The following article focuses on the newborn feeding schedule. For information related to this topic, see this article about breastfeeding on demand, as well this overview of the science in favor of infant-initiated meals.
Throughout much of the 20th century, Western medical professionals recommended that newborns be fed on a highly-regulated timetable (Fildes 1986).
Today we know better. The scientific evidence strongly suggests that newborns—defined as babies less than one month old—benefit when they are fed frequently and on demand. According to the latest recommendations, that means
(1) initiating feedings when babies show signs of hunger, and
(2) ending feedings when babies show signs of being satiated (i.e., don’t try to force them to finish a bottle).
It also means feeding infants approximately 8-12 times every 24 hours. If that seems like a lot, keep in mind: Our ancestors fed their babies this frequently — even after the newborn stage.
And consider these points:
- Frequent feedings reduce the time it takes for a mother’s milk to come in. In one study, moms who breastfed newborns every two hours began lactating eat least 24 hours earlier than did moms who breastfed every four hours (Salariya et al 1978).
- Frequent breastfeeds increase a mother’s prolactin levels, and high prolactin levels are needed to establish an adequate milk supply. In a U.S. study, breastfeeding frequency of about 10 times a day (range: 7-13 times a day) was associated with sufficient milk (de Carvalo et al 1982).
- Colostrum, the milk produced during the first few days postpartum, is lower in fat and calories than is more mature milk. It is also produced in smaller amounts. A higher-frequency newborn feeding schedule helps babies compensate for the lower caloric density of their milk.
- Newborns are more likely to thrive when they are fed approximately 8-12 times every 24 hours. Newborns fed this often first weeks of life tend to show greater weight gain at 15 days (De Carvalho et al 1983) and six weeks (Casiday et al 2004) postpartum.
So much for the frequency of feedings. Why is it also important to feed a newborn “on demand,” i.e., according to a schedule determined by the newborn’s cues of hunger?
- Newborns differ in sucking strength, and this affects how rapidly they empty a breast or bottle (e.g., Pollitt et al 1978). As a result, some babies require longer feeding bouts than others. This is especially true for the lower birth weight baby and the premature baby–both of whom may lack the strength to suck effectively (Institute of Medicine, National Academy of Sciences 1991).
- Newborns vary greatly in the amount of milk (or formula) they consume during a single feed (e.g., Pollitt et al 1978). As a result, some babies require more frequent feedings to achieve the same daily caloric intake. A demand-style newborn feeding schedule permits babies to adjust to their individual circumstances.
- Adult-led, scheduled feedings have been linked with poorer, long-term academic outcomes. Researchers tracking more than 10,000 children from infancy have found that babies fed on a schedule at 4 weeks of age had lower cognitive and academic scores in later years (Iacovou and Sevilla 2013).
But what about overfeeding? Won’t babies consume too much if we let them feed as long as they want?
The short answer is no.
Studies suggest that overfeeding isn’t a problem for breastfed infants.
In fact, breastfed infants tend to develop a better ability to self-regulate food intake (Lin et al 2010).
Moreover, babies consume much less than is potentially on offer. Between days 6-10 postpartum, breastfeeding mothers are capable of producing an average of 1200 g of milk per day. But their babies drink far less than this–only 500-700 g/day (Casey et al., 1986; Saint et al., 1984).
And overfeeding among bottle-fed newborns? That appears to depend on whether or not caregivers encourage infants to empty their bottles.
When we push infants to finish a bottle, we may be teaching them to override their own, internal sensations of satiety — training them to keep feeding even after their hunger subsides.
So it’s important to pay attention to your baby’s interest, and stop feeding when your baby indicates he or she is no longer hungry.
Common signs for babies under the age of 4 months include waving the arms; turning the head or body away from the bottle; spitting out formula; making negative facial expressions; falling asleep; and pushing away the bottle (Ventura et al 2015).
A good rule of thumb is to stop feeding after the baby has refused the bottle three times in a row (Ventura and Menella 2017).
Altogether, this sort of evidence has led the World Health Organization (WHO) to denounce the adult-imposed, regimented newborn feeding schedule as “clearly harmful or ineffective” (WHO 1998).
And the American Academy of Pediatrics advises parents to feed newborns “whenever they show signs of hunger,” or approximately 8-12 times every 24-hours (Work Group on Breastfeeding 1997).
Going overboard: Waking exhausted mothers who are recovering from childbirth?
Some maternity wards have a policy of waking mothers to breastfeed once every 3 hours. Because mothers are subjected to other interruptions as well — by people performing medical tests, hospital administrative duties, and janitorial tasks — this can leave mothers with very little time to sleep before they are awakened by yet another visitor.
