Cue Feeding: Wisdom and Science
Lisa Marasco, BA, IBCLC, Santa Maria, California
Jan Barger, MA, RC, IBCLC, Wheaton, Illinois
from Breastfeeding Abstracts,
May 1999, Volume 18, Number 4, pp. 28-29.
It is now commonly accepted
that infants, most especially breastfed infants, thrive best when allowed
to feed as they indicate their needs. Nevertheless, some mothers continue
to believe that they must wait for their breasts to "fill up"
between feedings in order to have enough milk for their babies, and
some popular sources of advice for parents urge mothers to stick to
a feeding schedule in which even young infants are fed at 3- to 4-hour
intervals. Some infants may be able to thrive on scheduled feedings,
but many others do not. Recent research on the breast's mechanisms for
regulating milk production provides a better understanding of the importance
of demand feeding and the role of infant appetite in the regulation
of milk production.
Until recently, efforts to
understand the processes that regulate milk synthesis have focused on
the prolactin surge that occurs in response to infant suckling. However,
researchers have not found a consistent relationship between plasma
prolactin levels and maternal milk production. Taking a different approach,
Peter Hartmann and his colleagues in Australia have studied human milk
production by making topographical-type maps of lactating breasts before
and after nursing sessions using video and computer equipment to assess
changes in breast volume.4 The accuracy of this technique
for measuring milk storage capacity and milk production has been assessed
at ±5 percent. Based on this work, Hartmann has concluded that the
rate of milk synthesis between feedings varies according to the degree
of fullness of the breast; the fuller the breast, the slower the milk
production rate, and conversely, the emptier the breast, the faster
the rate at which the milk is replaced.
Hartmann and colleagues also
quantified differences in the maximum storage capacity of women's breasts,
identifying at least a 300 percent difference between women in their
study. It was also noted that the women who had larger storage capacities
often nursed at longer intervals, whereas women with smaller storage
capacities nursed at more frequent intervals. Breast size was not always
a good predictor of production or storage capacity, and all of the women
had the ability to produce plenty of milk over 24 hours. What varied
was the amount of milk that could be delivered at one feeding.
High prolactin levels are
critical to the initiation of lactation, but as prolactin levels decline,
endocrine control becomes less important to milk production, and autocrine
systems take over.5, 6 However, successful long term lactation
depends on the development of adequate prolactin receptors during the
endocrine control period, which in turn appears to depend on the frequency
of feedings: the more frequent the feeds, the greater the receptor development.3,8
We have found that many women
experience success in schedule feeding their breastfed babies during
the first couple of months. However, these women have an unusually high
rate of milk supply failure around 3-4 months, as evidenced by babies
who fall below acceptable growth standards, require supplementation,
and/or who wean involuntarily, rejecting the slower-flowing, lower volume
breast for a more copious milk supply in a bottle.
Research on feeding intervals
and levels of fat in milk adds another dimension to the understanding
of how infant appetite, as reflected in demand-feeding, regulates milk
synthesis. Michael Woolridge has proposed that caloric intake at the
breast, specifically fat intake, is responsible for infant appetite
control and satiety. It is readily assumed that the mother of a baby
who remains unsettled after feeding has inadequate milk volume. In reality,
there may be a small but critical shortfall in her baby's fat or caloric
intake.10 Proponents of scheduled feeds often place time
restrictions upon how long babies should feed, thus limiting fat/caloric
intake at the end of feeds.
Supporters of schedule/routine
feedings believe that longer intervals make for hungrier babies who
will demand more aggressively and who will obtain the higher fat milk
available at the end of a feeding. However, Woolridge has shown that
prefeed fat levels are inversely related to the length of the interfeed
interval. Fat concentrations of milk can be maximized by increasing
both feed frequency and the amount of milk removed from the breast at
a feeding. When feed frequency and duration are restricted by predetermined
feeding schedules, the result may well be lowered infant fat intake,
symptoms of breast milk insufficiency, and underfeeding.2,10
A baby who is getting ready
to feed displays cues even before he awakens. At first, baby may wiggle,
toss and turn, or be restless in his sleep. If his hand is near his
face, he may begin to root towards it and even attempt to suckle it
or anything else near his mouth. If these early cues are ignored, the
baby begins to "squeak" and fuss slightly and eventually works
up to a full cry, expressing that he is now overdue for his needed nourishment.
