Night weaning – a decision that’s best left to the family
It’s safe to say that having a baby means a high likelihood of sleep disruption for parents.
As the Daily Maverick has written, studies have shown that all babies wake at night, and the number of night wakings varies among babies, with some suggesting three times is average, and others showing an average of almost five times per night for certain age groups. Even though some babies are able to sleep through the night from quite early on (four to six months), most babies don’t. It’s biologically normal for infants from newborn to 12 months to wake regularly throughout the night.
For parental mental health it’s important to note here that having a wakeful baby does not mean a parent is doing anything wrong.
Initially, most of these night wakes are for nutritional purposes – simply put, infants are hungry a lot of the time. Their stomachs are extremely small, so they need to feed regularly to meet their calorific needs. Most newborns feed roughly every two to three hours (timed from the start of one feed to the start of the next) or between eight and 12 times per day.
“Every infant is unique and will have equally unique nutritional requirements,” explains Dr Jessica Smith, a general practitioner with a special interest in children’s health.
“For example, a premature infant will require more protein for the duration of their first year of life while they play ‘catch-up’ on growth. A child with higher metabolic demands – such as those with cardiac defects, certain genetic conditions such as cystic fibrosis or even previously well babies during times of illness – will have much higher nutritional needs. If these nutritional needs are met within a 12-hour period during sunlit hours, or whether it gets drawn out over a 24-hour period will completely depend upon the individual baby’s capacity,” says Smith. Formula-fed babies will be given a set amount based on calorific requirements, but for breastfed babies it can be unclear how much an infant is taking in.
How hungry a breastfed baby is at night, and how often they need to feed, can also depend on how much milk they’re getting with every feed. “This can also depend hugely on a mother’s breast storage capacity,” explains Sister Tasha Perreard, a registered nurse and internationally and locally certified lactation consultant. Breast storage capacity “is the amount of milk a mother can store in her breasts between feeds and is determined by her amount of mammary glands. Some mothers store large volumes of milk in their breasts and they have large feeds and need fewer, less-frequent feeds. A mother with a small breast storage capacity stores smaller volumes in her breasts and baby then needs smaller, more-frequent feeds to make up their daily needs. And this may mean continued night feeds for some babies when some of their peers are already sleeping through the night.”
Says Smith: “The global recommendation for the first six months of life is to breastfeed on demand – i.e. as and when the infant shows need. It is also important to note that during periods of growth spurts (commonly around the two-week, five- to six-week, four-month and six-month marks) infants will change feeding behavioural patterns and often cluster feed in order to boost maternal breast milk supply. This biologically driven behavioural change is not time linked, and the infant’s hunger signals are not aware of day/night changes.”
Night feeding is extremely important for establishing breast milk supply in breastfeeding mothers, especially in the first few months of a child’s life, so it is a vital part of achieving the recommendations of the World Health Organization and the South African government to exclusively breastfeed for the first six months of a child’s life.
“A mother’s brain requires frequent ‘demand’ in order to secrete sufficient prolactin hormone, which stimulates the breasts to produce milk. If the demand is delayed or prolonged, the mother’s body will assume there is no need to continue to produce at that time and will adjust supply accordingly,” explains Smith.
There are risks to breastmilk supply when stopping night feeds, and to the baby’s nutrition if it is not yet ready. “If a baby under the age of six months is encouraged to sleep through the night before they are ready (sleep training, pushing out feeds by “dummying”, giving water, etc), a mom’s milk supply can drop before baby is ready to start reducing milk volumes,” says Perreard.
This was the experience for Jean Scrimgeour who decided to night wean her infant at six months to try to get better sleep. Having been the only responder to the baby at all night wakings until then, she was looking for a more egalitarian response to her baby’s night wakes where both she and her husband would be able to respond. But cutting out night feeds also resulted in an end to her breastfeeding journey. “There were a lot of tears for the first few days. My supply dropped so dramatically without night feeding that I knew that night weaning would mean the whole breastfeeding journey would be over quickly thereafter. So, it was quite sad initially, and a few times I chickened out, but my overwhelming desire to have a night’s sleep won out.” Although the night weaning did not dramatically improve her infant’s sleep, it did make it easier to share the parental load.
