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Feeding On Cue

Sue Iwinski
Prospect CT USA
Gwen Gotsch
Oak Park IL USA
From: NEW BEGINNINGS, Vol. 20 No. 4, July-August 2003, p. 126

"How often should I feed my baby?" It's an important question asked by most new parents in the first days after birth when they are a bit mystified by their newborn's behavior and don't yet trust their own abilities as caregivers. Depending on who they ask or which book they consult, new mothers and fathers may get different answers to what seems to be a simple question.

Some sources of advice about babies will advise parents to follow a rigid feeding schedule, specifying, for example, that babies should be fed every four hours. Feeding by the clock promises parents predictability. They feel confident about following directions laid down by trusted authorities. "We don't have a lot of experience with babies, and we want to do this right," one father explained as the reason he and his wife were following a schedule for their baby's breastfeedings.

Another category of answers to the question of when to feed the new baby will use terms such as "demand feeding" or "cue feeding." Cue feeding advocates explain that mothers should feed their babies when the babies seem to be hungry. This means that mothers must learn to recognize when their baby's behavior signals a need for food. This will be easier for some mothers than for others, depending on their previous experience with babies, their confidence in themselves, and their baby's ability to send clear signals and give positive feedback. For some parents, it may take several days or even weeks before they feel confident about their ability to understand their baby's needs and cues.

Which approach to infant feeding is best? Which one is best for breastfeeding mothers and babies? Why do parents choose one way or the other? Whether mothers feed their babies by cue or by the clock will be influenced by parents' culture and their individual preferences and values. However, biology suggests that cue-feeding is the better choice for breastfeeding mothers and babies.

Biological Facts

Many adults in industrialized cultures have little knowledge of what babies are like, and they enter parenthood with unrealistic expectations for how babies should behave. They may not realize that their baby comes into the world with the same biologically based needs for food, protection, touch, and interaction that babies have had for thousands of generations of human history. Human beings have survived and flourished because mothers have met these needs by responding freely to their babies' cues and behavior, particularly their feeding behaviors.

Breastfeeding is the physiological norm for human babies and mothers. Science has established that human milk meets the human infant's complex nutritional and immunological needs in ways that cannot be duplicated by artificial substitutes. In addition, what science has learned about how breastfeeding works indicates that cue feeding is more compatible with the biology of mothers and babies than scheduled feeding.

A young baby's stomach capacity is small and human milk is digested quickly. These two physiological facts suggest that newborn babies will be more content with small, frequent feedings as compared to scheduled feedings spaced three or four hours apart. In the first two or three days after birth, mothers' breasts produce only small amounts of colostrum, an easily digested, high-protein secretion filled with immune factors that prepare babies' digestive system for the more substantial feedings to come. So here is another biological fact that suggests that newborns do best with small frequent feedings. It's probably no coincidence that frequent feedings also ensure that babies get plenty of holding and skin-to-skin contact. These side-effects of frequent breastfeeding fill their need for human interaction and protection. Frequent, early feedings also give newborns opportunities to practice their sucking skills on a relatively empty breast, preparing them for the more plentiful milk supply to come. On mother's end, early, frequent breastfeedings are associated with a better, more stable milk supply in the months to come. Also, mothers who spend more time with their babies in their arms learn to understand babies' cues more quickly.

Research has shown that healthy, full-term breastfeeding infants have a remarkable ability to regulate their own milk intake when they are allowed to nurse "on cue" and that mothers' rates of milk production are closely related to how much milk their babies take. Regardless of the size of her breasts or the size of her baby, a mother who is responding freely to her baby's appetite will make just the right amount of milk to meet her baby's needs. Babies feed when they are hungry, and slow down and stop feeding when they are full. Some babies will take frequent small feeds, while other babies will take larger feeds less often. In either case, the healthy baby can be trusted to regulate his own milk intake, and in so doing, effectively regulate his mother's supply to fit his specific needs.

