Feeding and Sleeping Issues
Sleep
Newborns sleep the majority of the day up to 18 hours per day and sleep cycles typically do not
get regulated until 3-6 months. Occasionally babies will sleep through the night as early as 3
weeks (just be thankful if this happens). Most likely your baby will be getting up to feed every
2-3 hours regardless of the time. After your baby has regained his birth weight or after 1-2
weeks, let your baby sleep as long as he can during the night but, during the day, do not let your
baby sleep more than 3 hours at a time. This will help stimulate a more regular night time sleep
pattern.
Most infants can “sleep through the night” (at least 6 hours) somewhere between 3-6 months of
age, when they can tolerate 6 ounces at a time which usually correlates to a weight of 13-15
pounds. This is the point at which their stomachs can hold enough to sustain them through the
night and they are no longer awakening due to hunger. There will come a point when it is clear
they are getting up solely because of habit and just wanting to be comforted and held rather than
being truly hungry. Once they reach this milestone we recommend beginning to train them to
sleep through the night (see below). Sleeping through the night would be considered at least 6
hours. This is a good time to get them into a separate room.
Infants should sleep on their backs and/or their sides with no loose or thick bedding or pillows in
the crib. Be careful with loose-fitting bumpers or bumpers with long ties since a baby could get
stuck between the bumper and the mattress.
Not Sleeping Through the Night
Once you are prepared and your baby has reached the milestones outlined above, we recommend
the Ferber method. Essentially, this involves letting your baby cry if s/he gets up. Go in at 1020 minutes intervals to let him know you are there and that they are safe. Do not pick her up,
feed him or make a lot of eye contact. Be prepared for this! Your baby may cry for hours for the
first couple of days. Eventually, your baby will begin to realize that he can put himself back to
sleep if he wakes up and that he is safe. The hardest part about this is the guilt parents feel about
the perception of abandoning their child. Just remember it is all worth it as several days of
hardship is trivial compared to months to years of sleepless nights.
Stools and Constipation
Once the thick, black meconium stools have passed, stool frequency and consistency is variable
depending on the type of feeding. With breastfeeding, stool color transitions over to a yellow,
seedy color with a loose consistency sometimes just as thin as water. Color of stool is variable
and can be green, yellow, brown or just watery. Frequency can also vary from every diaper
change to every 3-5 days. Yes, it can be normal with breastfeeding to have bowel
movements as infrequent as every 3-5 days. Breast milk is often so well absorbed that
sometimes nothing is left after digestion. It is rare to have true constipation with breast feeding.
As long as the stools are not hard and there is no pain with bowel movements, we would not
recommend giving anything extra to stimulate more bowel movements. Just enjoy it - things will
change once solids are added! With formula, constipation can be an issue. Formula is thicker
than breast milk, not as rapidly absorbed, and contains iron which, for some babies, can be
constipating. With formula, the stool pattern should be, at a minimum, every 1-2 days. Also
remember, it is normal for babies to push and strain during bowel movements but it is not normal
to have pain or hard stools. If your baby is having infrequent or hard, painful bowel movements,
you should consider several options:
1) Start with a glycerin suppository up to twice per day to stimulate the rectum.
Along with this, you can try organic prune juice (mixed into the bottle) 1-2
tsp up to twice daily as needed. Sometimes, it is just a matter of giving the
digestive tract time to get used to the formula. If this doesn’t work, then
2) Start adding fiber to the formula. I recommend Benefiber 1 tsp mixed in
formula once per day (up to twice per day as needed) and probiotics (can be
purchased as Henry’s market or Whole Foods) mixed in formula once daily.
If this is inadequate after 1-2 days, then
3) Switch the formula. I would not recommend going to a low iron formula
although this usually solves the problem short term. Instead, I recommend
switching to a soy-based formula (Isomil or Prosoybee) or trying Nestle Good
Start (this has probiotics added in and often times aids in digestion). If this is
unsuccessful,
4) Prescription stool softeners. A stool softener called Colace can be mixed in
to the formula at this point. However, it is rare that it comes to this step.
If you child has had chronic constipation since birth, other tests to rule out anatomic abnormality
may also be indicated. Blood in the stools is never normal and most commonly an indicator of a
food allergy or local trauma from an anal fissure.
Feeding Your Baby
Nutrition Requirements: The average baby after 2 months of age will take 24 ounces per day
(about 2 ½ to 4 ounces every 3-4 hours). At 4 months, the average baby will take 32 ounces per
day. Formula or breast milk is all that they need. We do not recommend giving water until 6
months of age and then no more than 6-8 ounces per day.
Starting Solids: We recommend starting solids (pureed Stage 1 foods) after 6 months. From an
allergic standpoint, it is safe to start solids at 4 months, but from a mechanical standpoint, it is
easiest to just start at 6 months after the tongue protrusion reflex has subsided. If your baby
demonstrates a lot of interest at 4 months, give them a trial of solids and see how they do.
