by Dr Clare Macdonald, General Practitioner
Healthy infants are born primed for survival; a number of reflexes are present at birth and they have their roots in the evolutionary advantage they have provided in pregnancy and early infancy. Many of these reflexes are no longer necessary for survival– for example the Moro reflex is a throwback to our primitive beginnings whereby babies would need to cling onto their mother. Many of these innate reflexes are there to aid the infant to gain nutrition and hydration. Parents, other caregivers and healthcare professionals alike should understand common signs/‘cues’ infants give in order to care for them responsively.
Healthy infants placed on their mother’s abdomen immediately after an uncomplicated delivery will instinctively find their way to the mother’s breast and latch on. This is known as ‘breast crawl’. NICE recommend initiation of breastfeeding as soon as possible after birth, ideally within one hour and additionally it is not recommended that mothers are asked about their intended method of feeding the baby until after the first skin to skin contact1.
Babies are more likely to breastfeed effectively when they are offered the breast in response to early signs of hunger. The WHO recommends that mothers should be encouraged to breastfeed their baby as often as they want, day and night, whenever the baby shows readiness to feed2.
Early feeding cues include:
- Fluttering eyelids/eyes moving behind closed lids
- Opening mouth/sticking out out tongue
- Rooting (turning head and opening mouth)
The next cues indicating increasing hunger include:
- Stretching or other increasing movements
- Hands moving towards face and mouth
Late signs of hunger
Agitation and crying are late signs of hunger and can make an effective latch and subsequent feed more challenging.
Infants being fed with formula milk should be fed responsively and the same cues apply3.
Queensland Health: Baby Feeding Cues (Signs) Useful 1 page summary of feeding cues with pictures.
NHS Choices: Breastfeeding- the first few days Information for Parents
Global Health Media: Breastfeeding in the First Hours Includes video footage of ‘breast crawl’.
Although crying and agitation may be signs of hunger, other possible causes should be explored and corrected, for example tiredness, soiled nappy, pain, or simply seeking comfort. Parents may need signposting to information about how to soothe a crying or unsettled baby. Learning to understand a baby’s cues can take time and in the absence of any health concerns reassurance and encouragement should be given. See our webpage on ‘Colic‘ for information on managing babies who are persistently unsettled.
The use of a dummy may interfere with the establishment of breastfeeding and use of a dummy to prolong the interval between feeds can impact on milk supply. While parents may choose to use a dummy to soothe their baby with good effect, NHS advice is to aim to stop using a dummy between 6-12 months4. Dummy use is not advised until breastfeeding is well established5. There is an association with dummy use and a higher rate of otitis media6 and subsequent dental problems7. With regard to dummies and sudden infant death risk, the evidence is not conclusive. Studies have demonstrated a link between dummy use and reduced sudden infant death but the link is not clearly causal. However, babies who use dummies are known to be at increased risk if they are without it, therefore if a baby has become accustomed to using a dummy it should not be stopped suddenly in the first 26 weeks. A review of the evidence can be found from the Infant Sleep Information Source here.
NHS Choices: Soothing a Crying Baby Information for parents.
The Period of Purple Crying®: Common Sense and Well tried Soothing Methods US based site developed by a range of experts in the field of child development, using a concept called the Period of PURPLE Crying® to help parents deal with the time in a baby’s life when they cry more than any other time.
The Infant Sleep Information Source (ISIS Online): Dummies A review of the evidence on the use of dummies, their effect on SIDS risk and breastfeeding.
The Lullaby Trust Factsheet 7: Dummies/Pacifiers Information for parents on the use of a dummy and answers to FAQs.
Sleep is clearly vital for infants, and their carers. Western society places an emphasis on ‘how well’ babies sleep, with interested parties asking parents “is s/he good?”. It is, however physiologically normal for a newborn to sleep for periods no longer than 2-3 hours day and night.
Parents may present to primary care concerned about sleep, and may need reassurance that frequent waking and feeding is normal. It is important to consider not only the health of the infant, but also ask how the caregiver is coping with their own sleep being disturbed. Encouragement should be given to them to utilise support from family and friends which may enable additional periods of rest, and to have realistic expectations about what they can or should be able to manage in addition to caring for their infant. The role of sleep in parental mental wellbeing should not be underestimated and consultations concerning infant sleep should include this.
The Infant Sleep Information Service (ISIS Online) Site with evidence-based information for parents and healthcare professionals. Developed by Professor Helen Ball and the Durham University Parent-Infant Sleep Lab with senior representatives from La Leche League, NCT, The Breastfeeding Network and the Unicef UK Baby Friendly Initiative.
More information on infant sleep and safe sleeping is available via our dedicated webpage.
Skin to Skin
NICE guidance for post partum care and caesarean section both advise early skin-to-skin contact1, 9. This has been shown to improve breastfeeding outcomes, maternal perception of the infant and maternal behaviour. It may also improve cardio-respiratory stability and blood glucose levels in the neonate10.
Position Paper of the International Childbirth Education Association (ICEA): Skin-to-Skin Contact Summarises the benefits of skin-to-skin contact and implications for maternity practices.
Further Information on Issues Relating to the Infant
A number of issues pertaining to the infant can affect breastfeeding success and outcomes, and similarly, decisions around feeding and caring can impact on infant health outcomes. This sub-section of the website includes information on the following topics and their links to infant feeding:
A page on Child Safeguarding is coming soon.
Special circumstances whereby different considerations may be needed with regard to Infant Feeding:
It is important to assess every baby and child holistically within the context of their family and environment and be aware of safeguarding (child protection) and vulnerability concerns. Sharing information with child protection teams and social services where you have concerns in a timely manner is important. All GPs have a responsibility to ensure they remain up to date and maintain competencies in safeguarding and child protection. Local training should be available, and GPs should refer to local guidance when considering any child where there may be concerns.
- NICE Guideline CG37: Postnatal care up to 8 weeks after birth Updated February 2015
- WHO: Infant and young child feeding- Model Chapter 2009
- Unicef UK Baby Friendly Initiative & First Steps Nutrition Trust: Infant Formula and Responsive Bottle Feeding
- NHS Choices: Reduce the Risk of Sudden Infant Death Syndrome (SIDS)
- Start4Life: Breastfeeding- is my baby feeding well?
- Warren J, Levy S, Kirchner H, Nowak A, Bergus G. Pacifier use and the occurrence of otitis media in the first year of life. Pediatric Dentistry. 2001; 23(2):103-7.
- Duncan K, McNamara C, Ireland A, Sandy J. Sucking habits in childhood and the effects on the primary dentition: findings of the Avon Longitudinal Study of Pregnancy and Childhood. International Journal of Paediatric Dentistry. 2008;18(3):178-188.
- Parmelee A, Wenner W, Schulz H. Infant sleep patterns: From birth to 16 weeks of age. The Journal of Pediatrics. 1964;65(4):576-582.
- NICE Guideline CG132: Caesarean Section Updated August 2012
- Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD003519