Given the physical stress and sleeplessness associated with childbirth–and the risks that sleeplessness pose for the development of postpartum depression (Okun 2016)–is such a policy justified?
I’ve seen no evidence for it, and it’s certainly not “natural,” not if by that you mean “consistent with what humans do in the absence of hospital care.”
For example, contemporary hunter-gatherers–whose lifeways most closely resemble those of our ancestors–nurse their babies 2-4 times an hour (Konner 2006). But even they recognize the needs of mothers who have just given birth.
The common pattern in hunter-gatherer societies is to let mothers to recuperate for the first 24 hours. If the baby is hungry and the mother is asleep, somebody else nurses the baby.
Are there lessons here for us? I think so.
Yes, early initiation of breastfeeding is important for success. Yes, mothers need to nurse frequently to stimulate production of mature milk, and ensure adequate milk supply.
But I can find no evidence that families suffer when exhausted mothers are allowed at least one 4-hour stretch of postpartum recovery sleep.
In a survey comparing the perceptions of new mothers and maternity ward staff, this was the one area in which staff seemed out of touch with mothers’ needs: Staff underestimated how important it was for recovering mothers to receive help with nighttime child care (Valbø et al 2011).
Summing up: Recommendations for a flexible, infant-led newborn feeding schedule
Although feeding practices vary worldwide, the international medical establishment is in general agreement. These recommendations are endorsed by the World Health Organization (WHO 1998), La Leche League, and the American Academy of Pediatrics (Work Group on Breastfeeding 1997):
Reject an adult-imposed newborn feeding schedule that denies your baby frequent opportunities to feed
As noted above, newborns flourish when they are fed approximately 8-12 times a day.
Feed when baby when he or she shows early signs of hunger
Each newborn is different. Some may feel hungry every 30 minutes. Others may be fine with much longer intervals between feedings. Be sensitive to your baby’s hunger cues (Shloim et al 2017). These include
- Rooting (searching for a breast)
- Hand-sucking and hand-to-mouth movements
- Increased alertness or restlessness
Don’t wait for your newborn to cry. Crying is a late sign of hunger, and once a newborn begins crying it may take time for him to settle down and feed.
Don’t restrict time at the breast (or bottle)
This may prevent your baby from taking in enough calories. If you’re breastfeeding, a strictly-timed newborn feeding schedule may also deprive your baby of high-fat hind milk. Read more here.
Don’t try to encourage a baby to finish a bottle
As noted above, that may simply teach your baby bad habits. If your baby rejects the bottle three times in a row, that’s a sign that you should stop trying to feed (Ventura and Menella 2017).
Sleep or feed?
The American Academy of Pediatrics advises parents to awaken sleeping newborns if they haven’t fed for four hours or more. But the AAP offers no evidence in favor of this idea, and it’s not clear to me if any such evidence exists.
Watch the diaper count
By the fourth or fifth day postpartum, newborns should urinate at least six wet diapers a day. Urine should be clear or pale yellow. If your newborn is urinating less frequently–or is producing urine that is dark yellow or orange–your baby is probably not getting enough milk. Try increasing the frequency of feedings, and consult your pediatrician.
Watch your baby’s weight (and don’t panic)
Newborns lose weight after delivery, and breastfed babies lose more weight than do bottle-fed babies (Martens and Romphf 2007). This isn’t surprising, since new mothers produce very little milk in the first few days after birth. In one study of American breastfed newborns, more than half the babies lost at least 5% of their birth weight in the first three days postpartum (Dewey et al 2003).
But physicians say that weight loss should stop by around five days of age. By one to two weeks, most newborns have regained their birth weights. Again, check with your pediatrician to make sure that your baby’s weight gains are on target.
For more details, download the American Academy of Pediatrics’ paper on breastfeeding and the newborn feeding schedule.
References: The newborn feeding schedule
Nutrition during lactation (1991) is an excellent resource for parents who want detailed information about the newborn feeding schedule and other breastfeeding issues. It is available online. For more information regarding the newborn feeding schedule, see these publications (cited in the article above):
American Academy of Pediatrics. 1997. Breastfeeding and the Use of Human Milk. Pediatrics 100 (6): 1035-1039.
Casiday RE, Wright Cm, Panter-Brick C, and Parkinson KN. 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): 1290-1296.
Casey CE, M.R. Neifert MR, Seacat JM, and Neville MC. 1986. Nutrient intake by breastfed infants during the first five days after birth. Am. J. Dis. Child. 140:933-936.
de Carvalho M., Robertson S, Merkatz R, and Klaus M. 1982. Milk intake and frequency of feeding in breastfed infants. Early Hum. Dev. 7:155-163.
