Cluster feeding causes colic and reflux

Author Philippa Murphy

Cluster feeding causes colic and reflux

 

Cluster feeding – what a conundrum it is for our newborns and for our breastfeeding mothers. Often the two statements that come with breast feeding are that you have to feed a baby often because of their small stomachs, and you can't overfeed a breastfed baby. Hence making cluster feeding okay. But as you will read below, this is actually far from the truth when we shine a spot light on a newborn’s digestive biology, their reflexes, and their cues. You'll also discover why these mythical statements and the practice of cluster feeding are catalyst contributors to the symptoms that are labelled as colic, reflux, silent reflux, lactose overload and the witching hour - or what I call Digestive Overload the cause of these symptoms.

When you have a baby, you may hear the repeated sentence that every baby is different, and to a certain degree this is of course true.  Especially when it comes to breastfeeding, because supply is of course different from mother to mother, and a baby's suck and transference levels can vary. But fundamentally, when we come from the perspective of biology, we are all human, and it is from this firm foundation of knowledge that we can say, there is a manual for all babies - to a certain extent there is a one-size-fits all basis to go from. For example, we know the digestive system and how it functions, and we know the demand and supply mechanism of breastfeeding. It is from this innate perspective that we can then form some standard care practices to nurture all babies and infants. Then, from this stand point, we can take into consideration any individual sensitivities or conditions the baby has, or may run in the family.  This is the perspective I come from within my work, and when I talk about cluster feeding being unhealthy.

Introduction

Kelly Bonyata, BS and IBCLC from the ever popular website KellyMom, says this, “Cluster feeding, also called bunch feeding, is when babies space feeds closer together at certain times of the day and go longer between feedings at other times. This is very common, and often occurs in the evenings. It’s often – but not always – followed by a longer sleep period than usual: baby may be ‘tanking up’ before a long sleep. For example, your baby may nurse every hour (or even constantly) between 6 and 10pm, then have a longish stretch of sleep at night – baby may even sleep all night.” She goes onto say that “cluster feeding often coincides with baby’s fussy time. Baby will nurse a few times, pull off, fuss/cry, nurse a few minutes, pull off, fuss/cry…. On and on… for hours. This behaviour is normal!”1

That last statement, and much of what she and many other breastfeeding advocates believe, and teach has me crying and highly frustrated for our newborns. Babies don’t ‘space feed closer together at certain times of the day.’ We adults offer feeds close together, and we make that decision to feed again on what is largely, currently being taught to us as parents. I can hear some of you say, but they do as they tell us by their cues that they are hungry again. Cues like rooting, sucking on hands, nuzzling the breast, crying, screaming, and not wanting to be put down. These can indeed be hunger cues. But they are also pain cues, and because cluster feeding brings discomfort to the digestive tract, these cues get heightened.  

The common belief is that by cluster feeding you are being led by your baby - cue led, which sounds great. Right? We all want to nurture alongside what our newborn is telling us. To offer responsive care that fulfils their needs. But what if those cues are being miss taught? What if we have become blind to what the cues truly mean, because we have become so conditioned to believe that they are hunger cues? Well sadly, this is what is occurring, and it's having grave effects for our young.

Mother's also cluster feed because, quite frankly, they are not being taught other natural calming methods to sooth their baby's communicated pain, or to some degree, enable sleep. This lack of postnatal education prior to baby being birthed, or postnatally, often snowballs the parents into using the breast and milk as a pacifier, which then creates the Common Cycle of Digestive Overload. Most of us know that popping a baby onto the breast may bring peace, and relax bubs for a short time. But that doesn't make it the right thing to do for their overall health. Also, just because something is common, like cluster feeding, it doesn't necessarily make it 'normal' or natural.

Thirty years ago when I started working with newborns, if a baby was exhibiting the cycle that cluster feeding creates, on the rollercoaster of feeding a lot, short sleep cycles and distress, it told us that something wasn’t quite right. That the child needed help with something. Back then though, this kind of feeding and sleep patterns were actually rather rare, because the accepted way of caring for babies was feeding them either 3 ½ or 4 hourly, and cluster feeding didn’t even exist as a practice. But then a book was published that created an uproar worldwide in this health sector. It projected four hourly feeding quite strictly, and this brought a widely spread consensus that you can’t feed a baby according to the clock, we must be baby led. Thus, like many, I witnessed the birth of ‘demand feeding.’ This was projected to parents as being baby led. That it was intimate and created a close bond.

