Breastfeeding on demand: An evidence-based guide
© 2019 Gwen Dewar, Ph.D., all rights reserved
Breastfeeding on demand (also known as "responsive feeding," "feeding on cue," and "baby-led" feeding) is the practice of responding flexibly to your baby's hunger cues.
You initiate feedings when the baby requests them, and continue each feeding session until the baby is satisfied. You don't impose time limits, and you don't impose a strict schedule.
Why should parents feed their babies on demand, as opposed to following a strict schedule?
Evolutionary, cross-cultural, and clinical research suggests that babies were designed to feed on cue. And breastfeeding on demand comes with important benefits:
- It's the ideal way to keep milk production in sync with a baby's needs.
- It helps ensure that babies, especially newborns, get enough milk.
- It even might benefit emotional and cognitive development.
Let's take a closer look at these claims, and then tackle some frequently-asked questions.
Finally, we'll consider some tips for coping with the exhausting work of feeding a young infant. As I note below, new mothers shouldn't be pressured into ignoring their own health and well-being. They need helpers!
Breastfeeding on demand versus schedule feeding: What are the benefits of allowing babies self-regulate?
1. Breastfeeding on demand helps ensure that babies get enough milk -- especially during the early weeks
Breastfeeding on demand is recommended by major medical and advocacy groups, including the World Health Organization, the American Academy of Pediatrics, and La Leche League.
Why? It comes down to the feedback system that controls lactation.
Mammary glands make milk in response to the frequency of suckling. The more a baby nurses, the more milk a breast produces. If a baby suckles less frequently, milk production slows.
This feedback is necessary to establish the initial milk supply,
and early, frequent feedings matter.
Experimental research suggests that initiating feeding within an
hour of childbirth helps ensure larger milk volumes in subsequent
days (Liu 2018).
It also suggests that frequent feedings during the first few weeks
postpartum (e.g., 10 feedings per 24 hours, as opposed to 7 feedings
to per 24 hours) lead to greater milk intake and weight gain in
newborns (De Carvalho et al 1983).
So the evidence supports frequent feedings during the first few weeks. What about afterwards, and what about the specific approach to feeding -- scheduled feeds versus breastfeeding on demand?
To answer these questions, it's important to understand the most fundamental problem with feeding schedules:
The quality and energy content of breast milk are always changing, and so are a baby's needs. In addition, babies differ in their ability to extract milk efficiently.
For example, the quality and energy content of milk can vary by time of day, and in response to changes in the mother's diet. And the fat content of milk generally increases over the course of a single nursing session.
In addition, some babies -- larger babies, and babies undergoing growth spurts -- need more milk than others. And not every baby is equally skilled at suckling. Babies who have more trouble will extract milk at a slower rate, which means they need more time at the breast to get their fill.
So ending a session too soon can result in a shortfall of calories. If parents, rather than babies, determine when a breastfeeding ends, the baby is more likely to come away hungry, or unsated.
And if parents also ignore that baby's signals of hunger -- insisting that the baby wait until a parent-determined time for the next meal -- things can get even worse. Not only is the baby hungry, the baby may now be too frustrated and distressed to nurse efficiently.
Lactation consultants observe that that when a baby's hunger cues are ignored for even a couple of minutes, the baby becomes unsettled and upset. This makes it hard for the infant to latch on correctly, decreasing the efficiency of milk extraction.
In summary, adult-imposed feeding schedules are ill-suited to the task. The best way to ensure that babies get enough milk is to let them tell us when they are hungry, and to allow them to continue feeding until they appear sated.
2. Breastfeeding on demand may also deliver important non-nutritive benefits
Babies reap more than nutritional benefits from breastfeeding.
When babies breastfeed, they experience skin-to-skin contact, which helps infants regulate their body temperature and blood glucose levels (Anderson et al 2003).
Moreover, skin-to-skin contact helps babies cope with pain (Kostandy et al 2013). And it has been shown to reduce a newborn's levels of the stress hormone, cortisol (Beijers et al 2018).
Mothers, too, experience stress-related benefits. Breastfeeding triggers the release of oxytocin in the mother, which has an immediate, calming effect (Niwayama et al 2017; Uvnas Moberg 2003).
So responsive breastfeeding could help address a baby's physiological and emotional needs. And to the degree that breastfeeding on demand results in more frequent nursing sessions, it may help mothers cope with stress.
