Myth or Fact: Never Wake a Sleeping Baby

When it comes to sleep and babies, parents often get conflicting advice. Should a sleeping baby be awakened every few hours to nurse? If a baby begins sleeping longer stretches, is pumping necessary to maintain milk production? As with many baby-care questions, the answer is “it depends.”

When babies sleep for long stretches, several factors influence the best course of action: your comfort, baby’s age, and baby’s growth. Some common practices may also affect these decisions. Let’s start with the basics.

Your Comfort

No matter what is going on with your sleeping baby, if you wake up feeling uncomfortably full of milk, it’s time to take action. Go ahead and nurse. You can do this without fully awakening your baby by encouraging what’s called a “dream feed.” This means stimulating your baby just enough during light sleep (eyes moving under eyelids, any body movement) to latch and nurse but not so much that she is wide awake. After dream feeds, babies usually continue sleeping. This kind of turnabout is fair play, as baby likely wakes you when she needs to nurse. The longer unrelieved breast fullness continues, the greater the risk you’ll develop a problem, such as plugged ducts or mastitis. Your health is important, too!

Baby’s Age and Weight

In addition to your needs, are there times when—for baby’s sake—you should awaken a sleeping baby to feed? Yes. Most often, this need arises during the early weeks.

Early weight loss and gain.  After birth, nursing babies commonly lose up to 10% of birth weight,[1] with the lowest weight occurring on Day 3 or 4. From that point on, babies gain on average about 1 oz. (30 g) per day until they reach 3 or 4 months of age, when weight gain naturally slows.[2] It’s a good sign if baby is back to birth weight by 2 weeks, but some well babies may take longer than this. Most health organizations recommend babies see their healthcare provider for weight checks within a day or two after hospital discharge and again at around 2 weeks. Weight gain is the most reliable gauge of how nursing is going.

The first 2 weeks are like a “trial period,” when it’s a good idea to keep a close eye on the nursing baby. This usually involves weight checks, tracking number of nursing sessions per 24 hours and diaper output.  If baby is not gaining weight as expected or has a weight loss of more than 10% of birth weight, it’s time to see a lactation specialist to determine the cause. In some cases, this is unrelated to nursing (see HERE). But it may happen if a baby spends too much time sleeping and not enough time nursing. An overdressed or swaddled baby may become too warm (for more on swaddling, click HERE), which increases sleepiness (use adult clothing weight as a guide for baby). Some newborns don’t nurse effectively due to a shallow latch or other issues, which can contribute to both weight-gain issues and nipple pain in the nursing parent. When an ineffective  baby’s resulting calorie intake is too low, this not only causes weight issues, it saps her energy, causing excessively sleepiness.

Between these early weight checks, what are some signs baby needs to be awakened to nurse?   

• Number of nursing sessions per day: Make sure baby nurses at least 8 times each day (more is even better). Ignore the time intervals between feeds, focusing instead on each 24-hour period. Some thriving newborns sleep for one 4- to 5-hour stretch but still fit in at least 8 feeds by bunching their feeds close together, nursing like crazy while they’re awake (cluster feed). This pattern is common during the first 40 days.[3]

• Dirty diapers. Changes in stool color are a reliable sign of adequate milk intake during the first week.[4] If nursing is going well, stools change from black to greenish by around Day 3 and to yellow or brown by Day 4 or 5. If stools stay black and tarry after Day 5, it’s time to contact baby’s healthcare provider to get baby weighed and evaluated. After stools turn yellow, 3 to 4 or more stools per day is a rough indicator baby is getting enough milk, which creates the stools and puts on weight.

If a sleepy newborn does not fit in at least 8 nursing sessions per day, stool color does not change when expected, or baby’s weight is of concern, it makes sense to wake her to fit in more feeds and seek lactation help. When it is difficult to wake baby to feed actively at least 8 times per day, it is time to contact baby’s healthcare provider.

As the months pass, baby may begin sleeping for longer stretches. As her tummy grows, she can hold more milk. Some babies continue to gain weight as expected on fewer feeds per day. Others need the same number of nursing sessions to grow and thrive.[5]

Even if your baby begins sleeping for longer stretches, don’t expect this to continue. With babies and sleep, it’s often two steps forward and one step back. The baby who was sleeping for 5 or 6 hours at night at 3 months is often the same baby who wakes frequently again for night feeds when teething starts and developmental changes (like rolling over, crawling, and walking) occur.