Recent studies by a group of Australian scientists have demonstrated the elegant interactions between the baby's appetite, the mother's breast, and milk production-what breastfeeding books often describe as the supply and demand system. Their research shows that each breast makes milk slowly or quickly depending on how full or empty it is. A full breast makes milk slowly, an empty breast makes milk faster. This means that when a woman's breast seems the emptiest, it is making milk the fastest. So if a hungry baby's vigorous nursing leaves the breast relatively "empty," production speeds up. If the baby does not take much milk from the breast at a feeding, production slows down. This is how the baby's appetite controls mother's production. Thus, simply assuring the infant has access to the breast when hungry allows the baby to regulate milk production. If the baby is hungry and empties the breasts, the breasts will make more milk at a faster rate. If the baby is satiated and does not feed for several hours, the rate of milk production will slow down.

This suggests that the question "How often should I feed my baby?" will not have a one-size-fits-all answer. Rigid feeding schedules will get in the way of the complex interplay between baby's need for food and mother's ability to provide it. For example, if a baby is hungry but is not allowed to breastfeed because the schedule says it's not the right time, the breast will remain full and mother's milk production will slow down. If this happens over and over again, her milk supply may no longer meet her hungry baby's needs. Some advocates of feeding schedules tell mothers that they must wait for their breasts to "fill up" before they feed the baby and that allowing a baby to feed on a relatively empty breast will leave baby unsatisfied. Yet, the research about rates of milk production tells us that an empty breast will respond to baby's sucking by producing milk faster, and the milk produced by the emptied breast will have a higher fat content.

The changing fat concentration of human milk is another important factor influencing the interplay between baby's hunger, how much milk baby takes, and mother's milk production. The amount of fat in human milk increases as the breast is emptied. A baby who is not very hungry and who takes only a small amount of milk from a full breast will receive lower-fat milk. A hungry baby who takes more milk from the breast will get more of the higher-fat milk that becomes available as the breast is emptied. The high-fat milk will help him feel full towards the end of the feeding. If the baby is "allowed" to nurse only so many minutes on one breast and then is arbitrarily switched from this still-full breast to an even fuller breast, the baby may fill his tummy with the high-volume lower-fat milk but miss out on the "cream" that leaves him contented and satiated.

Editor's Note: Keep in mind that the examples in this article apply to healthy babies who can suck effectively, who can "empty" a breast and get plenty of milk, and who are gaining well. A baby who has a sucking problem and does not empty the breast effectively may not be able to keep up his mother's milk supply and get enough to eat at the breast. A newborn who is very sleepy needs to be encouraged to breastfeed more often.

Researchers have also found that the fat content of a mother's milk decreases as the time between feedings increases. In other words, the less time between feedings, the higher the fat content of the milk. A baby who goes back to the breast he emptied 30 or 40 minutes ago will get milk with a higher fat content than a baby who returns to a breast he emptied two or three hours earlier.

Editor's Note: Do not use the information in this article to concoct a new set of breastfeeding rules for yourself and your baby. Mothers do not need to think about whether one breast or the other is "empty" or "full," or about rates of production or fat concentrations. The baby's appetite will take care of all these issues. Just listen to your baby and feed him when he is hungry.

Breastfed babies can adapt their feeding pattern to a variety of circumstances, based on whether they are hungry, hot and thirsty, or in distress and need comfort. When babies are growing quickly, they nurse more often and boost mother's milk production almost immediately. As babies begin to eat other foods, they nurse less often and mother's milk production slows down. The built-in biological mechanisms in both mother and baby make it all work. Rigid feeding schedules will interfere with this system. Biology suggests that babies should be allowed to decide for themselves when they should breastfeed.

Cultural Reasons

Reading baby's cues involves a different set of skills than reading a clock or following the directions in a book about when to feed baby. Feeling uncertain about their ability to interpret baby's cues may be one reason that some new parents will choose to follow a prescribed feeding schedule. They may have other reasons as well for believing that feeding schedules are better for babies. For example, parents may be accustomed to routines in their own lives and hope that following a schedule with their babies will provide the consistency they feel is important. Others may have been told that placing a baby on a parent-controlled schedule is a way of ensuring compliant behavior later in childhood.