3. Breastfeeding on demand might contribute to improvements in cognitive development
Evidence links breastfeeding on demand to higher IQ scores
In a study tracking more than 10,000 children over a period of years, researchers found that mothers who fed their newborns on a schedule were more likely to say they were getting enough sleep during the early months.
But when researchers examined long-term infant outcomes, they found that newborns fed on a schedule showed modest lags in cognitive development. And by the age of 8 years, children who'd been fed on a schedule as young infants scored an average of 4.5 points lower on an IQ test (Iacovou and Sevilla 2013).
And these lags remained significant even after the researchers controlled for important factors like birth weight, maternal smoking, parental education levels, socioeconomic status, and how often parents read to their children.
Why was schedule feeding linked with poorer cognitive outcomes?
The researchers aren't sure, and caution that we can't jump to conclusions. But we should note that the researchers controlled for a variety of other, important factors, and found the link was still significant:
Children fed on demand as newborns were better off cognitively, even after taking into about birth weight, maternal smoking, parental education levels, socioeconomic status, and how often parents read to their children (Iacovou and Sevilla 2013).
So while we need additional, high-quality research to settle the question, this study gives us reason to think that early, responsive feeding contributes to cognitive development.
Other questions about breastfeeding on demand
How can you tell if a baby is hungry?
Early signs of infant hunger include:
- increased alertness (Hodges et al 2013)
- "mouthing," i.e., repeatedly opening and closing the mouth (Hodges et al 2013)
- licking the lips; sucking on hands (Hodges et al 2013)
- "rooting," i.e., responding to a brush on the cheek or lips by turning toward the stimulus and opening the mouth (Glodowski et al 2019)
As a baby's hunger intensifies, he or she will move around more, pulling on the caregiver, reaching for the caregiver's chest, an otherwise attempting to initiate a feeding.
Late signs of hunger include crying and fussing. Researchers and lactation consultants recommend that you offer your breast when the early signs of hunger appear.
How can you tell when a baby has had enough?
At the beginning of a feeding session, when the baby is hungry, your baby will make frequent eye contact with you. But as the session goes on, your baby will do this less and less, and your baby may also attempt to wriggle out of his or her feeding position (Shloim et al 2017).
So those are cues to look for, in addition to the more obvious ones: Your baby will show decreased interest suckling, disengaging or turning away from the breast.
How often do babies typically feed?
That depends on the baby. It also varies across cultures.
For instance, hunter-gatherer babies nurse very frequently: twice an hour or more. And for these frequent-feeders, (Woodridge 1995).
But in places like the United States, mothers who identify themselves as responsive feeders may nurse as infrequently as once every two hours.
Currently, Western breastfeeding experts typically estimate that newborns need 8-12 feedings a day.
And how much time does it take babies to finish a meal? How long is the typical breastfeeding session for a newborn?
That, too, depends on the baby, for the reasons outlined at the beginning of this article. Babies vary in their needs, and they vary in their ability to extract milk.
For example, according to the American College of Obstetricians and Gynecologists (2016), a single newborn feeding session may last anywhere from 20 minutes to more than an hour.
But it also varies across cultures. In societies where babies are fed very frequently -- more than once per hour -- feeding sessions may not last as long.
And as babies get older, they may take less time at the breast; feeds of 10-15 minutes are common (Woodridge 1995).
But 8-12 times a day? Really? How long should parents keep this up?
Among babies who are healthy and thriving, most babies will be ready to go longer between feeds by 4-6 weeks. They will have developed the ability to consume more milk per feeding, and they'll also have become more attuned to the rhythms of daily life.
For example, at 6 weeks postpartum, some babies may be ready to sleep for 5 hours at a stretch -- as long as they "tank up" first. Learn more in my article about "dream feeding."
Doesn't this put an unreasonable burden on mothers?
I believe it does, and that's why mothers should receive help --
the support of additional caregivers who sometimes bottle-feed the
This, of course, is what happens when new mothers must return to
the workplace: Alternative caregivers feed the baby during the
mother's work shift -- with bottles of expressed breast milk or
But I'm also arguing that mothers should get help with feedings
during the newborn phase, when mothers are on maternity leave,
recovering from childbirth and suffering from sleep deprivation.
