’s pituitary gland. Prolactin is the milk-producing hormone. The more often and effectively the baby sucks, the more prolactin the mother’s body releases and the more milk her breasts will produce. If the baby needs more milk than the mother is producing, he may need to nurse more frequently or suck more effectively in order to increase her supply. The second hormone, oxytocin, causes contractions within the breasts which squeeze the milk down the milk ducts to the nipple so that the baby can get it. This is called the let-down, or milk-ejection, reflex.
Milk production follows the principle of supply and demand. In the beginning, the mother’s body does not know how much milk her baby needs, but by nursing her baby often—at least eight to twelve times every twenty-four hours— her body will automatically adjust her milk supply to meet her baby’s needs.
More frequent but shorter nursings (at least twenty to thirty minutes) build and maintain a mother’s milk supply more effectively than less frequent but longer nursings.
f the mother is concerned about her milk supply, suggest she keep track of how often and how much her baby urinates. During a newborn’s first two or three days (while he is receiving colostrum), he will wet only one or two diapers per day. Once his mother’s milk becomes more plentiful (or “comes in”), the baby should have six to eight wet cloth diapers or five to six disposables per day.
Suggest that the mother try to get a sense of a minimally wet diaper by placing one to two ounces (30-60 ml) of water in a dry diaper to see how it feels.
After six weeks, the number of wet cloth diapers may drop to five or six per day and disposables to four to five per day, but their wetness will increase to four or more ounces (116 ml or more). This is because the baby’s bladder grows in size and is able to hold more urine. At all ages, urine should be pale in color and mild-smelling.
If the mother is worried about her milk supply or if her supply seems to be low, suggest she keep an “input/output” diary, writing down each nursing and each wet diaper and bowel movement as she increases the number of nursings per day.
In the first few days after birth, the baby’s dark, tarry stools are called meconium. This is the stool that the baby has been storing since before birth. Colostrum is a natural laxative and is important in helping the infant pass this first stool. Within twenty-four to forty-eight hours of the mother’s milk becoming more plentiful, the baby’s stools will change in color and consistency. Once the meconium has been eliminated, the stool of the baby who is receiving only mother’s milk will be loose and unformed, often of a pea-soup consistency, and may be yellow to yellow-green to tan in color. An occasional green stool is also normal. The odor should be mild and not unpleasant.
Bowel movements usually become more frequent as the baby regains his birth weight and continues to gain. Most young babies will have at least two to five substantial bowel movements every twenty-four hours. Many babies continue this pattern for as long as they are exclusively breastfed. If bowel movements are small (just a stain on the diaper), there should be many each day. If the baby has only one every few days, it should be very plentiful. (This is more common in the breastfed baby who is older than six weeks of age.) If the baby has fewer than two bowel movements per day during his first four to six weeks, ask the mother how often and how long he nurses, how many wet diapers he has each day, and his weight gain. This may be a normal variation (in which case the baby will be gaining at least 4 to 8 ounces [113 to 226 grams] per week) or it may be a sign that the baby is not nursing long or well enough to get the fatty, calorie- rich hindmilk he needs, or that there are other health problems.
Many babies continue to have frequent bowel movements for as long as they are exclusively breastfeeding. Less frequent bowel movements also may be normal in an older breastfed baby. Some breastfed babies may have bowel movements only once a week without signs of constipation (such as hard, dry stools).
Typical weight gain for the first three months is 4 to 8 ounces per week (113 to 226 grams). Weight gain should always be figured from the lowest point rather than from birth weight. Refer to “First, Establish Weight Gain and Loss” under “Slow Weight Gain” in the chapter “Weight Gain.”
Some mothers find that their milk supply varies during the course of a day. Most mothers feel fuller in the morning and less full in the evening. If the mother’s milk supply seems to be lower in the evening, more frequent breastfeeding will satisfy the baby’s needs.
Some mothers think they do not have enough milk when actually there is no problem with their supply. They worry about behavior or symptoms that have other causes or they’re unfamiliar with the variety of patterns that are normal in breastfed babies. If the baby is gaining well and has plenty of wet diapers and bowel movements, assure the mother there is nothing wrong with her milk supply even if she notices any of the following:
- The baby nurses very often. Many babies have a strong need to suck or a need for frequent contact with their mothers. If a baby is nursing effectively, frequent nursing means that the baby is getting enough—not that there is a lack of milk.
- The baby seems hungry an hour or so after being fed. Human milk digests more quickly than formula and places less strain on a baby’s immature digestive system, so the breastfed baby needs to be fed more frequently than the formula-fed baby.
- The baby suddenly increases the frequency and/or length of his nursings. Babies who are very sleepy as newborns often “wake up” at about two to three weeks of age and begin nursing more frequently. Babies also go through occasional growth spurts (at around two weeks, six weeks, and three months). During these periods they nurse more often than usual to bring in more milk for their increasing needs.
