Nighttime Management of Breastfeeding Infants
by Anne Eglash MD, IBCLC, FABM
What are evidence-based approaches to feeding the breastfed infant overnight?
The Academy of Breastfeeding Medicine recently published their clinical protocol #37- ‘Physiological Infant Care- Managing Nighttime Breastfeeding in Young Infants’. The goal of this protocol is to understand normal infant feeding overnight, and the benefits/risks of unphysiological behaviors, such as sleep training or pumping and bottle feeding overnight.
The protocol recommends responsive feeding, advising at least 8 feeds at the breast every 24 hours, but no restrictions on the frequency or length of breastfeeds, as responsive feeding is associated with exclusive breastfeeding.
Breastfeeding at night is considered normal and may naturally decline after adding complementary foods at 6 months. However, some infants will breastfeed more often at night when they are away from their mothers during the day.
The protocol recommends allowing infants to set their circadian rhythm in the first few months by exposing infants to a normal daytime environment when napping, such as avoiding dark rooms or significantly reducing ambient noise.
Nighttime separation of mothers and infants can cause infant distress and elevated cortisol levels, even if the infant is not crying. In addition, nighttime separation in the first 4 months for long periods may not be safe, and may explain why close proximity of the infant with the mother at night is associated with a lower risk of sudden infant death syndrome (SIDS).
The authors of the protocol discuss challenges to physiological infant care, such as parental and societal expectations that infants should be sleeping all night by themselves in a crib, and that breastfeeding at night contributes to maternal stress and depression due to less sleep.
They discuss that strategies to improve maternal sleep at night including pumping and bottle feeding and non-breastmilk feeding increase the risk of premature weaning. These strategies don’t necessarily improve maternal sleep, since they require artificial lighting and getting out of bed, both of which are probably more disruptive of maternal sleep as compared with bedsharing and nursing throughout the night. Research has shown that breastfeeding mothers who bedshare or are in proximity with their infants at night report sleeping well and often don’t recall how often their infants nursed overnight.
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- The risk of SIDS in relation to bedsharing is unknown among dyads who are fed by exclusive pumping.
- Sleep training in the first 6 months is not recommended and is considered reasonable between 6-12 months.
- Disrupted maternal sleep due to direct breastfeeding in the middle of the night increases maternal depression and anxiety.
- Tracking apps for infant feeding have been shown to increase parental anxiety.
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The ABM protocol states that direct breastfeeding overnight is not associated with poorer maternal sleep, especially when lights are not turned on and the infant’s diaper is not changed. In addition, direct breastfeeding at night is not associated with maternal anxiety or depression. Mothers who have a history of depression or anxiety are at risk for poor sleep, increasing the likelihood of premature weaning.
Sleep training is considered contraindicated in the first 6 months due to the risk of SIDS and not recommended in the first year of life due to infant stress. There is also a risk of decreased milk production whenever sleep training occurs.
This protocol, although not stated specifically, addresses normal nighttime infant feeding for dyads who don’t have breastfeeding difficulties. However, there are dyads with a variety of lactation problems, such low milk production or milk transfer issues, who require ‘nonphysiological’ coping strategies discussed in this protocol, such as pumping and bottle feeding overnight or supplementing with infant formula.
We also need to address how to identify and manage anxiety and lack of support that underlie nonphysiological behaviors such as topping infants off with formula before bed, timing the duration and frequency of infant feeding, and refusing to nurse an infant to sleep.