From this time, the discomfort of baby’s began to increase. Gradually we witnessed a rise in colic and reflux cases, and because of the discomfort that this kind of feeding created baby's started to look more hungry as the looked to suck to quell their discomfort. So then this heightened need to suck, and the increase of unsettled newborns, birthed the next teaching from the breastfeeding establishment of cluster feeding. That it was natural for baby’s to cluster feed in the evening, or during the day. When in actual fact that cluster feeding kept them on the cycle of Digestive Overload, creating more cases of colic and reflux, which really has now reached epidemic proportions.

Additionally, this type of feeding also created short sleep cycles. Slowly the next new teaching developed that said, 45 minute sleep cycles was also ‘normal’ and parents began to believe that this to was natural, because this information was, and is, coming from midwives, lactation consultants, GP's, and pediatricians. The people that are meant to know, so it must be right. Right? Wrong. It is not right, and it certainly is not healthy. 

The common cycle that cluster feeding creates

  • Baby cluster feeds for longer periods – generally this happens in the late afternoon to evening time when they are at their most unsettled from all of the overloading during the day.

  • Baby eventually falls asleep because their bodies are forced into food coma (postprandial somnolence) which has them feeling extreme fatigue, or lethargy, accompanied by bloating and a feeling of tightness in the belly. 

  • The trapped air from all the cluster feeding now sits in the stomach and begins to make it's way through the intestines and into the bowel. Pushing on any previous trapped air that wasn't released throughout the day.

  • Baby may sleep for a longer period from food coma, but then wakes uncomfortable from the overload of trapped air, and the overload of milk/waste that their digestive system is now trying to break down and process. Many of their digestive organs are now under pressure, and being asked to perform tasks they are not meant to.

  • From this discomfort baby then roots to suck, may be from hunger at this time (depending on how long it has been since the last feed – ideally 3 ½ to 4 hours) but certainly because they are instinctively using their innate tool of sucking to try and bring themselves comfort.

  • Parents are taught that the cue of rooting to suck only means hunger so they feed again. They often resume cluster feeding, or feeding at short intervals – before 3 ½ to 4 hourly.

  • Because of the discomfort baby sleeps for short intervals throughout the day. Parents are told that 45 minutes sleep cycles are normal. However, they are not - they are a symptom of Digestive Overload, and as you will read below a part of that cause is cluster feeding. 

  • Baby may not like being put down. Has the tendency to only sleep on the parents, and can look ravenous at times when feeding, but then pull on and off the breast, or have flailing arms and legs, while gulping back the milk in the bottle, as they react to the digestive discomfort they feel. The ravenous behaviour is actually their need to suck for comfort not milk – and yes, a baby that is sucking on the breast will be getting some milk along with telling the mother’s body to make more – which can bring other issues like fast flow, over supply, engorgement, blocked ducts, mastitis. The first three of these problems also cause the baby to gulp in more air while feeding, as they try to keep up with the flow. This causes more discomfort in the digestive system, and many babies will bring up milk when this happens. This is one of the contributors to reflux.

  • This pattern of so called ‘demand feeding, cluster feeding, cue feeding, bunch feeding’ continues throughout the day, until finally the baby is so sore from all the overloading, that they begin to grizzle, cry and sometimes scream from the pain. This is then labelled the ‘witching hour’ which parents are also told is ‘normal’! This behaviour then brings about more cluster feeding until the baby’s body shuts down into sleep. They are so tired, from little sleep and all the discomfort that they finally sleep for a longer period of time. 
     

The biology that cluster feeding disregards 

While it is fair to say that there is much we do not know about the digestive function of a newborn and infant, what we do know shows us that cluster feeding is not conducive to the holistic health of a newborn or infant. Add to this that my own clinical research consistently results in the elimination of colic, reflux, silent reflux, lactose overload and the witching hour, when cluster feeding is no longer offered – along with other adjustments of course - and we have to start acknowledge that it is time for a huge change in care practices! So let’s take a closer look at why this happens. 

 

Lactose Overload

Frequent feeding and cluster feeding often has the baby feeding from both breasts in quick succession. This feeding practice can heighten the levels of foremilk that the baby receives, or in other words, heighten the intake of lactose (sugar) since this is predominantly what foremilk is. When a baby receives heightened levels of lactose the lactase enzyme, which lives in the stomach and helps babies and infants breakdown lactose, cannot keep up. The overabundant lactose is then pushed onward to the duodenum where it ferments and causes gas.

