The importance of responsive feeding in establishing a good breastmilk supply
by Dr. Amy Brown
Responsive parenting e.g. responding promptly and appropriately to a baby’s needs is widely recognised as an important protective element for infant health, wellbeing and development1. When babies feel secure in the care of a primary caregiver, they go on to have better outcomes socially, educationally and emotionally2.
There are many elements to responsive parenting but one of the central aspects within this relationship is the importance of responsive feeding. Responding to a baby’s feeding cues (both of hunger and satiation), whether they are breast or bottle fed is an important step to helping a baby develop not only a secure attachment relationship, but in establishing longer term positive eating behaviours. Responsive feeding takes advantage of a young baby’s natural ability to regulate their intake of calories – something that can disappear when a baby gets older3. Feeding when they are hungry and being able to stop when they are full helps them to retain this ability4.
However, the notion of responsive feeding can lead to significant concerns for new parents, particularly in relation to how often breastfed babies feed. One concern is whether feeding frequently is a sign that the baby isn’t getting enough milk, exacerbated by not being able to see how much milk the baby is consuming. Others may worry about whether babies need to learn to feed less frequently in a set pattern. However, responding to a baby’s natural cues is a critical step in establishing milk supply and encouraging healthy weight gain and development in babies.
How often do babies breastfeed?
As with everything, how often a baby naturally wants to feed will vary amongst individuals. However studies that explore how often babies breastfeed find that most do so between 8 – 12 times per 24 hours, although some feed much more than that (up to around 18 times in some studies). Most tend to feed towards the latter part of that range, with around 11 – 12 feeds per 24 hours5.
Notably, babies calorie needs do not change vastly after the first few weeks, but they become able to take bigger feeds. This means that from around 8 – 12 weeks some babies start feeding in longer intervals. However, this pattern doesn’t necessarily remain. Studies that have tracked this longitudinally find that many babies do start to feed less often but then start feeding again more frequently (akin to a newborn) around 4 months of age, before dropping down again. This fits with the commonly observed ‘four month growth spurt’, which is often seen as a mistaken need for solid foods6. However, as with everything, some babies will continue to take smaller feeds more often until they move to solid foods (and, still even then). Just as with adults, some of us prefer set meals a day whereas others prefer to graze.
As well as being little and often, most babies don’t naturally breastfeed to a set pattern e.g. every three hours. If allowed to feed whenever they want to, many breastfed babies are good at feeding according to hunger, which doesn’t fit into a set pattern (how many adults truly eat or drink at precise set intervals?). Things like growth spurts and cluster feeding (where babies feed numerous times over a period of up to a few hours) are common and are thought to stimulate the body to produce more7.
Variations will also occur according to the content of the mothers milk. Research has shown that fat content can vary between mothers. Mothers who produce milk with a higher fat content are more likely to have babies that have shorter feeds e.g. they take in a similar energy density to those with lower fat content in their milk who take a little longer to consume it8.
Breastmilk also changes in content, particularly in terms of calories and fat. During a feed, milk becomes denser in fat as the feed progresses. Fat content and energy density are also higher during the day than the night. In hot weather breastmilk can also be less energy dense, encouraging infants to consume more of a higher water content milk9. Again, this can affect the amount or frequency of how often babies feed. Generally, the less energy dense the milk, the more they take in.
Feeding frequency is also context dependent. In Western culture our norm is to separate from our babies to some extent. Baby wearing for most of the day and co-sleeping are normal from an evolutionary perspective but not common in our society today. Put simply, this means that babies do not always have easy and unfettered access to the breast. However, in cultures where co-sleeping and carrying infants in a sling are common, and babies therefore have free access to the breast, they feed far more frequently than this. An observational stud of the rural hunter- gatherer tribe known as the !Kung, found that babies breastfed on average four times an hour, with an average feed being two minutes or less10. Other studies show less frequent feeds, but sill significantly more than in Western cultures. For example one study in rural Thailand found babies averaged 15 feeds over 24 hours11. In the UK, when babies do co-sleep, they feed more per night12.