For toddlers though it is safer to cut out night feeds without worrying about it from a breast milk supply perspective. “However, as babies and toddlers grow the requirement for milk goes down and they can dictate when they are ready to cut out night feeds. The mom’s breasts will then respond accordingly to their baby’s needs,” says Perreard.
A newborn who wakes regularly is probably doing so for nutritional reasons, but as babies grow and age there are many other reasons for frequent wakings (such as illness, disability, separation anxiety, nightmares or breathing challenges).
Parents’ response to these wakings might be to try to sleep-train their child, in the hopes of a restful night, or try to soothe the child using many strategies, including night feeds. For parents who are continuing to offer night feeds as a solution to night wakings well beyond infancy, it might be a question of whether there is a time that you must night wean, to prevent harm to your child’s health, or whether night weaning might help your child sleep through the night.
What do the experts say?
South Africa does not have any Department of Health guidelines on this topic and research specifically on the need to night wean or the experience thereof is scarce. What complicates matters, as with most things in parenthood, is that advice on the right thing to do differs depending on who you are asking.
International parenting sites like What to Expect suggest that babies no longer need to be fed at night once they’ve reached the 5kg weight marker, and that by five to six months, a baby who is waking to eat overnight is “probably not hungry unless she isn’t eating enough during the day”. But What to Expect also sets parental expectations that night weaning might not be easy and that although some babies self-wean from night feeds, “more often, you’ll have to give your little nosher a nudge in the right direction”.
Closer to home, parenting books like Meg Faure and Ann Richardson’s Baby Sense (and the app that goes with it), suggests that at about three to six months babies should be able to sleep for an eight- to 10-hour stretch without needing a feed. When I asked authors about the evidence for this suggestion, they said it was based only on what they see in their own practices and is not founded in research data or any infant sleep studies. So, hopefully this insight may alleviate some parents’ feelings of failure when their child does not stick to the sleep or night weaning rule book.
“Some societal expectations on infants to span a 12-hour ‘night period’ without nutrition and hydration are unreasonable. There is no evidence to support any set age or weight to determine whether a baby is ready to span a longer duration without feeds,” says Smith.
According to Perreard, “some practitioners recommend stopping night feeds once baby is eating three solid meals a day including a protein with every meal. However there is no scientific research to support this and is not useful advice. Some babies and toddlers are notoriously bad eaters so these babies may still need calories from breast milk [or formula] at night until their nutritional requirements are being met through solid meals. Prolactin production is also higher during the night so babies who may feed poorly in the day time, may make up for those poor feeds by feeding more in the night by drinking bigger volumes.”
That’s the case for Mel, whose child is nine months old. “Because she doesn’t always eat all her solid meals during the day, I prefer to give her an additional bottle at night if she wakes up for it, as it’s extra nutrition. I also believe it’s more important to provide her the comfort she’s looking for right now as she is also going through separation anxiety.”
Research also shows that increasing calories during the day may decrease night feeds, but it does not necessarily decrease night wakes, so although some suggest that eating solids might solve parents’ disrupted night times, the reality is that it may not help at all. Night feeds are not just for nutrition, but also hydration, with the effect that babies and toddlers may wake more frequently in summer because they are thirsty.
Kath Megaw, a paediatric dietician, co-author of Weaning Sense and founder of Nutripaeds, says “the most important thing to consider if a parent wants to night-wean is: does my baby use the milk feed for comfort or need it for nutrition?
Smaller babies, especially prem and special needs babies, might need night feeds for longer. It is safe to consider weaning off night milk feeds when your baby is taking enough milk in the day to sustain their growth. I wouldn’t recommend cutting out a night feed before four months unless a baby drops the feed spontaneously.”
Megaw acknowledges the reality that many babies will still wake at night, but encourages parents to use their discretion in discerning what the wake is caused by and feeding the infant if they think it is caused by hunger. “[Sensitive babies] often wake for the slightest discomfort and as a parent your role is to be able to discern the wake-up either as pain or comfort or hunger. It’s not always easy, but you can safely allow a three- to five-hour milk gap or longer in a breastfed baby from four months, and a four- to six-hour gap or longer in a formula baby.” Based on international guidelines, Megaw suggests that a guide for night weaning could look something like: 0 to four months, two to four feeds appropriate; four to six months, one to three feeds appropriate; six to nine months, one to two night feeds appropriate (may need extra if breastfeeding, prem or special needs); nine to 12 months, one night feed around 10pm or 4am may be needed; 12 months on, aim to do a late day feed by 8pm, and then first am feed after 4am.