Gas that then travels through the digestive tract where, Joy Anderson - BSc(Nutrition), PostgradDipDiet, APD, IBCLC, ABA Breastfeeding Counsellor says that, "the gas and fluid build-up causing tummy pain and the baby 'acts hungry' (wants to suck, is unsettled, draws up his legs, screams). Sucking is the best comfort he knows and also helps move the gas along the bowel. This tends to ease the pain temporarily and may result in wind and stool being passed. Since the baby indicates that he wants to suck at the breast, his mother, logically, feeds him again. Sometimes it is the only way to comfort him. Unfortunately another large feed on top of the earlier one hurries the system further and results in more gas and fluid accumulation. The milk seems almost literally to 'go in one end and out the other'.”2

While lengthening the time between feeds can stop lactose overload, feeding from one side in one sitting can also be helpful. Thus baby gets a healthy amount of lactose and fat and, if you feel baby may need more within thirty minutes of starting the feed, then place them back on that side you have fed off so they can receive even more of the good fat for weight gain.



Stomach size

Now remember that saying I mentioned earlier, that ‘you can’t overfeed a breastfed baby.’ Well, quite simply, you can. It’s logical right. All humans can overfeed and newborns and infants don’t have the capability to know when they are full. Knowing and making those decisions is one of our jobs as parents. 

Also, a newborns stomach does not stretch, and it is obviously only so big, and cluster feeding has a baby taking in more than the stomach can hold, which can cause discomfort and reflux symptoms as the milk obviously only has two ways to go. 

It also takes around twenty minutes before the brain tells the child their bodies are full. Zane Andrews - an associate professor of physiology and a neuroscientist at Monash University who studies how food (and lack of food) affects the brain states “Generally there is a delay - a disconnect between when you put food in (and your brain goes 'this is nice') to when it gets to your gut (and your gut goes 'hang on, brain, you better slow that down, mate'). There is a twenty minute window, generally speaking, where you're not getting some of those feedback signals.”3 So cluster feeding completely overrides that natural mechanism.

Natural digestive flow

Did you know that the developing digestive system of a neonate functions quite differently to an adults, and it takes two years for this to operate like an adults?

One of the differences that is present from birth is that our newbies do not have the capability to hold food in the stomach if there is too much to hold. As adults we can gorge ourselves on a huge meal, and our stomach will expand and hold this. Then an hour later we can have another piece of that yummy dessert, and still our stomach expands and holds this. A newborn or infant however, has a system that is like a conveyor belt. If there is too much food in the stomach then some of this will be pushed upward, with some also being pushed onward in the digestive tract, whether it has had the chance to be broken down or not. Forcing other digestive organs to deal with faucets of the milk that they are not meant to. A study on the 'Development of bowel habit in preterm infants' discovered this when they found that, "milk feeds override the intrinsic, fasting, motor activity of the colon, and induce regular defecation at a frequency determined directly by the volume of the products of digestion that reach the rectum."4

In clinic I see many cluster fed babies that have bowel motions indicative of this studies finding. Often they are having bowel motions after every feed. Their stools can be explosive, perhaps frothy and sometimes green as the excess milk feeds, and all the air intake from high levels of swallowing, and the higher consumed levels of lactose from cluster feeding, literally pushes the waste out the rectum. Whenever I nurture a baby back to biological levels of feeding, their bowels are reduced to one or two a day, or one every second day (depending on age) and they aren't as explosive, and they are not yellow/mustard in colour but more golden/brown.   

For our infant cluster feeders, the stools are not as explosive because of the solid food they are receiving. Instead they are more likely to become constipated as again, some organs try and cope with matter that they are not meant to. Like it does for newborns, this creates discomfort, which at high levels can bring unsettled sleep, crying and screaming that turns on the sympathetic nervous system (fight and flight way of being) which then turns off the digestive tract. Thus slowing bowel motions further. Infants in this scenario also tend to have undigested food within their stools.  

The manner in which babies are fed may also trigger differences in motor responses.5 Preterm infants fed by a 2-hour infusion display a brisk increase in motor contraction that is associated with faster gastric emptying compared to infants fed by a 15-min bolus. It went on to say, feeding volumes that provide as little as 10% of the daily fluid intake significantly induce (creates) the premature appearance of the migrating motor complexes (MMCs) in comparison to those that provide 30 or 100%.6. For those of you that don’t know, the migrating motor complex occurs between meal times, and it’s thought to serve as a housekeeping role and sweep residual undigested material through the digestive tube.7

So to clarify, the study showed that small feeds often, like cluster feeding, instigated the early appearance of this housekeeping role, thus pushing food and waste through the tract much faster, creating faster gastric emptying, compared to the larger volumes at extended interval times between feeds.

The study concluded that, minimal feeding volumes can be used to trigger maturation of motor function.5 In other words, when we feed our newborns often, we are asking their systems to mature faster than they would naturally mature. Thus pushing their systems beyond what they are made to cope with at their young, vulnerable age.