Breastfeeding
Below are some of the common questions I hear but by no means a comprehensive list. For
more information, please refer to www.breastfeeding.com or ask your lactation consultant.
Not Enough Breastmilk: For starters, make sure your baby has an adequate latch and suck to
give you the proper stimulation and that you are keeping hydrated and maintaining good
nutrition. If these are adequate, options include over-the-counter supplements such as fenugreek
and mother milk tea. If this is unsuccessful, the next step is a medication called domperidone
(also known as motilium). Domperidone acts on the neurotransmitter dopamine which is
responsible for prolactin secretion, the main signal from the brain for milk production. The IV
form is not available in the US due to an FDA warning about cardiac arrhythmias with large
doses of IV domperidone which is not used anymore. The oral form at correct dosages is safe
and approved by the American Academy of Pediatrics. Side effects include abdominal cramping
and sometimes headaches, both of which usually resolve with a lower dose. The dose is usually
20 mg 4 times per day for 2-3 weeks, then weaning down to 10 mg three times per day for 3
weeks then twice a day for a baseline dose. Most women stay on this regimen for an average of
3 months but it is safe long term. The best place to obtain this is from the internet at
www.inhousepharmacy.com. It is not available in US pharmacies because of the black box
warning with IV domperidone.
Feeding Non-stop (every hour): In the first 2 weeks of life this can be a common phenomenon
called cluster feeding. Try to keep up and as your breast milk supply increases and peaks,
usually at 2-3 weeks, this typically will resolve and your baby is satiated. If it seems that your
baby is continuing to cluster feed for hours at a time after the age of 3-4 weeks, there is probably
an issue with caloric volume. At this point, we should consider changing the feeding plan as this
can take an unbearable toll on a mother’s well being.
Will Not Take the Bottle: We recommend introducing the bottle at around 3-4 weeks. This is
late enough that your baby will not get lazy or confused with breastfeeding and early enough that
he will accept the bottle. If your baby will not take a bottle, try different types of nipples.
Unfortunately, there is no clear-cut solution. Sometimes this situation culminates in a very hard
first week of daycare.
Gas
All babies have gas, some more than others. Factors associated with breastfeeding usually have
to do with the mother’s food intake. The most common foods associated with increased gas
production for infants are milk products, caffeine, spicy foods, peppers, onions and the
cruciferous vegetables (broccoli, cauliflower). Rarely, wheat or gluten products can bring on gas
too. Keep a food diary and see if you can diagnose which foods are the culprit. With formula, it
is more common to have gas as formula is not as readily absorbed. Switching from a cow milkbased formula (Enfamil, Similac) to a soy-based formula (Isomil, Prosoybee) may help. Mylicon
(or simethicone) drops are also safe to use and can help in some instances.
Normally, gas is not painful. If gas is painful and associated with excessively loose bowel
movements, this probably represents an intolerance to either lactose or a food allergy. Milk
protein allergy is the most common and is associated with blood in the stool and/or a diffuse
rash. In this instance, we recommend first changing from the milk-based formula to a soy
formula (or if breastfeeding, avoiding all dairy). Soy formula contains a different sugar (not
lactose) and a different protein (soy protein instead of cow milk protein) so this change usually
solves both problems of lactose intolerance and milk protein allergy. Twenty percent of children
with true milk protein allergy can also be allergic to soy. The next step if the soy formula does
not help is to switch to a hydrosylated formula (such as Nutramigen or Alimentum) in which all
of the milk proteins have been broken down.
Formulas: Which ones should you use?
There are basically 3 types of formula1) Cow milk protein based formula- Enfamil, Similac or Good Start. Other
generic brands such as Kirkland brand or Target brand are also perfectly
suitable as long as they contain DHE.
- within this group are also available: lacto free formulas, lower lactose
formulas with partially hydrolyzed proteins (Enfamil Gentle Ease) (for babies
with lactose intolerance) and thickened formulas (Enfamil AR) (for babies with
reflux)
2) Soy protein based formula-Prosoybee or Isomil.
3) Hydrosylate formulas- Nutramigen or Alimentum (for milk protein allergies)
4) Formula for Premature babies- Neosure 22- this is a formula with extra
calories and nutrition.
I personally recommend starting with Enfamil Lipil and the Enfamil line of produtcts because it
has the highest concentration of DHE. DHE has been proven to help with brain and eye
development.
- For excessive gas/loose stools/pain1) 1st try Enfamil Gentle Ease (partially hydrolyzed proteins and less lactose) or
Nestle Good Start (has probiotics mixed in) or adding over the counter probiotics.
2) 2nd line would be to switch a soy formula (Prosoybee) for presumed milk protein
allergy.
3) Lastly, would be to switch to a hydrosylated formula (Nutramigen) (with predigested proteins) for presumed true milk protein allergy.
- For excessive pain with reflux
1) Try Enfamil AR- this formula is mixed with a rice substitute than becomes more
viscous after it hits the stomach, making it less likely to reflux.
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