Yes, it's important to start breastfeeding shortly after childbirth, and it's important to breastfeed frequently thereafter in order to ensure the adequate production of mature milk. But that doesn't mean we should deny mothers the opportunity to sleep more than 2-3 hours at a stretch!
Unfortunately, some mothers have gotten a different message. They've been told that bottle-feeding should be avoided during the early days postpartum. According to popular advice, exposing newborns to even occasional
bottle-feeding could jeopardize breastfeeding success.
What's wrong with this advice?
First, there is insufficient evidence in support of claims that occasional bottle feedings will derail breastfeeding.
On the one hand, a number of studies report correlations between the early use of bottles and shorter breastfeeding duration. But these studies don't tell us that bottle use caused shorter breastfeeding duration. Something else might explain the link.
For example, maybe the parents who made frequent use of bottle-feeding already had the intention of weaning babies early.
On the other hand, controlled, experimental studies have failed to find to show that limited bottle-feeding is detrimental (Gray-Donald et al 1985; Schubiger et al 1997).
For instance, in one study, researchers assigned newborns to either (1) exclusive breastfeeding for the
first 5 days postpartum, or (2) care that included the occasional bottle. When
the researchers followed up at 2, 4, and 6 months, they found no differences
between groups in breastfeeding frequency or duration (Schubiger et al 1997).
In sum, it's fair to say that we could benefit from more such
studies. But given the current state of the evidence, we can't
conclude that mothers are going to jeopardize breastfeeding success
because someone else feeds their babies once in a while. Not if they
initiate breastfeeding shortly after childbirth, and, overall,
maintain a pattern of frequent feedings.
The second problem I have with the never-bottle-feed advice is
that it is one-sided. It assumes that the only benefit to be factored into our decision-making is long-term breastfeeding success!
In reality, the mother's health and well-being are of great importance. Even people who devalue mothers -- and care only about
infant outcomes -- have to contend with this fact. Babies are less
likely to thrive, and more likely to develop problems, when their
mothers are stressed-out.
Finally, it seems to me that much of the debate about exclusive, maternal breastfeeding rooted in mythology
about the human race.
People assume that exclusive, maternal breastfeeding is
the "natural" condition of our species. It's what what hunter-gatherers do. It's what people living in pre-industrial, agrarian societies do.
As I explain below, this is a fantasy. Anthropological research
demonstrates traditional, non-industrialized peoples do not typically
engage in exclusive breastfeeding for the first 6 months. From the
earliest days after childbirth, mothers get help in the feeding of
their infants. In some groups, this includes having other, lactating women donate their milk to the cause.
And what about exhaustion?!
New mothers get precious little sleep, and may find breastfeeding on demand to be exhausting. It's nice to know that life will improve by 4-6 weeks postpartum. But that doesn't make those first few weeks any less exhausting.
What's the solution?
There isn't any one solution, but there are tactics and practices that can help you cope with breastfeeding on demand.
Breastfeeding on demand: Tips for coping
1. Don't underestimate the power of a nap. Naps can be surprisingly restorative when you're sleep-deprived.
When you lose many hours of sleep, you might naturally assume that you'll need to sleep long hours to make up the difference.
But happily, the human brain can tweak our sleep cycles, ensuring that we sleep more deeply when we've been sleep-deprived.
As a result, a couple of thirty minute naps can help reverse many of the ill effects of severe sleep restriction (Faraut et al 2015).
2. Don't let your newborn's upside-down schedule turn you into a vampire. Make an effort to expose yourself to sunlight during the day, and avoid artificial lighting at night.
It's easy to give up on normalcy when you're feeding a baby every 2-3 hours. But when it comes to lighting, resist the temptation.
The brain uses light cues to tune its "inner clock," so it's important expose yourself to morning and afternoon daylight, and avoid artificial lighting at night, especially light sources that feature the blue wavelengths of light.
Sticking to natural lighting patterns will help your brain maintain a grip on what time it is. It will help you preserve healthy circadian rhythms, making it easier for you to resume normal sleeping patterns as your baby matures.
And if you also expose your baby to natural lighting patterns, you will likely shorten the time it takes for your baby to develop mature sleep rhythms. So seek out opportunities to share the sunlight, and keep things dark at night.
3. Get help if you can!
I've already given you the preview: There is nothing "natural" about saddling mothers with all the work.