It may also be of interest to you that newborns actually have an inherent mechanism whereby gastric emptying and transit times are naturally delayed.8 So their bodies natural rhythm is to actually delay the milk in the stomach. Why? Well, research shows us that the digestion of the fat in their milk is particularly important in the stomach because milk fat droplets are not a good substance for the pancreatic lipase (an enzyme that breaks down fat in the duodenum), consequently high fat concentration in gastric contents delays gastric emptying.9

But as shown by the above research, frequent feeding and cluster feeding (small amounts at short intervals), overrides this natural function, making the fat empty out of the stomach in a faster fashion. This fat then travels onward without being broken down enough, and moves through to the duodenum where the pancreatic lipase is naturally low for our newborns.10, 11, 12, 13. So the fat is not broken down in the pancreas as it should be either, which compromises the intake of the important fat-soluble vitamins of A, D, E and K. You then have a cocktail of fat moving to the small intestines for absorption into the blood stream, but it simply cannot be absorbed. This fat then travels onward to the bowel, which it is not meant to do, causing considerable discomfort on its journey. 

Fat passing into the stools is called Steatorrhea and it tells us the digestive system is not working as it should be. Steatorrhea has been attributed mainly to the faster passage of food through the intestine.14 This fat in newborn and infant stools are often described as seed like deposits, or small lumps of cottage cheese substance. While the widely voiced opinions on the internet and by other health professionals is that these deposits are again, ‘normal’ and no problem. Biology and the research begs to differ, as do I – strongly. 

In my BabyCues clinic, time and time again, when I adjust baby’s feeding pattern to be in line with how their digestive biology works, thus stopping the overloading that cluster feeding, frequent feeding, or even spaced feeding with large amounts creates, is that these seed like deposits, the fat in the stools, disappears. Why? Because the child’s salivary lipase enzyme generally has the natural amount of time to break this down in the stomach so it can be absorbed in the intestine.  This also helps to reduce symptoms like pedalling legs, arching backwards, short sleep cycles, and constipation to name a few.  

It has also been reported that it takes on average, eight-and-a-half hours for milk to travel from the mouth through the digestive tract and onto a bowel motion (known as transit time)15  for newborns aged one to three months. On average it can take four to five hours for milk to move from the stomach in a healthy manner, meaning with all the nutrients broken down appropriately (not that you would leave your baby without a feed for 5 hours in the first 3-4 months of life). So this biological fact alone tells us that the taught breastfeeding belief that you have to feed a baby often because they have small stomachs, isn’t actually be based on biology. 

 

Weight gain

Another common scenario with cluster feeding is the baby has large weight gains. By that I mean over 220 grams a week, which sounds good, right. Many health professional would tell you that is marvellous, despite the fact that baby is sleeping for short sleep cycles, or crying at night. It is all normal. When in actual fact those large weight gains are symptomatic of Digestive Overload. The World Health Organisations guidelines for weight are 20-28grams a day (0.7-0.9ozs) and from six months it's 50-80grams a week (1.7 ozs to 2.8ozs). These guides are 

there for the reason - for best health practice and they should be the advice that is given by all health professionals. Particularly when research shows us that the first 3-4 years of life are extremely important for setting up precursors for obesity.
The lead author of a new study undertaken by the Department of Ambulatory Care and Prevention at Harvard Medical School and Harvard Pilgrim Health Care, as well as Children's Hospital Boston states, "There is increasing evidence that rapid changes in weight during infancy increase children's risk of later obesity. The mounting evidence suggests that infancy may be a critical period during which to prevent childhood obesity and its related consequences." The study has found that rapid weight gain during the first six months of life may place a child at risk for obesity by the age of three.16



Rooting and sucking
One of the cues that is held up to mean a baby is hungry, and causes cluster feeding, is baby rooting to suck. As mentioned above, this doesn’t necessarily denote that baby is hungry. Baby’s look to suck when they feel discomfort in their body too. It’s their innate calming mechanism.
We also know that sucking is a reflex for our baby’s and infants in the early stages of infancy. If you touch a newborns mouth or check, they will move toward that touch and open their mouth, looking to suck. If you pop a nipple into their mouth or bottle teat, the reflex continues on its natural path, which is to suck. It is us adults that then place the perception on that reflex that baby is rooting, or sucking because they are hungry.

My own clinical research over the past thirty years, also shows us that one of the so called ‘feeding cues’ is actually a wind-cue. It can be described as mouthing, or chewing with the tongue poking out. This is not a hunger cue, but it is your baby telling you they have trapped wind sitting high in the stomach and/or throat that is ready to be released. But unfortunately, the historical lack of knowledge around this cue has formed a miss teaching that has parents feeding bubs instead of burping them.

