6.2 Breastfeeding messages
Baby Friendly Step 8
Encourage breastfeeding on demand.
How often should a baby breastfeed?
-
How much milk is available for baby?
A mother's unique breast capacity and rate of milk synthesis dictates how much milk she has available in the breast at each feed. -
How hungry is baby?
The degree of hunger dictates how much the baby will take at each feed, and how frequently he will return for more milk.
Kent et al (2006) 1 in their study of 71 thriving, exclusively breastfed babies ranging in age from 1 to 6 months, found:
- they averaged 11 feeds (range 6 - 18) per 24 hrs.
- 10 of the babies always fed from both breasts per feed;
- 19 babies always fed from one breast per feed;
- the majority of babies sometimes fed from one and sometimes fed from both breasts;
- 2/3 of babies fed at night, and consumed 20% of their total daily intake at this time.
Babies' feeding cues:
- Early cues
- wriggling, moving arms or legs
- rooting, fingers to mouth
- Mid cues
- fussing, squeaky noises
- restless, crying intermittently
- Late cues
- full cry, aversive screaming pitch, turns red

Newborn exhibiting a late feeding cue

So what should I tell a mother?
Is the baby getting enough breastmilk?
Before you can answer this question you need to know how much breastmilk is normal at the various stages of lactation. The average is as follows: 1 2 3
Age of baby | 24hr volume | Infant intake |
---|---|---|
Note:
Individual breastmilk intake (and therefore production) does not significantly change between 1 and 6 months of age |
||
Day One | 37ml (range: 7 - 123ml) (av:1+oz) |
few drops - 5ml/feed |
Day Two | 84ml (range: 44 - 335ml) (av: 3.75oz) |
5 - 15ml/feed (1 teaspoon - 1/2 ounce per feed) |
Day Three | 408ml (98 - 775ml) (13+oz) |
15 - 30ml/feed (1/2 - 1oz per feed) |
Day Five | 705ml (452 - 876ml) (av: 23.5oz) |
depends on feeding frequency, volume available and infant appetite |
1 - 6 months | 780ml (500 - 1350ml) (av: 26oz) |
30ml - 135ml/feed (6 - 18 feeds/day) (1 - 4.5oz/feed) |
The colostrum received by the baby in the first few days contains highly concentrated immunoglobulins and other protective factors (1.2 Breastmilk Immunology). Also, babies are usually born somewhat 'waterlogged' and therefore a few days of low oral intake assists the infant to clear the excess fluids. The baby is in more need of immunological protection than nutrition in the first few days.
Physiologically the newborn's stomach is not able to hold volumes larger than this. At birth the gastric wall is non-compliant and non-relaxing, which, when combined with the hypomotility of the duodenum, results in early satiety and frequent regurgitation in the first few days.4

Workbook Activity 6.3
Complete Activity 6.3 in your workbook.
Observations to make to ensure good intake
In the first 3 days postpartum it can be assumed that the intake is adequate if the baby is positioned well, latches well and sucks actively.
After secretory activation (average range of clinical onset is 50-73 hrs postpartum) 5 it is essential that mothers know how to recognize signs that their baby is feeding well.
- observe the sucking pattern. Baby should be seen to move from a quick suck:suck:suck pattern (a stimulation pattern) to a slower suck:swallow:breathe:suck:swallow:breathe pattern (the nutritive pattern) which is sustained for 2 to 3 minutes. Baby may pause after this and repeat the pattern again. Observation of this pattern confirms milk transfer is occurring.
- observe the urine and stool output. It will indicate intake: If it's coming out, it must have gone in!
- after most feeds the baby will appear satiated
- baby's mucous membranes will be moist
Normal output table
Age | Urine output | Stool output |
---|---|---|
0 - 24 hours | one wet nappy/diaper | one or more meconium stools |
24 - 48 hours | two wet nappies/diapers | one or more meconium stools/possible transitional stool |
48 - 72 hours | three wet nappies/diapers | transitional stool |
from Day 4 onwards | 6 - 8 thoroughly wet nappies/diapers, with clear urine | soft, yellow, curdy (at least daily, preferably more frequent) until about 6 weeks |

#1 Rule of infant output - If it's coming out it must have gone in!
Describe the amounts that are displayed in the table above so that parents have a realistic expectation.
Exception: the baby is being given fluids other than breastfeeding

How do mothers receive this information?
Is this information routinely given to ALL mothers? It is critical to the well-being of her baby. If you aren't able to identify when a mother has had this information discussed with her, form a group to develop a protocol to ensure this safeguard is put in place as soon as possible.

