NORMAL BREASTFEEDING PATTERNS
There is a wide variation in what’s normal. This is as true of breastfeeding patterns as it is of other areas of child development and growth. Two different—yet perfectly normal and healthy—children may walk, talk, and get their first tooth at different ages. Their nursing patterns may differ, too. One baby may breastfeed every hour while another baby may breastfeed only every four hours and both may thrive. Individual differences and variations must be taken into account when discussing breastfeeding, which is why breastfeeding is an art and not a science.
Many new mothers, however, expect simple and straightforward answers to questions such as: “How often and long does my baby need to breastfeed?” or “When will my baby stop waking at night to nurse?” When a mother asks a general question like this, the most honest response will be, “It depends on your baby.” This is because cut-and-dried answers do not take into account individual differences.
Encourage the mother to look to her baby for the answers to these kinds of questions. No one can tell a mother with certainty exactly how often or long her baby will need to nurse or at what age he will “sleep through the night.” Babies’ nursing patterns vary, and a pattern that is right for one baby may not be right for another. Also, an individual baby’s nursing pattern may vary as he grows. Assure the mother that a healthy baby with a good suck will naturally fall into the nursing pattern that is best suited for him. If she is worried about her milk supply, see the later section “Concerns about Milk Supply.” Also assure her that by responding to her baby’s cues she can be confident that she is doing the best for her baby.
In the Early Days
It is normal for a baby to want to breastfeed long and often in the early days. When breastfeeding is unrestricted during the first few days after birth many mothers report that their babies nurse for a couple of hours at a time then sleep for a couple of hours and repeat this pattern until the mother’s milk becomes more plentiful (Frantz 1983). Another common pattern is more frequent breastfeeding for shorter periods of time. Occasionally a baby may be uninterested in nursing or very sleepy in the first few days. In this case, suggest the mother encourage her baby to breastfeed at least eight to twelve times per day by trying to rouse the baby when he’s in a light sleep cycle. (Look for rapid eye movements under closed eyelids, arm or leg movements, lip movements, and changes in facial expression.) See “How to Rouse a Sleepy Baby” in the section “Positioning, Latch-On, and the Baby’s Suck.”
The colostrum, the yellow or golden first milk the baby receives in his first few days of life, has high concentrations of nutrients and immunities, but it is small in quantity (teaspoons, not ounces). Not feeling full encourages the baby to nurse frequently, which assures that the baby gets the colostrum he needs. Frequent nursing helps to establish a good milk supply early on, as well as providing a variety of health benefits.
A mother’s labor and delivery may affect breastfeeding at first. For example, a cesarean birth or a difficult labor may make the baby sleepy for several days or may affect the baby’s suck.
Recent studies indicate that pain relievers and anesthesia used during labor and delivery may contribute to breastfeeding problems by causing baby’s suck and overall coordination to become disorganized and may also delay the first nursing. Sepkoski (1992) found that babies whose mothers received epidurals were less alert, less able to orient themselves, and had less organized movements than babies whose mothers gave birth without medication and that these differences were measurable during the babies’ entire first month. Righard and Alade (1990) concluded that sucking problems were more common among babies whose mothers received pethidine (also known as meperidine or Demerol) during labor than among babies whose births were unmedicated. Nissen (1995) later replicated this finding and concluded that infants whose mothers received pethidine had delayed and depressed sucking and rooting. Crowell (1994) observed that the first effective breastfeeding was delayed an average of more than eleven hours among mothers who received butorphanol or nalbuphine during labor when compared with mothers who received no labor analgesia.
Righard and Alade (1990) found that in addition to the effects of labor medication, separating mother and baby before the first nursing also resulted in sucking problems when mother and baby were reunited to nurse, even though the separation was only about twenty minutes long. Of the babies who had unmedicated births with no separation from mother, 16 out of 17 breastfed well. Of the babies who had unmedicated births and were taken from mother for about twenty minutes for weighing and measuring, only seven out of 15 babies breastfed well. Of the babies who had medicated births and were briefly separated from mother, none of the 19 babies breastfed well at the first nursing. Other studies have correlated early separation with shorter overall duration of breastfeeding (Wimmer-Puchinger and Nagel 1982; deChateau and Wiberg 1977).
If the mother and baby are positioned well and the baby is latched on well and sucking effectively, frequent and unrestricted breastfeeding does not cause sore nipples (deCarvalho 1984). It does, however, offer the following advantages for both mother and baby.
Provides the baby with the colostrum he needs. Although colostrum is small in quantity, it is rich in nutrients and immunities. A baby receives most of his immunities to illness while in utero, but a significant portion comes from his mother’s colostrum.