Among the modern peoples whose lifestyles most closely resemble those of our ancestors -- hunter-gatherers -- new mothers get help from the very beginning.
During the first few days postpartum, other women, women who are lactating, may pitch in by breastfeeding the newborn (Tronick et al 1987).
Experienced helpers also pitch in by taking care of a mother's older children.
And families receive food subsidies from other group members. Parents can't afford to care for babies and raise children without this outside help.
Among people living in other traditional societies -- from from Southeast Asia (Jambunathan 1995), to China (Raven et al 2007), to Morocco (Westermark 1926) -- it's also common for new mothers to spend the first 30-40 days after childbirth in postpartum seclusion.
During this time, mothers are excused (if not downright forbidden) from doing most work except for breastfeeding. Friends or relatives (usually the mother’s mother or mother-in-law) help with housework and food preparation.
Postpartum seclusion isn’t necessarily stress-free. Cultures may impose rituals and taboos that mothers may find restrictive (Leung et al 2005). But the help mothers receive probably makes breastfeeding on demand less difficult.
So it's silly to imagine that you are meant to handle everything yourself. Recruit partners, relatives, and friends to pitch in. Pump your milk, and allow someone else to feed your baby while you attempt to nap. Take advantage of whatever opportunities you have to rest.
4. Share a room with your baby at night, and keep your baby within arm's reach. A bedside sleeper or bassinet -- designed according to the latest safety guidelines -- will make it easier for you to provide nighttime feedings with minimal disruption.
Rooming together allows parents to keep tabs on their babies. It also makes nighttime feeding sessions less disruptive to maternal sleep. The baby awakens at night, and is fed there, on the spot.
5. Try baby-wearing, or, if that's not possible, find other ways to include your baby in your daily activities.
Since the 19th century, many Westerners have taken up the practice of "parking" their infants in cribs, bouncers, car seats or playpens for much of the day. But that's not normal for our species.
In most societies, babies are held or carried throughout the day, accompanying caregivers as they go about their business (Barry and Paxton 1971; Severn Nelson et al 2000; Konner 2006).
The close proximity is helpful for breastfeeding. You're more likely to notice when your baby begins showing signs of hunger. Maybe that's why infant carrying practices are linked with early responsiveness to hunger cues:
In an online survey, mothers who carried their babies during the day (in their arms, or in a sling) were much more likely to report that they respond quickly to their infant's early cues of hunger (Little et al 2017)
But research also suggests another benefit. When babies are included in our everyday activities, they are quicker to adopt mature rhythms of waking and sleeping (Tsai et al 2011; Wulff and Siegmund 2002). So baby-wearing and carrying may help your baby develop the habit of sleeping for longer stretches during the night.
6. Connect with people and institutions that support breastfeeding on demand. And if you face criticism from friends or family members, point them to the evidence.
It isn't just a question of understanding the benefits of responsive breastfeeding. It's also a question of giving women the opportunity to nurse as they go about their daily business -- wherever they might be.
Mothers need to be able to nurse their babies when they are away from home.
Unfortunately, not everybody gets it. Many people are uncomfortable with the sight of a woman breastfeeding, usually because they associate bared breasts with eroticism or sexuality. So we need to remind them: This is a cultural hang-up, and one that most societies on the planet do not share.
On the contrary, in most societies known to anthropologists, breasts are first and foremost regarded as sources of infant nutrition. In one cross-cultural study, breasts were considered as objects of erotic interest in only 13 out of 190 cultures surveyed (Ford and Beach 1951).
And as anthropologist Katherine A. Dettwyler argues (1995), sexual attitudes about breasts are a barrier to breastfeeding on demand. In places like Mali or Nepal, women’s breasts are not sexualized, and women nurse their babies in public whenever the baby is ready to feed.
More reading about breastfeeding on demand
For more information about breastfeeding on demand, see these tips, as well as these articles:
References: Breastfeeding on demand
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Content of "Breastfeeding on demand" last modified 2/2019
image credits for "Breastfeeding on demand":
Title image by Mae Catherine Melchor / flickr
Painted image by Paul Gaugin
image of rooting reflex by Ashley Arbuckle /flickr
image of father feeding baby by Ryan Grimm / flickr
"Breastfeeding on demand: Benefits, questions, and evidence-based tips" © 2019 GWEN DEWAR, PH.D., ALL RIGHTS RESERVED
content last modified 2/11/2019