Is it necessary after the newborn stage to wake a baby to nurse? Assuming you’re comfortable, it all depends on how she’s doing. If baby is gaining weight as expected, no need to make any changes. If not, more feeds are likely needed. In some cases, nursing more often during the day might be enough for a baby to get the milk she needs. But if you have what’s called a “small storage capacity” (explained HERE), going for too long between milk removals (nursing or pumping) at night may slow milk production. Getting a sense of your own “magic number” (the number of milk removals per day needed to keep production steady, also explained on the link in the previous sentence) is vital to meeting your long-term feeding goals.[6]

Common Practices to Consider

Some nursing parents worry that if their baby sleeps for too long at night, this might decrease their milk production. But when they are responsive to baby’s cues, if milk production decreases, most babies will simply cue to feed more often to get the milk they need, which also stimulates ample milk production. In short:  if you continue to feed your baby on cue, day and night rather than following a feeding schedule (even a loose schedule), extra pumping should not be necessary to maintain milk production.  However, some common baby-care practices may interfere with this automatic demand-and-supply regulation of milk-making and cause a decrease production and infant weight gain. Unlike other mammal species, with our large brains, it is not only possible to overthink lactation, we can also be convinced to inadvertently thwart our biology.

Night weaning and sleep training.  Making ample milk for our baby (even twins and triplets) is something that usually happens automatically when a baby nurses effectively and nursing parents are responsive to baby’s feeding cues. Even during the newborn stage, however, some baby-care authors advise parents to disregard human physiology and feed babies on a strict schedule, which the American Academy of Pediatrics linked to increased risk of dehydration and slow weight gain.[7] Other authors advise parents to night wean or use sleep-training methods to reduce infant night-waking. These practices involve being less responsive to baby’s feeding cues at night.

These methods may temporarily reduce baby’s night-waking, but they often need to be repeated multiple times as baby enters different stages of growth and development. In addition to being stressful for many nursing parents, depending on their storage capacity, milk production (and baby’s growth) may be compromised as nursing sessions are eliminated. When milk production is no longer automatically regulated by the baby, these practices may prevent families from meeting their long-term feeding goals.

When parents struggle to deal with night-waking, there are alternatives to these practices. An Australian study found that parents were better able to cope with infant night-waking when they learned about infant-sleeping norms and received support.[8] To learn about infant sleeping norms, a good place to start is the free Infant Sleep Info app (details HERE) created by UK infant-sleep researchers at the University of Durham. With this app, parents can chart their baby’s sleep patterns and compare them with other babies their age.

Bottle-feeding and baby’s sleep patterns. Many nursing babies are also bottle-fed occasionally, partially, or exclusively. Depending on how it’s done, bottle-feeding may either reinforce healthy nursing and sleeping patterns or distort them. If paced bottle-feeding techniques (described HERE) are used, this creates an ebb and flow of milk during feeds similar to nursing that helps prevent overfeeding. Bottle-feeding with a consistent, fast milk flow, however, increases risk of overfeeding, overweight, and obesity.[9] If babies are routinely overfed by bottle during the day (a common issue for employed parents), too much milk during their daylight hours can leave babies less interested in nursing at night. This major alteration in normal infant feeding patterns may decrease milk production and interfere with parents’ ability to keep their long-term milk production steady. If this happens, switching to paced bottle-feeding may help get nursing back on track.  

Should you wake a sleeping baby? One size definitely does not fit all. As with most aspects of parenting, following a simple adage will never be right 100% of the time. You are the expert on your baby. If your approach is working for your family and enables you to meet your feeding goals, trust your instincts. On the other hand, if a practice doesn’t feel right or negatively affects you or your baby, it’s time to consider alternatives or to seek help.

References

1 Kellams, A., Harrel, C., Omage, S., et al. (2017). ABM Clinical Protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017. Breastfeeding Medicine, 12(3), 188-198.

2 WHO. (2009). WHO Child Growth Standards: Growth Velocity Based on Weight, Length and Head Circumference: Methods and Development. (2006/07/05 ed. Vol. 450). Geneva, Switzerland: World Health Organization.

3 Benson, S. (2001). What is normal? A study of normal breastfeeding dyads during the first sixty hours of life. Breastfeeding Review, 9(1), 27-32.

4 Nommsen-Rivers, L. A., Heinig, M. J., Cohen, R. J., et al. (2008). Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy. Journal of Human Lactation, 24(1), 27-33.

5 Kent, J. C., Mitoulas, L. R., Cregan, M. D., et al. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), e387-395.

6 Mohrbacher, N. (2011). The ‘Magic Number’ and long-term milk production. Clinical Lactation, 2(1), 15-18.

7 Aney, M.  (1998). ‘BabyWise’ advice linked to dehydration, failure to thrive. AAP News, 14(4):21.

8 Ball, H. L., Douglas, P. S., Kulasinghe, K., et al. (2018). The Possums Infant Sleep Program: Parents’ perspectives on a novel parent-infant sleep intervention in Australia. Sleep Health, 4(6), 519-526.