Prevents painful engorgement in the mother. When breastfeeding is unrestricted, mothers are less likely to become painfully engorged. While it is normal for the breasts to enlarge, one study found that the more minutes the newborns spent nursing during their first 48 hours the less painful breast engorgement was reported by their mothers (Moon and Humenick 1989).
Stimulates uterine contractions in the mother and lessens the chances of hemorrhage. After birth, the newborn’s immediate nursing hastens the delivery of the placenta. The mother will have less blood loss because the baby’s sucking causes the uterus to contract (Chua 1994).
Prevents newborn jaundice. Research comparing groups of babies breastfed at varying intervals has confirmed that those fed more frequently have lower bilirubin levels. In one study (deCarvalho 1982), babies who breastfed at least eight times a day had bilirubin levels three mg/dl lower than babies who breastfed less frequently. This is because the colostrum has a laxative effect, stimulating the baby’s bowels to expel his bilirubin-rich stool before the bilirubin is reabsorbed by his body.
Gives the baby practice at nursing before his mother’s breasts become full. Giving the baby lots of time at the breast in the first few days allows him to learn to breastfeed effectively before his mother’s breasts become fuller as her milk supply becomes more plentiful, usually on the third or fourth day after birth. This is especially important for the mother with flat or inverted nipples.
Stimulates the mother’s milk to increase more quickly. One study that followed two groups of newborns from birth found that on their third day of life the milk intake of the babies who nursed six or fewer times per day was only about 54% of that of the babies who nursed seven to eleven times per day. The babies who nursed more frequently also lost less weight initially and began regaining their birth weight more quickly. The difference in intake continued to be significant through the fifth day of life, when the group nursing less frequently consumed 83% of the milk consumed by the more frequently nursing group (Yamauchi and Yamanouchi 1990).
Some babies are sleepy or uninterested in nursing during their first few days, especially if they are small, labor and delivery were difficult, or their mothers received certain medications during labor and delivery.
To ensure that the baby receives the nutrition he needs and to help prevent or minimize maternal engorgement, suggest the mother encourage her sleepy baby to breastfeed at least eight to twelve times every twenty-four hours. Rather than trying to rouse the baby when he is in deep sleep, she should wait until she notices cues that he is in a light sleep cycle, such as eyes moving under eyelids, movement of lips or arms and legs. See “How to Rouse a Sleepy Baby” in the chapter “Positioning, Latch-On, and the Baby’s Suck.”
During a newborn’s first day or two (while the mother is producing colostrum alone), he will wet only one or two diapers per day. When his mother’s milk becomes more plentiful (or “comes in”), the baby’s output will gradually increase (over the next day or two) to six to eight wet cloth diapers or five to six disposables and two to five bowel movements every 24 hours.
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.
Whether breastfed or artificially fed, newborns tend to lose weight during the first three to four days after birth. This is due to the shedding of excess fluids in the baby’s tissues at birth and the passage of meconium (the first stool).
A weight loss of 5% to 7% is normal. One study found that when mothers received regular breastfeeding guidance and support, very few babies lost more than 7% of their birth weight (DeMarzo 1991). While a weight loss of 10% is considered acceptable, it may be a sign that breastfeeding is not going smoothly and that the mother needs additional help.
Birth weight should be regained by two to three weeks of age.
When breastfeeding is going well, water or formula supplements are not needed (Nylander 1991). Early supplements are not only unnecessary, but they can also contribute to health problems in mother and baby and interfere with breastfeeding in the following ways.
Supplements fill up the baby, making him less interested in breastfeeding, and water supplements contribute to weight loss. A baby who fills up on water is not getting the calories he needs. Water and glucose solutions interfere with breastfeeding, and babies who receive these tend to lose more weight than babies who are exclusively breastfeeding (Kurinij and Shiono 1991; Glover and Sandilands 1990; Houston 1984).
Water supplements contribute to newborn jaundice. Studies indicate that the more water a baby receives in the early days, the higher his bilirubin levels (Kuhr and Paneth 1982; Nicoll 1982). The baby’s first stool (called “meconium”) is rich in bilirubin. Colostrum has a laxative effect, helping babies to pass this meconium more quickly, thereby keeping bilirubin levels down. Water supplements, on the other hand, do not stimulate bowel movements, causing the bilirubin to be reabsorbed into the baby’s system and contributing to newborn jaundice.
Formula supplements in the newborn period can sensitize some babies to milk allergy or intolerance. Babies who receive formula in the newborn period are at greater risk of becoming sensitized to cow’s milk and going on to develop cow’s milk allergy or intolerance during their first year (Host 1988).
When given with an artificial nipple, supplements can cause breastfeeding problems, weakening a baby’s suck or causing baby to refuse the breast. Many breastfeeding experts have observed that a newborn may become confused when switched back and forth from bottle to breast in the early weeks (Neifert 1995). This may be because his tongue, jaw, and mouth move differently during breastfeeding than while using a bottle, pacifier (dummy), and most types of nipple shield (Newman 1990). One study found that 30% of mothers whose babies received bottles in the hospital reported severe breastfeeding problems, as compared with 14% of those whose babies did not (Cronenwett 1992).