- The baby suddenly decreases his nursing time, perhaps down to five to ten minutes per breast. He may simply be able to extract the milk more quickly now that he is more experienced at nursing.
- The baby is fussy. Many babies have a fussy period each day, often at about the same time of the day. Some babies are fussy much of the time. Fussiness can be caused by many things other than hunger, but often there is no discernible reason. Many mothers believe their babies’ irritability and fussiness are indications that they are not getting enough milk. Some studies have indicated that breastfed babies may initially tend to be fussier than their formula-fed peers (DiPietro 1987). This may be a way of making sure they will breastfeed as often as they need to. It is the baby who is placid and easygoing who seems to be more likely to go longer between feedings and gain weight slowly.
- The mother’s breasts leak only a little or not at all. Leaking has no relationship to the amount of milk the mother produces, and the mother whose breasts do leak during feedings usually finds that leaking between feedings is no longer a problem once her supply becomes established and regulated to her baby’s needs.
- The mother’s breasts suddenly seem softer. This happens as the mother’s milk production adjusts to her baby’s needs and the initial breast fullness or engorgement subsides within the first few weeks.
- The mother never feels the let-down, or milk-ejection, reflex or it does not seem as strong as it did before. This may occur as time goes on. Some mothers do not feel a let-down at all, but they can learn to recognize that it is occurring by watching their baby’s pattern of sucking and swallowing go from fast sucks with little swallowing to slow deep sucks and more frequent swallows.
- The baby was weighed before and after a feeding and the mother was told her baby did not receive enough milk. Studies have shown that test weighing is not a reliable indicator of whether a baby has breastfed well, because most baby scales are not sensitive enough to record such small changes in weight accurately (Whitefield 1981). However, modern elec-tronic scales that are more sensitive to small weight changes have been found to accurately reflect how much milk a baby receives (Meier 1994). Test-weighing on this type of scale may be helpful to mothers in certain situations. (For more on these special scales, see “Determining a Baby’s Readiness to Breastfeed” in the chapter “Prematurity.”)
- The baby takes a bottle after nursing. Many babies will suck on a bottle even when they are full, because they like to suck. This is not necessarily a sign that the baby did not get enough at the breast.
- The mother cannot express much milk. Milk expression is a learned skill and the amount of milk expressed will increase with practice and the mother’s ability to let down her milk to the pump. Pumping effectiveness may also vary depending on the type of pump used, as some pumps tend to be more effective than others. The amount of milk a mother expresses may be unrelated to her milk supply.
After the Baby Starts Solids
Human milk is recommended as the primary food for the baby’s first year. Since solid foods displace human milk in a baby’s diet, suggest the mother breastfeed first, before offering solids, until the baby is nine to twelve months old. She can gradually increase the amount of solids she offers her baby.
In one study, researchers observed 141 mother-baby couples. The mothers exclusively breastfed their babies until solid foods were introduced at no earlier than four months of age. They found that the energy value of the human milk the baby consumed when he was exclusively breastfeeding matched closely the combined energy value of human milk plus solid foods he took later. The researchers concluded that rather than increasing their intake of calories when solid foods were started, the babies balanced their mother’s milk and solid food intake to maintain a stable intake of calories. The volume of the mother’s milk dropped when solid foods were introduced (Cohen 1994).
By breastfeeding the baby before offering solids until he is about a year old, the mother can be sure that he is receiving the milk he needs for growth. At one year of age, it is appropriate to offer solids first. (More information on introducing solid foods can be found in the chapter “Starting Solid Foods.”)
If solids are introduced too quickly and replace many nursings during the baby’s first year, he may not get enough fluids, causing constipation. In the breastfeeding baby, constipation means hard, dry stools. Going for several days without a bowel movement or straining while passing a bowel movement are within the range of normal behavior and are not considered signs of constipation. If other fluids, such as juice or water, are given instead of human milk or formula the baby may not have his nutritional needs met (Smith and Lifshitz 1994).
If the baby is constipated, suggest the mother nurse her baby more often. When the baby is nursing more, he will have softer stools.
The Breastfeeding Toddler
In cultures where breastfeeding is unrestricted, breastfeeding continues for years, not months. Natural weaning occurs on average when the child is two to four years old. In developed countries, however, extended nursing may be considered unusual. If the mother would like suggestions on how to encourage her toddler to shorten or eliminate nursings, refer to “Approaches to Weaning” in the chapter “Weaning.”
Breastfeeding beyond infancy has many benefits for both mother and child. If the mother would like more information on nursing longer than one year, refer her to the book, MOTHERING YOUR NURSING TODDLER by Norma Jane Bumgarner, available from La Leche League International.