9 Azad, M. B., Vehling, L., Chan, D., et al. (2018). Infant feeding and weight gain: Separating breast milk from breastfeeding and formula from food. Pediatrics, 142(4)

Do Older Babies Need Night Feedings?

Has somebody told you that your baby doesn’t need to breastfeed at night past a certain age?  This age often varies by advisor. However, science tells us that in many cases, this simply isn’t true.

Why? Babies and mothers are different and these differences affect baby’s need for night feedings. Some babies really do need to breastfeed at night, at six months, eight months, and beyond.  This is in part because if their mother has a small “breast storage capacity” and tries to sleep train her baby, her milk production will slow, along with her baby’s growth. To find out what this means and if this applies to you, you need to know the basics of how milk production works.

Degree of Breast Fullness

Two basic dynamics are major influencers of milk production. The first, “degree of breast fullness,” refers to a simple concept: Drained breasts make milk faster and full breasts make milk slower. Whenever your breasts contain enough milk to feel full, your milk production slows.1 The fuller your breasts become, the stronger the signal your body receives to slow milk production.

Breast Storage Capacity

This second basic dynamic refers to a physical characteristic known as breast storage capacity, which varies among mothers.2 This physical difference explains why feeding patterns can vary so much among mothers and why one breastfed baby does not need to breastfeed at night while another one does.

Breast storage capacity is the amount of milk your breasts contain in your milk-making glands at their fullest point of the day. Storage capacity is not related to breast size, which varies mainly by how much fatty tissue is in your breasts. In other words, smaller-breasted mothers can have a large storage capacity and larger-breasted mothers can have a small capacity.

Both large-capacity and small-capacity mothers produce plenty of milk for their babies. But their babies feed differently to get the daily volume of milk they need.3 After baby’s first month, a mother with a large storage capacity may notice that her baby:

• Is satisfied with one breast at most or all feedings.
• Is finished breastfeeding much sooner than other babies (sometimes just five minutes).
• Gains weight well on fewer feedings per day than the average eight or so.
• Sleeps for longer-than-average stretches at night.

If this describes your breastfeeding experience, your baby may already be sleeping for longer stretches at night than other babies you know. But if after the first month of life your baby often takes both breasts at feedings, feeds on average longer than about 15 to 20 minutes total, typically takes eight or more feedings per day, and wakes at least twice a night to breastfeed, your breast storage capacity is likely to be small or average. 

Again, what’s important to a baby’s healthy growth is not how much milk he receives at each feeding, but rather how much milk he consumes in a 24-hour day. Breastfed babies of both large- and small-capacity mothers receive plenty of milk, but their breastfeeding patterns will necessarily differ to gain weight and thrive.4 For example, a baby whose mother’s breasts hold six ounces or more (180 mL) may grow well with as few as five feedings per day.  But to get this same 30 ounces (900 mL) of milk, if a mother’s breasts hold only three ounces (90 mL), a baby with a small-capacity mother will need to feed ten times each day.  (This may not apply in the same way to a mother who’s pumping.)

How These Dynamics Affect Night Feedings

How does this apply to night feedings? A mother with a large storage capacity has the room in her milk-making glands to comfortably store more milk at night before it exerts the amount of internal pressure needed to slow her milk production. On the other hand, if the baby of the small-capacity mother sleeps for too long at night, her breasts become so full that her milk production slows.

In other words, if you are a mother with an average or small breast storage capacity, night feedings may need to continue for many months in order for your milk production to stay stable and for your baby to thrive. Also, because your baby has access to less milk at each feeding, night feedings may be crucial for him to get enough milk overall. Again, what’s important is not how much milk a baby receives at each individual feeding, but how much milk he consumes in a 24-hour day. If a mother with a small storage capacity uses sleep training strategies to force her baby to go for longer stretches between feedings, this may slow her milk production and compromise her baby’s weight gain.

Each mother-baby pair is unique. Babies will outgrow the need for night nursings at different ages, so a simple rule of thumb doesn’t consider either the emotional needs of the baby or his physical need for milk.

References

1Daly, S. E., Kent, J. C., Owens, R. A., & Hartmann, P. E. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis, Experimental Physiology, 81(5), 861-875.

2Cregan, M. D., & Hartmann, P. E. (1999). Computerized breast measurement from conception to weaning: clinical implications. J Hum Lact, 15(2), 89-96.

3Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day, Pediatrics, 117(3), e387-395.