Is it the same for bottle-fed babies?
Urine and stool output is also an excellent guide to intake sufficiency for babies fed with a bottle, though those receiving breastmilk substitutes will have a firmer stool and be prone to constipation.
Twins, or more!
Can mothers produce enough milk for multiples?
Studies7 of milk production in mothers of multiples found that the mothers of exclusively breastfed three-month-old twins were producing between 2.2 - 3.4 litres (73 - 113oz.) of breastmilk per 24 hours, while a mother of exclusively breastfed 2½ month old triplets produced 3.08 litres (~103 oz). This compares with studies of breastmilk production for singletons of 750 to 1100 ml (25 - 36oz.) per 24 hours.8
Assisting breastfeeding
There are several issues that should be addressed, namely education about breastfeeding, working with the mother to find the positions that work for her, discussing how she will cope with fatigue and the extra workload, and increasing her food intake to maintain her health.
- Find an appropriate long couch or bed that provides space on each side of the mother for her to place essentials or place a baby down while she is attending to another baby.
- Use a firm pillow or foam that will not sink during feeds.
- The newborn may perform better with breastfeeding if the mother feeds each baby individually during the early learning phase. This allows her the opportunity to bond and learn about each baby's breastfeeding needs and abilities.
- When breastfeeding two babies at the same time
- initially the mother will require competent assistance to help with positioning her babies, ensuring correct latch and effectiveness of feedings
- encourage and assist the mother to experiment with which baby to latch first, which positions are best at different times of the day, whether to always feed together or sometimes feed separately, whether to keep one breast per baby or swap them each feed, etc to see what works best for her
- For triplets, two babies can be fed at the same time, then the third baby feeds from both breasts. At subsequent feeds the babies are rotated.
- Encourage the mother to ask for and accept help from family and friends who have offered assistance so she can concentrate on her task of breastfeeding and caring for the babies, and herself.

Breastfeeding twins
Beginning complementary foods
Baby Friendly Point 5
(Canada: Step 8: Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.)
Encourage exclusive and continued breastfeeding (beyond six months)(to two years), with appropriately timed introduction of (adequate and safe) complementary foods.
- the infant is not functionally ready to take complementary foods earlier than 6 months of age.
- At, or soon after 6 months, strengthening of the infant's musculature allows him to independently control his head and sit up.
- The development of fine motor coordination of more distal muscles, including the tongue and lips and their function of bringing in and manipulating more solid food in preparation for swallowing, is indicative of his ability to handle these foods at this age. 9
Physiological readiness:
- Coincidentally, at around 6 months of age, most infant's energy needs for growth and development are beyond the provision of breastmilk alone and appropriate complementary foods are required to provide additional calories and nutrients for future growth.10

The MOST important food
Between 6 and 24 months of age is a critical time for promotion of optimal growth, health and behavioral development with longitudinal studies demonstrating this is the peak age for growth faltering, deficiencies of certain micronutrients, and common childhood illnesses.
The World Health Organisation 11 recommends the following guiding principles for appropriate complementary feeding to ensure nutritional well-being continues once complementary feeding begins:
- continue frequent, on demand breastfeeding until two years old or beyond;
- start at six months with small amounts of foods and increase gradually as the child gets older
- practise responsive feeding. Feed child slowly and patiently, encouraging them to eat but do not force them, talk to the child and maintain eye contact;
- practise good hygiene and proper food handling.

Baby-led or mother-led eating?
However, there are a growing number of parents practicing baby-led weaning. This is an alternative method for introducing complementary foods to infants in which the infant feeds themselves hand-held family foods at mealtimes instead of being spoon-fed by an adult. Mothers who use this method are generally very satisfied, while health professionals express concern at the risk of choking.12
Weaning
Breastfeeding and breastmilk continues to provide protection and growth factors as well as being a quality food source for as long as the child is breastfed. There is no stage of lactation where breastmilk stops having these beneficial effects.
- The introduction of complementary foods from 6 months of age is the beginning of the weaning process.
- The weaning process can take as long as the mother and baby want it to take, but infants should continue to receive breastmilk until they are a minimum of 12 months and preferably 2 years old.
Despite health professionals having this knowledge, the number of babies who are being exclusively breastfed at 6 months of age, and the number of babies receiving any breastmilk at 12 months of age is much less than it should be in most countries.

Weaning too early
Brainstorm some ideas with your colleagues and implement them. Examples could be a poster that simply states “Breastmilk only to 6 months; Breastmilk plus family foods to 2+ years.
” Sometimes a simple statement such as that is all the mother needs to know. However, you could also address education about artificial feeding and talk to mothers about the barriers they may see to continuing to provide breastmilk.
What should I remember?

- The infant feeding cues.
- The variation in milk production and infant intake in the first 5 days.
- The expected infant output which indicates adequate intake.
- How to teach mothers to recognise milk transfer.
- Expectations for mothers about the frequency of breastfeeding.
- When and how to begin complementary feeding.
- The minimum age an infant should be weaned completely from breastmilk.
Self-test quiz
Notes
- # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
- # Riordan J (2005) Breastfeeding and Human Lactation
- # Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum
- # Zangen S et al. (2001) Rapid maturation of gastric relaxation in newborn infants
- # Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview
- # Friedman S et al. (2004) The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants.
- # Saint L et al. (1986) Yield and nutrient content of milk in eight women breast-feeding twins and one-woman breast-feeding triplet.
- # Kent JC et al. (2004) Frequency, volume and fat content of breastfeeds of exclusively breastfed babies
- # World Health Organization (2001) Report of the expert consultation of the optimal duration of exclusive breastfeeding
- # Dewey K (2003) Guiding Principles for Complementary Feeding of the Breastfed Child
- # World Health Organisation (2010) Infant and young child feeding - Fact sheet N,.342
- # Cameron SL et al. (2012) Healthcare professionals\' and mothers\' knowledge of, attitudes to and experiences with, Baby-Led Weaning: a content analysis study.