Breastfeeding and Infant Sleep Patterns
Typically, a newborn has one long four-to-five hour sleep period, which often occurs during the day. It is common for a newborn to have his days and nights mixed up, because during pregnancy the mother’s movements during the day lull the baby to sleep and her stillness at night promotes baby’s alertness. Parents can gradually shift this longer sleep period from day to night by keeping stimulation to a minimum during normal sleep hours. Keeping lights low (using a night light only or turning on the closet light and pulling the door partly closed), minimizing movement, and changing diapers only when absolutely necessary (when baby has a bowel movement or clothing is soaked) all lessen the stimulation that promotes wakefulness. Over time this will help a baby learn to sleep at night instead of during the day.
One study of 26 newborns showed that it is possible to “teach” breastfeeding infants to have a long five-hour stretch of sleep from midnight to 5 AM during their first eight weeks of life by gradually lengthening feeding intervals during the night. Instead of nursing, other comfort measures were given, such as swad-dling, diapering, and walking. By eight weeks of age, all 13 of the babies who were “trained” to sleep were sleeping five hours at night, while only 3 of the control babies slept that long. According to the researchers, both groups of babies took in equal amounts of milk per day (Pinilla and Birch 1993). While this may work in some families, other families may find that nursing the baby back to sleep is easier than persuading the baby to accept other comfort measures.
The young baby is growing at a phenomenal rate and often has a physical need to be fed during the night. Also, the mother’s breasts can become engorged and uncomfortable if she goes for five, six, or more hours without a feeding. If her breasts become uncomfortably full, she is at increased risk for mastitis and the baby might have trouble latching on to very full breasts in the morning.
Many babies continue to wake at night, even into their toddler years. Some reasons for waking are: hunger, teething, restlessness due to a new developmental stage, individual differences in sleep patterns, and loneliness. Even older babies may be hungry at night.
One study of breastfeeding mothers and babies, who were followed into their second year, found that the breastfeeding babies and toddlers did not conform to the usual sleep patterns of artificially fed babies and that these differences were even more pronounced among babies who slept with their parents. Rather than beginning to have a long stretches of unbroken sleep after about four months of age, as was common among the artificially fed babies, the breastfeeding babies continued to sleep in short bouts with frequent waking. The researchers concluded that as extended breastfeeding becomes more common in Western society, expectations of babies’ sleep/wake patterns may need to be revised (Elias 1986).
The belief that starting solids will help a baby “sleep through the night” motivates many parents to begin solids earlier than they otherwise would. However, this popular belief has no basis in fact. Two studies found no difference in the sleep patterns of babies who received solids before bedtime in comparison to babies who were not given solids (Macknin 1989; Keane 1988).
Although some babies in these studies began sleeping more at night when solids were started, about the same number of babies in the control group also began sleeping more at night. Macknin concluded, “Infants’ ability to sleep through the night is a developmental and adaptive process that occurs regardless of the timing of introduction of cereal.”
In many cultures where breastfeeding is the norm, mothers and babies sleep close to each other at night so that the baby can be nursed with less disruption of sleep. Parents in these cultures expect babies to wake frequently to nurse at night until they have matured enough to naturally outgrow this behavior, a process that may take years. A wakeful baby—even a wakeful older baby or toddler—is not considered unusual or a problem in these cultures (Morelli 1992).
In many Western cultures, however, artificial feeding is the norm and consequently the expectations are different. Babies are expected to sleep for long stretches alone, often in a separate room, by the time they are three to four months old. When a baby’s sleep patterns do not conform to these expectations, the parents may feel frustrated and upset. The mother may wonder what she is doing “wrong” to cause her baby’s wakefulness. If she spends her nights going back and forth between her bed and her baby’s room and nursing sitting up rather than sleeping while she breastfeeds, she may be exhausted from lack of sleep. Listen to the mother’s frustrations and worries and rephrase them so that she knows she has been heard and understood.
Assure her that night waking is normal for many babies (see previous points), and encourage her to find ways to make night nursings easier so that she can get more sleep. For example, if the baby sleeps in a crib, bringing the crib into the mother’s room might make it easier for her to hear her baby stir before he has fully awakened and begun to cry. Most mothers and babies settle down to sleep again more quickly if they are not fully awakened.
There are many alternatives to the usual sleeping arrangements that can make night nursings easier. The baby’s crib could be attached to the parents’ bed in a “side-car” arrangement. A mattress or sleeping bag could be put on the floor in the parents’ or baby’s room, so that the mother can lie down and sleep while nursing the baby back to sleep, and return to her own bed if she wishes after the baby goes back to sleep. Or the parents could simply bring the baby into their bed, either for part of the night—after he awakens—or for the whole night. The mother should be encouraged to do whatever works best for her and her family.
If the mother would like more information on why babies sleep differently than adults and about alternative sleeping arrangements, refer her to the book, NIGHTTIME PARENTING by William Sears, MD, available from La Leche League International.