4Kent, J. C. (2007). How breastfeeding works. Journal of Midwifery & Women's Health, 52(6), 564-570.

Unintended Consequences

What’s a breastfeeding mother to do?  Is it riskier to bedshare with her baby during the night or is it riskier not to?  That’s what a survey of 4789 U.S. mothers with babies under one year clarified.1

In the U.S. parents are admonished never to sleep with their babies.2 The Milwaukee, Wisconsin health department, for example, uses the image of an adult headboard transformed into a tombstone as a warning about the dangers of bedsharing. (Click here for a video on this campaign.) 

Bedsharing appears even more dangerous when—as often happens in the U.S.—infant deaths are blamed on it even when other more hazardous practices are present, such as adult alcohol intoxication and drug use and when the “bed” is actually a recliner, chair or sofa.  One Scottish study, for example, found that the risk of an infant dying was nearly 67 times higher on a sofa compared to an adult bed.3

According to the U.S. mothers surveyed, despite their awareness of these public campaigns, nearly 60% of their babies shared their beds for at least part of the night.  Among the mothers who attempted to follow the recommendations against bedsharing, 55% fed their babies at night in chairs, recliners, or sofas and 44% of these (25% of the total) reported falling asleep some of the time in these much more dangerous places.  In other words, their attempts to “follow the rules” often led to the unintended consequence of much riskier behaviors.

The authors of this survey concluded that safe-sleep campaigns should include information on safe bedsharing, because when this information is absent, parents will continue to bedshare in unsafe ways.  The Japanese experience confirms this.  As bedsharing as has become more common in Japan (it is now the cultural norm), rates of SIDS have decreased. 4What’s different there is that Japanese families bedshare safely.  Families sleep together on futons on the floor away from walls, so babies cannot fall far or get trapped.  Fluffy pillows and bedclothes are not used. 

To save more lives, U.S. safe-sleep campaigns should consider taking a page from the Japanese playbook.  By emphasizing how to create a safe sleeping environment—rather than trying to browbeat parents into avoiding bedsharing—more babies’ lives would be spared.  And as an extra plus, more families would also get a better night’s sleep.

For a brochure for parents on safe sleep, click here.

References

1Kendall-Tackett, K., Cong, Z., and Hale, T.W.  Mother-infant sleep locations and nighttime feeding behavior.  Clin Lact 2010; 1(1):27-30.

2American Academy of Pediatrics, Task Force on SIDS.  The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk.  Pediatrics 2005; 116:1245-55.

3Tappin, D. et al.  Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: A case-control study.  J Pediatr 2005; 147:32-37.

4McKenna, J., Ball, H., and Gettler, L.T.  Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: What biological anthropology has discovered about normal infant sleep and pediatric sleep medicine.  Amer J Phys Anthropol, Suppl 2007; 45:133-61.

For More Sleep, Breastfeed

Fatigue is a fact of life for new parents no matter how their newborn is fed.  When sleep is at a premium, they may consider their alternatives.  If a new mother's partner takes over some night feedings, will she get more sleep?  Will giving formula at night make baby sleep longer?  According to research, neither of these strategies produces the desired results.  One U.S. study of 133 new mothers and fathers during the first three months postpartum found that mothers who exclusively breastfed averaged 40 to 45 minutes more sleep at night than those whose babies also received infant formula.  Why didn’t sharing night feedings help mothers sleep more?  Because the mothers’ sleep was significantly disrupted while the baby’s father fed the baby.  The researchers wrote:

“…formula feeding not only failed to improve parent sleep, but actually resulted in parents getting less sleep, even when fathers helped during the night with…feedings” (Doan, Gay & Lee, 2007, p. 204).

Exclusive breastfeeding leads to more sleep, and it also leads to better sleep.  Compared with women without children and formula-feeding mothers with babies the same age, Australian research found that breastfeeding mothers spent more time in deep sleep (Blyton, Sullivan, & Edwards, 2002).  The exclusively breastfeeding mothers had “a marked alteration in their sleep architecture,” giving them longer periods of slow-wave sleep, a type of deep sleep.  The researchers concluded that “enhanced SWS may be another important factor to support breastfeeding in the postnatal period” (Blyton et al., 2002, p. 297).

References

Blyton, D. M., Sullivan, C. E., & Edwards, N. (2002). Lactation is associated with an increase in slow-wave sleep in women. Journal of Sleep Research, 11(4), 297-303.

Doan, T., Gardiner, A., Gay, C. L., & Lee, K. A. (2007). Breast-feeding increases sleep duration of new parents. J Perinat Neonatal Nurs, 21(3), 200-206.