New parents often rely on other people-a mother-in-law, a doctor, "the book," a friend-to define for them what is the right way to care for their baby. When someone a mother trusts reassures her that following a schedule will encourage her baby to sleep longer periods of time or will guarantee that her baby is breastfeeding "properly," she is likely to give scheduled feedings a try.

However, the reasons for parents choosing to schedule feedings may have roots deeper than individual choice. When the values of the culture around them stress that adults should control children's behavior, parents will be more likely to follow a feeding schedule. If the culture frowns upon parenting practices that accommodate infant "demands," it will be harder for parents to respond freely to their baby's needs and cues. When the bottle-feeding of artificial milk is the predominant feeding method in a culture, the behavior of artificially fed babies, who feed less often, may become the norm, leaving parents to believe that they should discourage frequent feeding in their breastfed baby. New mothers and fathers may place more faith in these messages from the culture than in their own parenting instincts.

Some Problems

Putting breastfed babies on rigid feeding schedules with restrictions about when the baby may be fed can lead to problems for both parents and babies. Most babies will be hungry "too soon" and will cry and complain. Even babies who seem to comply easily with feeding schedules are at risk. These "good" babies may have difficulties with adequate growth. When the clock, rather than baby's need for food, is used to determine how often baby eats, both infant weight gain and mother's milk supply may be in jeopardy. The problems with baby's weight gain may be attributed to the mother's inherent inability to produce enough milk, a process over which she feels she has little control, rather than to her baby's infrequent breastfeeding, a behavior which could be changed.

Many babies will protest mightily if they are not fed promptly when they are hungry. When parents are determined to feed their baby only when an acceptable amount of time has passed, that baby will frequently find himself feeling unsatisfied. The baby's intense expression of normal, healthy infant needs may leave parents perplexed and stressed, and the ensuing battle in which parents deny or attempt to change those needs is frustrating for both parents and infant. It also carries the risk of compromising the baby's emotional and physical growth and harming the parent-child relationship.

Infants who express their distress between scheduled feedings may be labeled difficult or unhealthy babies. They may be considered spoiled, or at risk for becoming so, by their parents and others. The parents themselves may be seen by others as misguided or inept as they struggle to meet their baby's needs. Parents in this situation feel they cannot trust their own judgment as to what are appropriate responses to infant behaviors. After all, their instinctual reaction, the response that feels positive and natural, is to do whatever they can to bring contentment to their precious and dependent infant. In most circumstances, contentment can be achieved simply by holding and/or by breastfeeding. However, a mother can't try what works when she has been warned that comforting or breastfeeding when baby "demands" it may delay healthy development.

The disparity between what parents would like to do and what they have been led to believe they should do results in diminished self-confidence and distances them from their spontaneous, natural responses. Parents' unspoken feelings of incompetence create tension in their interactions with their babies, and babies can pick up on this. Not only are parents less able to trust their own feelings, but they are also unable to trust their babies' expressions of emotions. And since babies rely on parents to interpret the world for them, this baby may end up not trusting himself.

Benefits of Cue-Feeding to the Breastfeeding Family

When mothers can accurately interpret common newborn behaviors and recognize early feeding cues (see sidebar on page 129 [below]), they feel confident about responding to their baby's basic biological needs. Mother's prompt and consistent responses are rewarded with a healthy, happy, secure, and trusting infant who does not need to cry in order to get a response. Baby's contentment reinforces parents' confidence and parents enjoy being with their baby.