James McKenna, professor of anthropology at Pomona College in Claremont, California, calls babies sleeping alone at night “an extremely recent cultural experiment,” and questions whether this practice is good for babies. Several of McKenna’s studies provide evidence that when mother and baby sleep together, the mother’s breathing and movements affect the baby’s breathing and arousal patterns. McKenna suggests that in certain vulnerable infants this may help prevent Sudden Infant Death Syndrome (SIDS), also known as cot death (McKenna and Mosko 1993; McKenna 1990; McKenna 1986). Breastfeeding, independent of sleep practices, has also been found to lower the risk of SIDS (Mitchell 1992).
McKenna suggests that scientists and pediatricians rethink the assumptions underlying infant sleep research and the recommendations they give parents about where and how babies should sleep. According to McKenna, the current Western view of normal sleep patterns for babies reflects only how infants sleep under solitary conditions; he expresses concern about “whether our cultural preferences as to how we want infants to sleep push some infants beyond their adaptive limits” (McKenna 1993). In many non-Western cultures, sharing sleep with infants is the norm (Morelli 1992).
In the United States over the past ten years, “sleep training” methods have risen in popularity. Sleep training proponents warn that children may have sleep problems later unless they learn to fall asleep alone and soothe themselves back to sleep when they wake at night. Due to these warnings, many parents question whether it is healthy to nurse and comfort their child at night. However, the sleep patterns used as norms by these sleep training proponents may not be appropriate for breastfeeding babies (see previous points).
One of these proponents advises parents to put babies as young as four months old in the crib at bedtime and let them “cry it out” until they fall asleep, which may take hours at first. According to this doctor, the crying will diminish over the first week and the child will learn to go to sleep easily in his crib (Weiss- bluth 1987). Another sleep training proponent takes a similar approach, but encourages parents to go into the baby’s room every five minutes to reassure him without picking him up until he falls asleep (Ferber 1985).
Although it may be possible to train infants and young children to adopt sleep patterns that are developmentally appropriate for older children and adults, no research has been done on the long-term effects of these practices. The fact that sleep training methods “work” for many children is no guarantee that the long-term effects are positive.
- Within two weeks after birth, colostrum is completely replaced by mature milk.
- Within the first month of nursing, most mothers notice that their breasts feel softer and not as full as they did at first.
- Most exclusively breastfed newborns need to nurse on average eight to twelve times in 24 hours in order to get enough milk.
- The healthy baby with a good suck will naturally settle into the pattern of nursing that is right for him.
- When the baby is allowed to finish the first breast first, before the mother offers the second, he will get the proper balance of fluid and calories.
- Length of feedings vary due to differences among babies and mothers, nursing efficiency at different ages, and degrees of hunger from one feeding to the next.
- “Growth spurts’’—or periods of increased nursing—commonly occur at around two or three weeks, six weeks, and three months of age.
- More frequent but shorter nursings build and maintain a mother’s milk supply more effectively than less frequent but longer nursings.
- A breastfed baby does not need water or formula supplements.
- New mothers may worry about whether or not their babies are getting enough milk.
- The more often and effectively a baby nurses, the more milk there will be.
- After the mother’s milk “comes in” on the third or fourth day after birth, she can tell her baby is getting enough fluids if he has at least six to eight wet cloth diapers (five or six disposable diapers) every twenty-four hours.
- During the first six weeks, two to five bowel movements per day indicate the baby is getting enough calories.
- In the baby older than six weeks, less frequent bowel movements may be normal.
- From birth to three months, typical weight gain is four to eight ounces (113 to 226 grams) per week.
- A mother’s milk supply may vary at different times of the day.
- “False alarms” cause some mothers to worry that their milk supply is low.
- After her baby starts solids and until he is about a year old, encourage the mother to breastfeed before giving solids so that he will receive the milk he needs for growth.
- If solids become a major part of the baby’s diet during his first year, he may eliminate many nursings. Suggest the mother watch for constipation and be sure her baby’s nutritional needs are met.
- It is normal for breastfeeding to continue past infancy.
- Typically, newborns have one long four-to-five hour sleep period, which may or may not be at night. Parents can help encourage sleep by keeping all stimulation at night to a minimum.
- During the early months, it is beneficial for both mother and baby to breastfeed at least once during the night.
- It is common for babies to continue to wake during the night, even after the early months.
- Studies show that starting solid foods does not cause babies to sleep longer.
- If the mother is having difficulty coping with her baby’s night waking, listen to her feelings and discuss ways she can minimize the disruption to her sleep.
- Keeping mother and baby close at night not only minimizes sleep loss, it may also have health benefits for baby.
- Although it may be possible to “train” babies to adopt sleep patterns appropriate for older children and adults, the long-term effects of altering natural sleep patterns have not been studied.