The newborn feeding schedule:

What the scientific evidence tells us

© 2008 Gwen Dewar, Ph.D., all rights reserved

Here I outline the special problems that young babies face--problems that might get worse if caregivers stick with a regimented newborn feeding schedule.

The high-frequency newborn feeding schedule: Why newborns may benefit from being fed 8-12 times every 24 hours

But today, few pediatricians promote a regimented newborn feeding schedule. The scientific evidence strongly suggests that newborns—defined as babies less than a month old—benefit when they are fed frequently and on demand.

This doesn’t mean that maternity ward workers are justified in preventing exhausted new mothers from getting sleep during the 24 hours immediately following childbirth.

Some people seem to think it’s acceptable to awaken new mothers every 2-3 hours during the first 24 hours postpartum. But I’m not aware of any research demonstrating that this practice is, on balance, beneficial.

And it’s certainly not “natural,” not if by that you mean “consistent with what humans do in the absence of hospital care.”

Among hunter-gatherers, the common pattern is to leave mothers to recuperate in the first 24 hours after birth. If the baby needs to be fed and the mother is asleep, somebody else nurses the baby.

So should an exhausted mother who has just given birth--and who may be suffering from complications--feel guilty if she sleeps for 4-6 at a stretch? I don't think so. Some women have been awake for 36 hours or more, and their sleep deprivation puts them at higher risk for postpartum depression--a condition that can have far-reaching, negative consequences on mothers and babies alike.

So we need to consider the big picture when they are coping with those first few hours postpartum.

But let's get past the first 24 hours. What are the benefits from frequent feedings in the days following birth?

Consider these points:

• Frequent feedings reduce the time it takes for a woman’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).

• Frequent feedings during the newborn period are associated with long-term breastfeeding success. Moms who breastfeed frequently are more likely to continue breastfeeding after the newborn phase (e.g., Salariya et al 1978).

• 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.

• More frequent feedings (8-12 times per 24 hours) during the first weeks of life are associated with greater overall milk intake (De Carvalho et al 1983) and greater weight gain at 15 days (De Carvalho et al 1983) and six weeks (Casiday et al 2004) of age.

• 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.

• Breastfeeding newborns don’t overeat. Between days 6-10 postpartum, mothers are capable of producing an average of 1200 g of milk per day. But their babies consume far less than this—-about 500-700 g/day (Casey et al., 1986; Saint et al., 1984).

This sort of evidence has led the World Health Organization (WHO) to denounce the timed-interval newborn feeding schedule as a practice that is “clearly harmful or ineffective” (WHO 1998).

In addition, the National Academy of Sciences advises new mothers nurse at least 8 times a day during the day to establish an adequate milk supply (Institute of Medicine, National Academy of Sciences 1991.) And the American Academy of Pediatrics (APP) recommends that parents feed newborns “whenever they show signs of hunger” (Work Group on Breastfeeding 1997)—an average of 8-12 times a day.

But it’s not clear how many parents are doing this.

The newborn feeding schedule around the world

For instance, a Japanese study reported that breastfeeding mothers fed their infants an average of 7.4 times every 24 hours (Yamauchi and Yamauchi 1990).

In a U.S. study, mothers characterized as “feeding on demand” breastfed their babies an average of 6.5 times (range: 5.5-8.0 times) every 24 hours for the first 3 days of life (Maisels et al 1994).

In a large study of 12 different European countries, 1-month old infants got an average of 7.1 breastfeeds per 24 hours (van’t Hof and Haschke 1997).

These relatively infrequent feedings may reflect a kind of culture lag. For several generations, Western doctors advised parents to observe a strictly-timed newborn feeding schedule. Even though these recommendations have changed, mothers living in Western (and Westernized) societies may persist in feeding babies the way their mothers did (Manz et al 1999).

Whatever the cause, we see a different pattern in the less developed parts of the world.

A 2006 study reported that Nigerian mothers nursed their newborns an average of 13.3 times within the first 24 hours of life (Okechukwu and Okolo 2006). Seven days later, these mothers were still following the same high-frequency newborn feeding schedule.

In rural Guatemala, mothers nurse their 3-month old babies over 10 times a day (Delgado 1982). In rural Bangladesh, mothers nurse their 18-month old children 9.5 times every 8 hours. Presumably, these mothers nurse newborns at least as frequently as they do their older children.

But even these high-frequency feeders seem stingy when compared hunter-gatherer moms. Hunter-gatherer infants feed very frequently—between 2-4 times an hour (Konner 2006)!

The new consensus: Making sense of the latest recommendations

Feed frequently

Feed when your baby shows signs of hunger

• 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)

Sleep or food?

Watch the diaper count

Watch your baby's weight (and don't panic)

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

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

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.

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.

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.

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.

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