How does a mother learn when to offer the breast and when to offer something else? New parents may assume that most, if not all, newborn cues are about the need to breastfeed. Sometimes baby may need to breastfeed for nourishment, sometimes for comfort, sometimes for the benefits of interacting with another human. Breastfeeding meets all of these needs, so new parents do not need to concern themselves about figuring out exactly what baby needs at the moment. As baby grows and develops, parents refine their ability to understand what baby needs or is trying to communicate. Experience quickly teaches them how baby acts when hungry, bored, overstimulated, or tired, and which of these needs are best satisfied at the breast and which can be satisfied in other ways as baby grows.

The benefits of this "cue-reading" approach to infant feeding go well beyond infancy. Parents who respond to their baby as an individual with unique, valid needs will continue to respect these needs as their child grows. They will be better able to adapt their parenting to their child's changing needs, they will be more confident of their ability to cope with each new age and stage, and they will enjoy a rich, multi-faceted relationship with their child.

Learning to trust your baby and trust yourself is no small lesson to master at the beginning of the journey that is parenthood. When mothers breastfeed according to infant cues, they embark on a life of two-way communication with that child, where the ability to listen is their most valuable skill.

What are a newborn's early feeding cues?

  • Rapid eye movements (fluttery eye movements while eyes are closed)
  • Muscle tension, such as flexed arms or closed fists
  • Wriggling or fidgety body movements
  • Vocalization
  • Hand to mouth movement (even if eyes are closed, may include sucking on own hand)
  • Rooting (when touch on either cheek results in their actively turning towards anything, including their own hand, shoulder, any inanimate object, a finger on their cheek, or any other part of another person's body)

Editor's Note: Crying in newborns is usually a late indicator of hunger and may lead to difficulty with latching on to the breast or feeding well. Parents will soon recognize their own baby's individual style and cues through experience and trial and error. They need not rely on a general list (including the one above).

Other Information

  • Infants grow rapidly. Breastfed babies typically double their birth weight by four to six months of age and can triple it by about one year of age. This remarkably rapid early growth means they are hungry often and need to eat often. A relatively frequent feeding pattern is understandable when we consider the growth phase infants are in.
  • Infants are born with 25 percent of adult brain size at birth. They are the least mature mammal at birth and are more dependent on mature humans for their survival. Furthermore, infants seem to be designed to guarantee the protection they need by protesting their distress when separated from mother (or another responsive adult). Frequent feedings help to meet baby's need for close contact and may reduce the likelihood of distress due to separation.

  • Unrestricted breastfeeding, when compared with scheduled feedings, has several additional health advantages for mother and her newborn baby. For baby, these include greater weight gain and milk intake, lower serum bilirubin levels, and less supplementation with formula. For mother, these include: decreased incidence of sore nipples, engorgement, and decreased ovulation (with potential to increase natural child spacing).

For More Information

American Academy of Pediatrics Policy Statement on Breastfeeding and the Use of Human Milk (RE9729). Pediatrics 1997 Dec; 100(6):1035-1039.

Biancuzzo, M. Breastfeeding the Newborn, Clinical Strategies of Nurses. St. Louis, MO: Mosby, 2003.

Cregan, M. and Hartmann, E. Computerized breast measurement from conception to weaning: Clinical implications. J Hum Lact 1999; 15(2):89-96.

Daly, S.E. and Hartmann, P. Infant demand and milk supply. Part 1: Infant demand and milk production in lactating women. J Hum Lact 1995; 11(1):21-26.

Daly, S.E. and Hartmann, P. 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.

Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International, 2003.

La La Leche League International. Common Breastfeeding Myths. Schaumburg, IL: La Leche League International, l998.

Marasco, L. and Barger, J. Cue feeding: Wisdom and science. Breastfeeding Abstracts 1999; 18(4):27-28.

McKenna, J. Natural History of Breast Feeding: An Evolutionary and Developmental Perspective. SUNY@Stonybrook School of Nursing Breastfeeding Conference, May 11, 2001.

Woolridge, M. Baby controlled breastfeeding: Biocultural implications. In Breastfeeding: Biocultural Perspectives. New York: De Gruyter, 1995.

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