Being a “semi-demand feeding” parent

We all love and need to eat! It makes us feel good and gives us the energy to do things in life.
Human babies are no different in this need.  They want to eat when fuel is needed and then feel content. Where they do differ from adults though is in their ability to get their food.

Once out of the womb, human babies are dependent on adults to create the right conditions to enable them to feed. If this is breastfeeding, the baby needs to be in full body contact with its mother’s body, on its tummy in an alert state (not too groggy after birth) so it can step, crawl, push, feel, smell and see its way to the breast. If the feeding is to be by bottle, the baby needs holding in an appropriate manner so it can drink safely from it.

We as adults all recognise that babies need feeding soon after birth. Birth, after all, means the ending of the constant food delivery system that baby’s been used to for many months. The drip-feeding from mother to baby via the placenta and umbilical cord has to be replaced quickly so that blood sugar levels stay steady. This is why – in Baby Friendly hospitals in particular – there’s an emphasis on getting babies to feed within the first hour.

Why then do I come across – on the national telephone helplines, in groups, in private practice – so many situations where, within the first week, the baby has either become very jaundiced and sleepy, or very unsettled and crying a lot, weight gain is stalling or even still sliding down, mother may feel her breasts have never become very full, and baby is being topped up with formula out of desperation? What happened after the laudable effort to get baby breastfeeding quickly after birth?

I feel it lies in a continuing misunderstanding of the frequency of newborn feeding. The word ‘frequent’ is used a lot. But how frequent is frequent? Nils Bergman says it could well be hourly in the first days. Jill Bergman reminds us that the stomach empties a milk meal in 60 minutes; that the sugar content of milk lasts just 60 minutes; that the proteins in human milk come in low concentrations which also need topping up every hour; and that the normal sleep cycle of a baby from deep to light sleep states is also approximately every 60 minutes. It’s known that a full-term baby can use its brown fat stores for several hours after birth if for any reason access to the breast is limited. But by day 2 of life, the baby needs to be receiving additional fuel from the breast and from then on needs to feed a lot. Very often though, a lot of asking to be fed is interpreted as something inadequate about mother’s milk quality or production; and mothers may be counselled to rest after the effort of labour.  These are misguided concerns and can be very detrimental for the future of the breastfeeding journey.

The baby, nevertheless, is primed to want to ask to feed a lot. S/he’s been anticipating the necessity to feed frequently and has been doing a lot of practice in the womb. At 15 weeks gestation, swallowing starts; at 21 weeks, tongue cupping (like it would be around a breast) has been observed; at 22-24 weeks the baby is doing consistent swallowing of amniotic fluid. The volumes it swallows are big compared to when it starts swallowing colostrum after birth. These volumes of colostrum are small: for some it’s 2-10 mls per feed, for others it’s 5-7 mls per feed on day 1. For the baby who has been accustomed to bigger swallows in the womb, it’s a real incentive to keep going back to the breast to ask for more – and this is just what the breasts need for stimulating the onset of full milk production within 72 hours of birth. So even if the feed volumes seem small, if the baby goes to the breast a lot, then the small amounts add up to an appropriate amount of intake. By day 2 the intake may be 5-15 mls per feed with an average total of 150mls per day; by day 3 it’s increasing to approximately 15-30mls per feed totalling an average intake of 250mls per day. As can be seen, there are some babies who will need to feed more often to get an overall adequate amount of milk.

Which babies need more attention paid to how often and how effectively they feed? The baby who arrives early, a baby who is a lighter weight, a baby who is producing high amounts of bilirubin, the baby of a mother who had gestational diabetes or who is diabetic – these babies have compromised reserves (less brown fat stores) and increased demands. Babies born earlier than 39 weeks (and especially those 34-37 weekers) have immature systems which means that they’re at much greater risk of under-nutrition, hypoglycaemia and jaundice.  We know in addition that these will compromise their breastfeeding skills: babies need energy in order to be able to feed robustly so as soon as they’re not getting enough fuel (for any of the reasons above), they feed even less well. How often do we hear of the baby who can just about get to the breast but falls asleep almost immediately?

Unfortunately, even though early and smaller babies are most at risk, they’re not the only ones. Full-term babies can quite quickly drop into this risky place of not getting enough calories. These well-known and often used phrases – “be led by your baby”, “feed on demand”, even “responsive feeding” – can unwittingly cause insufficient breastfeeding for a baby. Separation of mother and baby – even if it’s just into a bedside cot – takes baby away from the habitat it needs to achieve breastfeeding. Jill and Nils Bergman have written extensively about the need of the human infant to be in the mother’s chest zone, in order for it to signal and then follow-through its intention to breastfeed. The baby not on mother (or on some other aware adult’s body) may do some wiggles or head-turning or a bit of grimacing or move its eyes under its eyelids and then drift back to sleep again – and that is a feeding opportunity missed. The full blown cry or very obvious hands in mouth aren’t every baby’s signal and it can be easy to miss the more subtle signals of a less alert baby, especially in cultures where a sleeping and quiet baby is preferred. As the minutes tick by and baby’s energy flags a little more, the cues may become even less obvious – so it’s confusing for a mother to be “led by her baby” if the baby appears to be ‘saying’ nothing.

I believe we need to be explicit with new parents about the importance in the earliest days of life of keeping baby adequately energised.  They need to be aware of possibly quite subtle signs from their baby of wanting to feed; and that if a baby is sleeping more than expected (the birth could be having an impact here), then it’s vital to get milk into baby. This is “semi-demand feeding”, when parents observe their baby closely, step in and make the decision themselves to feed baby, getting those all-important calories in, using a spoon or finger-feeding tube or syringe if baby is too sleepy to actively breastfeed.

This is where breastmilk production needs to happen too. Mother needs to be expressing in order to facilitate the normal course of breastmilk production if baby is already not stimulating her breasts appropriately. Hand-expressing colostrum (which has more fat by this method) on to a spoon is ideal; and if it’s done more than 5 times daily in the first 3 days of life, the rate of breastmilk production is influenced for up to 8 weeks.

In addition, unlimited skin-to-skin will help to achieve better attachment, meaning good latching and effective milk transfer. But good attachment only really works if the calories are going in to baby quickly and repeatedly in the first hours and days after birth. If there’s any compromise for baby in how well it feeds – due to separation, birth interventions, size, earliness, jaundice, musculo-skeletal effects from in utero positioning or birth – then mother needs to follow the Three Keeps, neatly summarised in The Womanly Art of Breastfeeding: keep baby fed, keep baby close, keep milk flowing out of the breast.

Feeding every 60-90 minutes may seem a lot to start with – so women need support and encouragement and skilled assessement of good positioning, their breasts and the state of the baby. It can help if parents are reminded to think of the breast replacing the frequency of food passing through the umbilical cord; and if they can be reassured that as baby’s energy levels are kept high through lots of milk giving, the feeding frequency will tame down somewhat – then mothers will always try to do what they know their baby needs.

Let’s ditch “3 hourly” from our breastfeeding vocabulary. Let’s instead encourage parents to be vigilant – to be “semi-demand feeders” if necessary – and to feed babies really little and often with the hopeful result that lactation specialists will see fewer and fewer infants who simply need more milk. Calories, breastmilk production and good attachment are what all babies need, frequently (perhaps hourly for some), effectively and comfortably at the start of life.

Sources:
Nancy Mohrbacher, 2012.
Jane Morton, GOLD 2010; GOLD 2016.
Jill Bergman, ‘Hold your Prem’, 2010.