Why do babies need to breastfeed so often?
Firstly, breastmilk is low in fat and protein but high in carbohydrates and lactose, which makes it easy – and quick – to digest. It is more easily digested than formula milk, which means that breastfed babies often feed more frequently than formula fed babies (approximately every two hours compared to three hour for formula fed babies) 13. Breastfed babies reach a fasting state quicker than formula fed infants, with 75% of breastfed infants reached a fasting state within 3 hours from the last feed compared to 17% of formula fed babies 14.
Breastfed babies also tend to consume less milk than formula fed babies at each feed, preferring to feed little and often compared to many formula fed babies. A baby’s tummy has a maximum capacity of 90ml. Breastfed babies tend to take smaller feeds, not completely filling their stomach. In the first six months babies need around 750ml of milk a day meaning that even at maximum capacity that equates to feeding around every three hours14. Research has shown that formula fed babies take in more milk from the first day of life (about twice as much on day one and three times as much by day two)15.
Why is responsive feeding so important?
Meeting the frequent and unpredictable feeding needs of a breastfed baby can feel challenging and is a common reason why mothers stop breastfeeding – either through anxiety that something is wrong, or a belief that formula will offer a more convenient feeding schedule16. However, responsive feeding is not only normal but important for a number of reasons.
Feeding responsively is particularly important when a baby is breastfed because it is intrinsically linked to establishing and maintaining a good supply of breastmilk. Breastmilk starts to be produced in small amounts during pregnancy. Once the placenta is removed after birth this production shoots up, supported by rises in the hormones prolactin and oxytocin17.
However, once this initial surge has occurred, one of the most important things for breast milk supply is frequent feeding. Simply, the more milk is removed from the breast (either by a baby or by expressing), the more milk is produced. The human body is very clever at matching how much milk is removed (e.g. how much the body believes the baby needs) to how much it produce18. One study that asked mothers to either feed their newborn baby responsively or to feed to a set 3 – 4 schedule found that babies who were fed responsively consumed a third more milk19.
Because responsive feeding is linked to a better milk supply, it has a knock on effect onto outcomes for babies. Responsive feeding is associated with mature milk coming in quicker after the birth20, regaining birth weight faster19, and a lower risk of jaundice21. Conversely, supplementing with formula milk, particularly in the early days and weeks, can lead to a drop in supply, or difficulties with latch22. Using a pacifier can also reduce milk intake as it can lead to a delay in how often babies are fed. Babies who use a pacifier feed on average for half an hour less each day which equates to one fewer feed<23.
Based on this, it is not surprising that babies who are fed responsively are more likely to continue being breastfeed24. Meanwhile, trying to breastfeed to a parent led routine is associated with stopping breastfeeding25. This can apply to wider parenting style; mothers who adopt a routine for feeding, sleep and day to day care of their infant are more likely to stop breastfeeding in the early days26. Notably, those who stop breastfeeding after using a routine are more likely to report breastfeeding difficulties e.g. low milk supply, pain on latch and a fussy baby – likely a knock on impact of lower milk supply from less frequent feeding16.
What about night time feeding?
Babies’ needs do not cease to exist simply because it is dark outside. One of the main needs infants have at night is to feed. A baby’s stomach is still the same size and breast milk still easily digested at night as it is in the day. Research suggests that it is not until around two months that a baby’s natural day and night circadian rhythm kicks in. Until that point, the concept of sleeping for an extended period of time is not something that babies are physiologically designed to do – and even then it can take a while to get into the habit27.
However, society continues to sell us the myth that babies should start sleeping through the night after the first few weeks, and that getting them to this stage is an achievement. Aside from evidence to the contrary, given that around a third of adults report at least mild insomnia, should we really believe that babies who cannot meet their own needs if they wake should be able to sleep all night? How many adults when they wake have a drink of water?
Waking at night is also thought to be protective. Babies want to be close to their mother at night and sleeping close to them helps babies maintain their temperature28, heart rate29 and have steadier breathing30. Sleeping too deeply may be a risk factor for SIDS. Babies who have died of SIDS are more likely to have longer periods of uninterrupted sleep and moved about less in their sleep31.