Summary

It breaks my heart, to my deepest core within me that this cycle of miss information has created such a painful epidemic for our young. It is just so WRONG! Thankfully though, it can be changed. Our newborns do not have to be stuffed to the brim to enable sleep. Our mothers do not have to be bound to the couch having to constantly feed, sometimes in awful pain, while trying to mentally cope with this apparently 'normal' way of breastfeeding life. Parents do not have to feed bottles, only to have baby bring a lot of it back up, or have bottle aversion because the baby actually is not hungry.

Instead, when we learn how to respond holistically to a newborns cues, inclusive of their Six-Wind-Cues, while also learning how to nurture the baby within their digestive capabilities and capacities - when these aspects are fully known, cluster feeding simply doesn’t happen because you can see and understand that the child cannot be hungry. BabyCues Bio-logical Care also teaches parents other ways to sooth baby, and eliminate the other causes of upset, which means the breast no longer has to be used as a pacifier.


So yes, lets ‘cue feed,’ let’s ‘demand feed,’ 'let's offer 'responsive feeding' but let’s skill ourselves appropriately with what the child's cues truly mean, and marry this with the knowledge we know about the digestive function, so parents get taught to feed baby with a holistic approach. For when we do this, the need to cluster feed disappears. As does colic, reflux, silent reflux, lactose overload and the witching hour.

Bio-logical Care, and Bio-logical Feeding is not only logical, responsive, respectful and intimate. It also supports healthy digestive function for your baby, healthy breastfeeding outcomes, along with parenting confidence and attachment, because parents learn how to knowingly respond to their baby’s full array of cues in each moment with the solid, but simple knowledge of their digestive biology aiding their decisions. It stands to reason then that Bio-logical Care also supports social, emotional and cognitive development for baby’s. All at a time of their exponential growth.

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1    https://kellymom.com/parenting/parenting-faq/fussy-evening/
2   Lactose Overload in Babies, Australian Breastfeeding Association, reviewed 2019
3  http://www.huffingtonpost.com.au/2016/11/09/we-found-out-if-it-really-takes-20-minutes-to-feel-full_a_21602736/
4   Weaver, LT., Lucas, A. Development of bowel habit in preterm infants. Archives of Disease in Childhood 1993; 68: 317-320
5   Hernell O, Schmitz J (eds): Feeding during Late Infancy and Early Childhood: Impact on Health. Nestlé Nutr Workshop Ser Pediatr Program, vol 56, pp 85–98, Nestec Ltd., Vevey/S. Karger AG, Basel, © 2005
     Development of Motility Annamaria Staiano and Gabriella Boccia Department of Pediatrics, University of Naples ‘Federico II’, Naples, Italy
6   Owens L, Burrin DG, Berseth CL: Minimal enteral feeding induces maturation of intestinal motor function but not mucosal growth in neonatal dogs. J Nutr 2002;132:2717–2722.
7   Colorado State University, VIVO Pathophysiology The migrating Motor Complex
8   The Anatomical Basis of Clinical Practice, Gray's Anatomy 39th Edition
9  Hamosh, M., Scanlon, JW., Ganot, D., Likel, M., Scanlon, K., and Hamosh, P. Fat Digestion in the Newborn — Characterisation of lipase in gastric aspirates of premature and term infants
10 Delachaume-Salem, E., and Sarles, H.: Evolution en fonction de I'age de la secretion pancreatique humaine normale. Biol. Gastroenterol. (Paris), 2: 135 (1970).
11 Gschwind, von Ruth: Das verhalten der Pankreasenzyme bei Frugheburten. Ann. Pediatr., 175: 176 (1950).
12 Norman, A., Strandvik, B., and Ojamae, 0.: Bile acids and pancreatic enzymes during absorption in the newborn. Acta Pediatr. Scand.. 61: 571 (1972).
13 Zoppi, G., Andreotti, G., Pajno-Ferrara, F., Njai, D. M.. and Gaburro, D.: Exocrine pancreas function in premature and full-term neonates. Pediatr. Res., 6: 880 (1972).
14  Pediat. Res. 13: 615-622 (1979) Fat lingual lipase A Review. Fat Digestion in the Newborn: Role of Lingual Lipase and Preduodenal Digestion MARGIT HAMOSH Department of Physiology and Biophysics, Georgetown University Medical School, Washington, D.C., USA
15  Nyhan WL., Stool frequency of normal infants in the first week of life. Pediatrics 1952:10:414-25
16  https://hms.harvard.edu/news/infant-weight-gain-linked-childhood-obesity-3-30-09

 
Last Updated: 30 November 2019

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