An experienced breastfeeding mother with baby nearby usually quickly
discerns baby's needs and puts him to the breast early in this sequence
of cues. For the mother who is scheduling her baby and/or sleeping apart
from him, however, it is much different.7
A newborn who is left to
cry for even a few minutes can become very disorganized and have a more
difficult time latching on and sucking correctly. As a result he often
does not take as much milk as he needs, and if this scenario is repeated,
mother's milk production will decrease over time. This is yet another
way in which feeding schedules can inhibit maternal milk production.
In an attempt to prevent excessive crying, some proponents of infant
schedules promote the use of pacifiers to delay feedings and/or eliminate
non-nutritive sucking at the breast. Such interventions are not without
risk. A recent study has documented that pacifier use is associated
with a shorter duration of breastfeeding,1 while another
study found that mothers who utilize pacifiers for their infants frequently
exercise a higher degree of behavioral control while breastfeeding,
often leading again to shorter duration of breastfeeding overall.9
Empirical and theoretical
evidence combined continues to support current recommendations of the
American Academy of Pediatrics11 that babies, most especially breastfed
babies, need to be fed on cue and should be allowed to set their own
routine, rather than placed on a predetermined schedule. It is our further
conclusion that practices which interfere with babies' cuings have been
responsible for low weight gains, failure to thrive, milk supply failure,
involuntary early weaning, and possibly even some cases of colic, as
well as infant regression and depression due to lack of parental responsiveness
to baby's frantic cues. Maternal milk production and infant intake are
influenced by many factors, including frequency of feeding during the
establishment of lactation, maternal milk storage capacity, infant stomach
capacity, milk fat content, and the degree of breast emptying at any
given feeding. Thus the evidence is very strong that arbitrary scheduling
of breastfed infant feedings is inadvisable for any mother who desires
to breastfeed successfully.
Lisa Marasco is a La
Leche League Leader and a lactation consultant in private practice in
Santa Maria, CA. She is currently a Master's student at the Lactation
Institute in Encino, CA.
Jan Barger is a clinical instructor and Program
Director for Breastfeeding Support Consultants. She is a lactation consultant
for a pediatric group in Wheaton, Illinois and has a private practice.
She is also a past president of the International Lactation Consultant
Association (ILCA).
REFERENCES
1. Barros, F. C., C. G. Victora
et al. Use of pacifiers is associated with decrease of breastfeeding
duration. Pediatrics 1995; 95:497-99.
2. DeCarvalho, M. D. et al.
Effect of frequent breastfeeding on early milk production and infant
weight gain. Pediatrics 1983; 72:307-11.
3. De Coopman, J. Breastfeeding
after pituitary resection: Support for a theory of autocrine control
of milk supply? J Hum Lact 1993; 9(1):35-40.
4. Daly, S. E., J. C. Kent,
D. Q. Huynh et al. The determination of short-term breast volume changes
and the rate of synthesis of human milk using computerized breast measurement.
Experimental Physiol 1992; 77:79-87.
5. Daly, S. E. and P. Hartmann.
Infant demand and milk supply. Part 1: Infant demand and milk production
in lactating women. J Hum Lact 1995; 11(1):21-26.
6. Daly, S. E. and P. Hartmann.
Infant demand and milk supply. Part 2: The short-term control of milk
synthesis in lactating women. J Hum Lact 1995; 11(1):27-37.
7. Neifert, M. Early assessment
of the breastfeeding infant. Contempory Pediatr 1996; October,
2-16.
8. Perry, H. M. and L. S.
Jacobs. Rabbit mammary prolactin receptors. J Biologic Chem
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9. Victora, C. G., D. P.
Behague, F. C. Barros et al. Pacifier use and short breastfeeding duration:
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10. Woolridge, M. Baby controlled
breastfeeding: Biocultural implications. In Breastfeeding: Biocultural
Perspectives, ed. P. Stuart Macadam and K. A. Dettwyler. New York:
De Gruyter, 1995.
11. American Academy of Pediatrics
Work Group on Breastfeeding. Breastfeeding and the use of human milk.
Pediatrics 1997; 100:1035-39.
Page last edited Sun Oct 14 09:32:42 UTC 2007.