Research exploring night waking in the first year brings estimates of between 30 – 80% of babies still waking at least once with a number of studies saying most babies continue to wake once or twice a night throughout the first year32. Although sleep problems in older children can be an issue, waking at night as a baby has no link with later sleep problems or development33.
Feeding at night is also common – and important – in supporting breastfeeding. Firstly, the body takes into account feeds at night when establishing milk supply. Babies take in around a third of their milk supply at night (although in toddlers in cultures where co-sleeping is the norm, this can rise to 50% as many are busy and distracted during the day)11. Feeding at night is an important step in developing a good milk supply. Although it may be dark outside, the body still considers frequency of feeds at night when establishing milk supply.
Feeding at night is also an essential part of providing a high level of contraceptive cover through the Lactational Amenorrhea Method. This method offers 98% security of contraception as long as babies are fed responsively (and are under 6 months and receiving no formula milk or solid foods). Feeding at night is an important part of this34.
Additionally, feeding at night is important from a hormonal perspective. Prolactin is linked to milk supply; generally the higher prolactin levels you have, the more milk is made. Prolactin levels are already higher at night but also rise further when your baby feeds, so feeding at night is a great opportunity to really drive those levels higher and help your milk supply35.
Sometimes parents worry about their baby continuing to breastfeed at night based on the myths that a) babies should sleep through the night and b) breastfeeding stops babies sleeping through the night. However, rather than being something breastfed babies do more, breastfeeding at night should be recognised as something that is very normal. In countries where night-time infant care and co-sleeping is the norm, babies breastfeed around four times a night36.
Some studies do show that very young babies who are formula fed start sleeping for longer at an earlier age37 and have longer periods of deep sleep38. However once babies get a little older, this difference disappears. One study found that for babies aged 6 – 12 months, babies who were breastfed did feed more at night than babies who were formula fed. However they did not wake more, suggesting that breastfeeding was likely used as a tool to encourage the baby back to sleep quickly32. Indeed, two studies exploring the sleep patterns of mothers who breast or formula fed found that breastfeeding mothers got more hours of sleep overall, alongside feeling in better health<39 whilst another found that mothers who were breastfeeding actually had more rest per night that those who formula fed because it took less time to resettle the baby40.
When parents are thinking about a routine for feeds, one of the most common places they start is by trying to reduce night feeds, and more generally encourage ‘sleeping through the night’. However, sleep training can have a negative impact on breastfeeding success. One intervention to reduce night waking in babies aged 6 – 12 months found that although babies started sleeping for longer, breastfeeding rates dropped far more rapidly than expected during the course of the study41.
Feeding responsively is therefore a critical element of establishing and maintaining milk supply, supporting weight gain and promoting positive longer term eating behaviour in children. More importantly, it is the norm and biological expectation of young babies, and a central element of a responsive parenting relationship however a baby is fed. Feeding responsively can be demanding for mothers though and as a society, rather than trying to normalise routines and scheduled feeding, we should be looking towards how we can value and support our new families better. Mothering the mother so she can breastfeed her baby, and more widely, supporting the new family and a unit makes the new responsibility of caring for a young baby that little bit easier.
References and links
1. Landry, S.H., Smith, K.E. and Swank, P.R., 2006. Responsive parenting: establishing early foundations for social, communication, and independent problem-solving skills. Developmental psychology, 42(4), p.627.
2. Gaertner, B.M., Spinrad, T.L. and Eisenberg, N., 2008. Focused attention in toddlers: Measurement, stability, and relations to negative emotion and parenting. Infant and Child Development, 17(4), pp.339-363.
3. Fomon, S.J., Filmer, L.J., Thomas, L.N., Anderson, T.A., & Nelson, S.E. (1975). Influence of formula concentration on caloric intake and growth of normal infants. Acta Paediatrica Scandinavia, 64/2, 172 – 81.