Kittie Frantz, retired LLL Leader, pediatric nurse practitioner, and instructor for the UCLA Lactation Educator and Consultant Courses, estimates that 95% of babies will become confused if given artificial nipples during the first three to four weeks after birth. For some babies it may take a week of bottles before they become nipple confused; for other babies, only one or two bottles—or other artificial nipples—will cause it. Once a baby has been breastfeeding well for three to four weeks, nipple confusion is less likely to develop, so if a mother plans to give her baby bottles, suggest she wait until after her baby’s first month to introduce them.
Supplements contribute to engorgement, because they decrease the amount of time baby spends breastfeeding. More time spent nursing has been associated with decreased engorgement (Moon and Humenick 1989).
Supplements interfere with the establishment of a mother’s milk supply. Milk production is dependent upon how often, long, and effectively the baby nurses. If the baby is supplemented, he will go longer between nursings and take less milk at the breast, possibly developing a less effective sucking pattern and delaying the increase in his mother’s milk supply.
Early supplementation is strongly correlated with a shorter duration of breastfeeding, which may be caused by the factors listed above as well as by the unspoken, incorrect message the mother receives when her baby is supplemented—that her milk is not enough for her baby. This may lead her to continue supplementing after the early days (Kurinij and Shiono 1991).
Glucose, plain water, or formula supplements are unnecessary. These are sometimes offered to babies for a variety of reasons.
To detect a possible T-E fistula. The possibility of tracheoesophageal fistula (an abnormal hole between the windpipe and the esophagus) is sometimes given as a reason for postponing the first breastfeeding. Plain or glucose water may be given routinely in some hospitals before putting the baby to the breast. However, the mother can ask her doctor to check for this in other ways. The incidence of T-E fistula in newborns is about 1 in 4,000.
To prevent or “flush out” jaundice. Research has refuted the validity of this belief, demonstrating that water supplements do not reduce bilirubin levels (Kuhr and Paneth 1982) and can actually increase them (Nicoll 1982). See “Avoid Water Supplements” in the chapter “Newborn Jaundice.”
To prevent dehydration in the sleepy or uninterested baby. Stimulating a sleepy newborn to nurse frequently is the preferred approach, due to the disadvantages of supplements listed above (See “How to Rouse a Sleepy Baby” in the chapter “Positioning, Latch-On, and the Baby’s Suck.”) Because babies are born with excess fluids in their tissues at birth, dehydration is rarely an issue in the first few days. However, if the mother has concerns about it, she may appreciate knowing the symptoms of dehydration so she can be certain that her baby is not at risk:
- skin losing its resiliency (when pinched, it stays pinched looking),
- dry mouth, dry eyes,
- weak cry,
- minimal urine output (one to two wet diapers is normal during the first two days, after that fewer than three wet diapers would be a danger sign), and
To treat or prevent hypoglycemia. Hypoglycemia, or low blood sugar, is usually due to delayed or inadequate feedings. In most cases, frequent nursing (or feedings of human milk) is all that is needed. Unless a blood test indicates that a baby’s blood-sugar level is below normal, supplements should not be considered. See “Neonatal Hypoglycemia” in the chapter “Illness—Baby.”
Pacifier (dummy) use has been associated with the following breastfeeding problems:
- slow weight gain,
- nipple confusion,
- increased risk of early weaning,
and it may contribute to an earlier return of fertility in the mother. For more information, see the section “Pacifier Use” in the section “Common Questions” later in this chapter.
- Answers to questions about breastfeeding patterns are rarely simple and straightforward.
- During the first few days after birth, many babies want to breastfeed often and long—sometimes for an hour or more at a time—until the mother’s milk supply becomes more plentiful.
- The length and difficulty of labor and delivery, the use of medications during labor and delivery, and separation of mother and baby after birth have been found to affect a baby’s interest and ability to nurse in the early days.
- Frequent and unrestricted breastfeeding in the early days offers health benefits for both mother and baby.
- If a baby is sleepy or uninterested in nursing during his first few days, suggest the mother encourage him to breastfeed often.
- One or two wet diapers a day are normal for the exclusively breast-feeding baby during the first two days after birth.
- Weight loss is considered normal during the first three to four days.
- Routine supplements during the early days are unnecessary, can interfere with breastfeeding, and can contribute to health problems in mother and baby.
- The baby’s first bowel movement, meconium, is dark and tarry.
- Many of the reasons given for supplementary bottles are not valid.
- Pacifier use has been associated with breastfeeding problems in some babies.