Dewey KG, Nommsen-Rivers LA, Heinig MJ, and Cohen RJ. 2003. Risk Factors for Suboptimal Infant Breastfeeding Behavior, Delayed Onset of Lactation, and Excess Neonatal Weight Loss. Pediatrics 112: 607-619.
Fildes VA. Breasts, bottles and babies. 1986. Edinburgh: Edinburgh University Press.
Freeman V, van’t Hof M, and Haschke F. 2000. Patterns of milk and food intake in infants from birth to age 36 months: the Euro-growth study. J Pediatr Gastroenterol Nutr. 31 Suppl 1:S76-85.
Huffman SL et al. 1987. Suckling Patterns and Post-partum Amenorrhea in Bangladesh. Journal of Biosocial Science, 19:171
Iacovou M and Sevilla A. 2013. Infant feeding: the effects of scheduled vs. on-demand feeding on mothers’ wellbeing and children’s cognitive development. Eur J Public Health. 23(1):13-9.
Institute of Medicine, National Academy of Sciences. 1991. Nutrition during lactation. Washington, DC: National Academy Press.
Kaucher M, E.Z. Moyer EZ, Richards AJ, Williams HH, Wertz AL, and Macy IG. 1945. Human milk studies. XX. The diet of lactating women and the collection and preparation of food and human milk for analysis. Am. J. Dis. Child. 70:142-147.
Konner M. 2005. Hunter-gatherer infancy and childhood: The !Kung and others. In: Hunter-gatherer childhoods: Evolutionary, developmental and cultural perpectives. BS Hewlett and ME Lamb (eds). New Brunswick: Transaction Publishers.
Li R, Fein SB, Grummer-Strawn LM. 2010. Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? Pediatrics. 125(6):e1386-93.
Maisels MJ, Vain N, Acquavita AM, de Blanco NV, Cohen A and DiGregorio, J. 1994. The Effect of Breast-Feeding Frequency on Serum Bilirubin Levels. American Journal of Obstetrics & Gynecology 170(3):880-883.
Manz F, van’t Hof MA, and Haschke F. 1999. The mother-infant relationship: Who controls breastfeeding? Lancet 353: 1152.
Martens PJ and Romphf L. 2007. Factors associated with newborn in-hospital weight loss: comparisons by feeding method, demographics, and birthing procedures. J Hum Lact.23(3):233-41, quiz 242-5.
Okechukwu and Okolo 2006. Exclusive breastfeeding frequency during the first seven days of life in term neonates. Nigerian Postgraduate Medical Journal 13(4): 309-312.
Okun ML. 2016. Disturbed Sleep and Postpartum Depression. Curr Psychiatry Rep. 18(7):66.
Pollitt E, Gilmore M, and Valcarcel M. 1978. The stability of sucking behavior and its relationship to intake during the first month of life. Infant Behav. Dev. 1:347-357.
Saint L, Smith M, and Hartmann PE. 1984. The yield and nutrient content of colostrum and milk of women giving birth to 1 month post-partum. Br. J. Nutr. 52:87-95.
Salariya EM, Easton PM and Cater JI. 1978. Duration of breastfeeding after early inititation of frequent feeding. Lancet 2 (8100): 1141-1143.
Shloim N, Vereijken CMJL, Blundell P, Hetherington MM. 2017. Looking for cues – infant communication of hunger and satiation during milk feeding. Appetite 108:74-82.
Valbø A, Iversen HH, Kristoffersen M. 2011. Postpartum care: evaluation and experience among care providers and care receivers. J Midwifery Womens Health. 56(4):332-9.
Ventura AK, Inamdar LB, Mennella JA. 2015. Consistency in infants’ behavioural signalling of satiation during bottle-feeding. Pediatr Obes. 10(3):180-7.
Ventura AK, Mennella JA. 2017. An Experimental Approach to Study Individual Differences in Infants’ Intake and Satiation Behaviors during Bottle-Feeding. Child Obes. 13(1):44-52.
Whitehead RG, Rowland MGM, Hutton MA, Prentice AM, Muller EM, and Paul AA. 1978. Factors Influencing Lactation Performance in Rural Gambian Mothers. Lancet ii: 178 – 181.
The World Health Organization, 1998. Postpartum care for mother and newborn: report of a technical working group.
Worthman CM and Melby M. 2002. Toward a comparative developmental ecology of human sleep. In: Adolescent Sleep Patterns: Biological, Social, and Psychological Influences, M.A. Carskadon (ed). New York: Cambridge University Press, pp. 69-117.
Yamauchi Y and Yamauchi I. 1990. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics 86: 171-175.
Written content of “The newborn feeding schedule” last modified 9/2017
Image credits for “The newborn feeding schedule”
image of father feeding newborn cropped from a photo by istock / fiorigianluigi