4. Brown, A. and Lee, M., 2012. Breastfeeding during the first year promotes satiety responsiveness in children aged 18–24 months. Pediatric obesity, 7(5), pp.382-390.
5. Kent, J.C., Mitoulas, L.R., Cregan, M.D., Ramsay, D.T., Doherty, D.A. and Hartmann, P.E., 2006. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), pp.e387-e395.
6. Hörnell, A., Aarts, C., Kylberg, E., Hofvander, Y. and Gebre‐Medhin, M., 1999. Breastfeeding patterns in exclusively breastfed infants: a longitudinal prospective study in Uppsala, Sweden. Acta paediatrica, 88(2), pp.203-211.
7. Frantz, K.B., 1991. The slow-gaining breastfeeding infant. NAACOG’s clinical issues in perinatal and women’s health nursing, 3(4), pp.647-655.
8. Tyson, J., Burchfield, J., Sentence, F., et al. (1992). Adaptation of feeding to a low fat yield in breast milk. Pediatrics, 89/2, 215-220.
9. Khan, S., Hepworth, A.R., Prime, D.K., Lai, C.T., Trengove, N.J. and Hartmann, P.E., 2013. Variation in fat, lactose, and protein composition in breast milk over 24 hours: associations with infant feeding patterns. Journal of Human Lactation, 29(1), pp.81-89.
10. Konner, M. and Worthman, C., 1980. Nursing frequency, gonadal function, and birth spacing among! Kung hunter-gatherers. Science, 207(4432), pp.788-791.
11. Imong, S.M., Jackson, D.A., Wongsawasdii, L., Ruckphaophunt, S., Tansuhaj, A., Chiowanich, P., Woolridge, M.W., Drewett, R.F., Baum, J.D. and Amatayakul, K., 1989. Predictors of breast milk intake in rural northern Thailand. Journal of pediatric gastroenterology and nutrition, 8(3), pp.359-370.
12. Blair, P.S. and Ball, H.L., 2004. The prevalence and characteristics associated with parent–infant bed-sharing in England. Archives of Disease in Childhood, 89(12), pp.1106-1110.
13. Casiday, R.E., Wright, C.M., Panter-Brick, C. and Parkinson, K.N., 2004. Do early infant feeding patterns relate to breast-feeding continuation and weight gain? Data from a longitudinal cohort study. European journal of clinical nutrition, 58(9), pp.1290-1296.
14. Tomomasa, T., Hyman, P.E., Itoh, K., Hsu, J.Y., Koizumi, T., Itoh, Z. and Kuroume, T., 1987. Gastroduodenal motility in neonates: response to human milk compared with cow’s milk formula. Pediatrics, 80(3), pp.434-438.
15. Dollberg, S., Lahav, S. and Mimouni, F.B., 2001. A comparison of intakes of breast-fed and bottle-fed infants during the first two days of life. Journal of the American College of Nutrition, 20(3), pp.209-211.
16. Brown, A., Raynor, P. and Lee, M., 2011. Maternal control of child‐feeding during breast and formula feeding in the first 6 months post‐partum. Journal of Human Nutrition and Dietetics, 24(2), pp.177-186.
17. Moulden, A., 1994. Feeding difficulties. Part 1. Breast feeding. Australian family physician, 23(10), pp.1902-1906.
18. Dewey, K.G. and Lönnerdal, B., 1986. Infant self‐regulation of breast milk intake. Acta Paediatrica, 75(6), pp.893-898.
19. Illingworth, R.S. and Stone, D.G.H., 1952. Self-demand feeding in a maternity unit. The Lancet, 259(6710), pp.683-687.
20. De Carvalho, M., Klaus, M.H. and Merkatz, R.B., 1982. Frequency of breast-feeding and serum bilirubin concentration. American journal of diseases of children, 136(8), pp.737-738.
21. Woolridge, M.W., Greasley, V. and Silpisornkosol, S., 1985. The initiation of lactation: the effect of early versus delayed contact for suckling on milk intake in the first week post-partum. A study in Chiang Mai, Northern Thailand. Early human development, 12(3), pp.269-278.