“Past a year, night feeding is normally a soothing or comfort to sleep need,” says Megaw.
But does it matter if night feeds are ‘just’ for comfort?
International organisations like Unicef suggest that comfort-feeding a baby is as important as feeding to meet nutritional needs. Unicef’s UK Baby Friendly Initiative recommends responsive breastfeeding, noting that “crucially, feeding responsively recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and mother. For example, when a mother breastfeeds her baby responsively, she may offer her breast when her baby shows signs of hunger or when her baby is distressed, fractious or appears lonely.”
Research supports Unicef’s argument that there are many non-nutritional aspects of breastfeeding that are important for both mothers and their children.
Breastfeeding provides pain relief to children, reducing their heart and metabolic rates, and reducing their ability to perceive pain during suckling. Suckling (whether on breast, bottle or dummy) and the absorption of fat from milk also stimulates the release of the hormone cholecystokinin which induces relaxation and further pain relief. Skin to skin contact between a child and parent, for instance while breastfeeding or held closely during bottle feeding, helps to stabilise infants’ blood glucose levels, body temperature and breathing rates as well as helping to reduce the release of stress hormones, and aiding neurobehavioural self-regulation.
Feeding also creates a sense of intimacy between mother and child, which may result in the release of another anti-stress hormone – oxytocin. Although much of the research around these impacts tends to focus on newborns, there is evidence that the positive impacts continue for as long as breastfeeding occurs.
The benefits of breastfeeding, including night feeding, extend to the mothers too.
Breastfeeding stimulates the hormones oxytocin, prolactin and cholecystokinin in the mother. Oxytocin aids breastfeeding and milk supply, and also has an anti-stress effect. Like with their children, when a mother breastfeeds, cholecystokinin is released in her body, inducing relaxation and pain relief, which may help breastfeeding mothers return to sleep faster after a night feed. Research has shown that mothers who breastfed exclusively had more sleep than those who used formula at one month postpartum.
Won’t extended night feeding harm my baby’s teeth?
According to Megaw, “the biggest risk factor [to night feeding after one year] is dental health. The sugars in breastmilk and formula increase the risk of dental caries in toddlers. It can also reduce day appetite and enhance the picky eating stage so ideally by a year your toddler needs to use other ways to soothe and comfort themselves during the night.”
Dr Raveena Manga, an integrated dental surgeon, disagrees that night breastfeeds have a negative impact on toddlers’ teeth.
“It’s a common misconception that feeding your baby to sleep, or while sleeping (dream feeding), has adverse consequences to your baby/toddler’s teeth. This is what many practitioners sadly still believe and tell mothers.
“The reality is, there is no evidence supporting the correlation between extended breastfeeding and the incidence of “early childhood caries” (ECC)/cavities in the milk teeth. And if breast milk were to cause ECC, this would make very little evolutionary sense as breastfeeding is biologically designed to soothe our babies and help them sleep.” In addition, Manga explains that “breast milk contains lactoferrin, which is a glycoprotein that is bactericidal. It kills Streptococcus mutans, the main bacteria responsible for the formation of cavities.”
However, formula and bottle feeding may put toddler teeth at risk, says Manga.
“The confusion often comes in with bottle-fed babies, as these babies who sleep with the bottle in their mouths (that contain formula, tea or juice) are often the ones that present with ECC.”
This is linked to the difference in the mechanics of breast and bottle feeding. “When a baby latches on to the breast correctly, the nipple and areola are drawn far back into the mouth. The milk does not transfer unless the child is actively sucking and swallowing, reducing the time the milk has to pool in the mouth. When it transfers, the milk bypasses the teeth and is released directly into the throat. These factors all reduce the exposure of the teeth to the milk. The mechanics of bottle feeding differs in that the latch isn’t as deep, and depending on what kind of bottle is used, the milk/formula/juice/tea can pool in the mouth.”
That’s not to say, Manga explains, that breastfed toddlers don’t develop cavities. “They most certainly can, but there are other factors to consider. Healthcare professionals should encourage mothers to breastfeed their children for as long as they/their child want to/need to, without any pressure to wean them at night.” DM