22. Chantry, C.J., Dewey, K.G., Peerson, J.M., Wagner, E.A. and Nommsen-Rivers, L.A., 2014. In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. The Journal of pediatrics, 164(6), pp.1339-1345.
23. Aarts, C., Hörnell, A., Kylberg, E., Hofvander, Y. and Gebre-Medhin, M., 1999. Breastfeeding patterns in relation to thumb sucking and pacifier use. Pediatrics, 104(4), pp.e50-e50.
24. Hörnell, A., Hofvander, Y. and Kylberg, E., 2001. Solids and formula: association with pattern and duration of breastfeeding. Pediatrics, 107(3), pp.e38-e38.
25. Brown, A. and Lee, M., 2013. Breastfeeding is associated with a maternal feeding style low in control from birth. PloS one, 8(1), p.e54229.
26. Brown, A. and Arnott, B., 2014. Breastfeeding duration and early parenting behaviour: the importance of an infant-led, responsive style. PloS one, 9(2), p.e83893.
27. Rivkees, S.A., 2003. Developing circadian rhythmicity in infants. Pediatrics, 112(2), pp.373-381.
28. Tuffnell, C.S., Petersen, S.A. and Wailoo, M.P., 1996. Higher rectal temperatures in co-sleeping infants. Archives of Disease in Childhood, 75(3), pp.249-250.
29. Richard, C.A. and Mosko, S.S., 2004. Mother-infant bedsharing is associated with an increase in infant heart rate. SLEEP, 27(3), pp.507-511.
30. Richard, C.A., Mosko, S.S. and McKenna, J.J., 1998. Apnea and periodic breathing in bed-sharing and solitary sleeping infants. Journal of Applied Physiology, 84(4), pp.1374-1380.
31. Hoppenbrouwers, T., Hodgman, J., Arakawa, K. and Sterman, M.B., 1989. Polysomnographic sleep and waking states are similar in subsequent siblings of SIDS and control infants during the first six months of life. Sleep, 12(3), pp.265-276.
32. Brown, A. and Harries, V., 2015. Infant sleep and night feeding patterns during later infancy: Association with breastfeeding frequency, daytime complementary food intake, and infant weight. Breastfeeding Medicine, 10(5), pp.246-252.
33. Price, A.M., Wake, M., Ukoumunne, O.C. and Hiscock, H., 2012. Outcomes at six years of age for children with infant sleep problems: longitudinal community-based study. Sleep medicine, 13(8), pp.991-998.
34. Labbok, M.H. et al. Multicenter study of the lactational amenorrhea method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception 1997; 55(6):327-36
35. Riordan, J. & Wambach, K. (2010) Breastfeeding and Human Lactation 4th ed. Jones and Bartlett, p. 89
36. Sellen, D.W., 2001. Weaning, complementary feeding, and maternal decision making in a rural east African pastoral population. Journal of Human Lactation, 17(3), pp.233-244.
37. Ball, H.L., 2003. Breastfeeding, bed‐sharing, and infant sleep. Birth, 30(3), pp.181-188.
38. Butte, N.F., Jensen, C.L., Moon, J.K., Glaze, D.G. and Frost, J.D., 1992. Sleep organization and energy expenditure of breast-fed and formula-fed infants. Pediatric research, 32(5), pp.514-519.
39. Kendall-Tackett, K., Cong, Z. and Hale, T.W., 2011. The effect of feeding method on sleep duration, maternal well-being, and postpartum depression. Clinical Lactation, 2(2), pp.22-26.
40. Galbally, M., Lewis, A.J., McEgan, K., Scalzo, K. and Islam, F.M., 2013. Breastfeeding and infant sleep patterns: an Australian population study. Journal of paediatrics and child health, 49(2), pp.E147-E152.
41. Hall, W.A., Saunders, R.A., Clauson, M., Carty, E.M. and Janssen, P.A., 2006. Effects of an intervention aimed at reducing night waking and signaling in 6-to 12-month-old infants. Behavioral Sleep Medicine, 4(4), pp.242-261.