Written by Jody Segrave-Daly, MS, RN, IBCLC

As a NICU/nursery nurse and IBCLC who has worked with newborn babies my entire nursing career, I was mystified when I first heard the phrase “second-night syndrome.” When I began to research where the phrase came from, it became clear that it is not based on any scientific research but rather on a theory that describes the behavior of exclusively breastfed newborns on their second day of life. I think it is a frightening phrase for new parents to hear, as the word “syndrome” is defined as a group of signs and symptoms that occur together and characterize a particular abnormality or condition. 

The truth is, the “second night syndrome” is a theory that describes abnormal newborn behavior.

Babies go into a very deep recovery sleep period after the first 2 hours from birth. This period can range from 8-12 hours after birth and is often a time that babies may not wake up on their own to feed every 2-3 hours. Babies often need encouragement from their parents to wake them up for feeding sessions. Some babies are so sleepy that they will nurse for 5 minutes or suckle on a bottle for 5 minutes or less and fall back asleep. It’s well known that babies fast during this time, and if they have enough caloric reserves, they may tolerate this fasting period without complications.

Nursery nurses are skilled in performing clinical assessments of babies to ensure they are stable. They are looking for signs of hypoglycemia or low blood sugar levels, jaundice, and other abnormal clinical markers.  Ten percent of healthy, full-term, exclusively breastfed newborns develop hypoglycemia in the first days of life and may require specialized care until they are stable.  All babies transition from intrauterine to extra-uterine life and require skilled nurse observation.

After babies begin to ‘wake-up’ from their deep recovery sleep period on their second day of life, they will begin to exhibit stronger hunger cues to nurse or bottle-feed every 2-3 hours and become much more alert. This is a new opportunity for parents to bond because their babies become alert again, opening their eyes while gazing at their parent’s adoring faces. Some babies are very demanding during this time because they are hungry.

Newborn babies are very easy to console after their feeding by being held and snuggled. Every nursery nurse will tell you something is wrong if a baby is not content after feeding. I suspect this is where the word “syndrome” came from, which describes abnormal infant behavior.

What does the newborn feeding pattern look like?

Breastfeeding: Every 2-3 hours, a baby will nurse for at least 15 minutes on each breast.   Breastfeeding every 2-3 hours also stimulates the milk-making hormone cascade, which brings in a mother’s full milk supply in 2-3 days.  If your sleepy baby is not nursing effectively, self-expression of colostrum or pumping is necessary. Supplementing is also necessary because drops of colostrum are not enough to sustain your baby’s hunger and thirst. Make sure to check our resources on breastfeeding latch and safe positioning while breastfeeding. To learn how to supplement your baby, click here.

Bottle and formula feeding: Sometimes, bottle feeding will take about half as much time as breastfeeding, but similar feeding patterns occur because of the same caloric needs and the same infant stomach size, which is roughly 20 mLs. 

Common volumes of formula per feeding by age:

1. 1-24 hours old: 15-30 mL 
2. 24-48 hours old: 20-40 mL
3.  48-72 hours old: 25-50 mL

These are approximate volumes as some babies may, in fact, take more milk per feeding depending on the fuel reserve they are born with, what size they are, their gestational age, and many other variables. For example, a 9-pound baby may want to take 45 ml at each or some feedings. If they do take more, that is okay. A 24-hour volume intake is what is most important as babies can vary from feed to feed, as exhibited by their hunger cues. Ultimately, your newborn is the only one who knows what volume of milk they need to meet their needs.

Frequency of feeding for bottle-feeding babies:

• Term newborns weighing over 6 pounds will feed for the first three days of life, nearly every 3 hours.
• Term newborns who weigh less than 6 pounds will feed the first three days of life every 2-3 hours.
• After three days, feed on demand according to your pediatrician’s guidelines.
• A newborn should not go greater than 4 hours without a successful and satisfactory feeding, especially in the first days of life.

 

Some breastfeeding mothers talk about the “second-night syndrome” by describing it as absolute hell! They describe their babies as nursing non-stop, and as soon as they take the baby off the breast, they cry frantically. The only time their babies are not crying is when they are breastfeeding. Some mothers say their babies even cry while frantically nursing, and nothing consoles them. The second night of your baby’s life should never be hell. If your baby is crying non-stop despite adequate breastfeeding, an immediate physical assessment by the RN or MD should be made to determine why your baby is crying and if immediate supplementation is necessary. A check of their glucose, bilirubin, and weight should be performed by a nurse, physician, or nurse practitioner to assess whether a newborn is being sufficiently fed and whether supplementation is needed to protect your newborn. Research tells us that 1 in 5 mothers have delayed the onset of full milk production, so we simply cannot ignore the abnormal behavior of a non-stop crying baby,  knowing there will be babies who need to be supplemented. 

 

 

What happens when a newborn’s hunger cries are ignored? 

Bottle-feeding babies do not have ‘second-night syndrome’ because we can see how much milk they eat and have access to the needed volume. Many mothers make enough colostrum to feed their babies fully, but at least 1 in 5 mothers will not. We must provide timely supplementation for these babies while a mother is instructed on how to stimulate both breasts adequately until the onset of full milk supply. Studies show supplementation, when necessary, nearly doubles exclusive breastfeeding rates at three months. 

 Preventing breastfeeding complications from inadequate colostrum intake is the ethical and safe thing to do, as no baby should be underfed and forced to cry out in hunger to increase exclusive breastfeeding rates before hospital discharge. 

Unfortunately, 1 in 71 exclusively breastfeeding babies are rehospitalized because of insufficient milk intake during the first days of life. 

What to expect in the first days home FOR Breastfed Babies

Most breastfeeding mothers are discharged from the hospital before their full milk supply is in. Some mothers will find their babies very fussy and unsatisfied after constant breastfeeding and become increasingly jaundiced. They panic when they realize their baby needs more milk than they are producing, and they don’t know how to supplement their baby or how to prepare formula safely.

Some babies will be very sleepy and lethargic when they are not receiving enough colostrum, which is the exact opposite of the non-stop crying baby. These babies will also need to be supplemented if they are not feeding well. 

If at anytime a mother has concerns about her baby not being well-fed, it is necessary to call the pediatrician or family physician immediately. You may supplement your baby after nursing sessions, especially if your milk is not to keep your baby safely fed. Research has shown that properly managed supplementation in the first days of life to relieve hunger will not impact your breastfeeding relationship and may, in fact, protect it. More importantly, it can protect your baby from serious complications due to insufficient feeding. It is also recommended for a mother to see her pediatrician the next day after discharge (within 12 hours) from the hospital.

Special considerations

Unfortunately, the phrases “cluster feeding” and the “second-night syndrome” are phrases that are often confused with each other. I wrote about what cluster feeding is.

When is cluster feeding considered normal?

• It happens only after a mother’s full milk supply is in, after birth.
• It is during a limited time period of 3-4 hours in 24 hours.
• The breastfeeding mother has an adequate milk supply.
• Baby has plenty of dirty and wet diapers.
• The baby is gaining enough weight.

Painful, cracked, and bleeding nipples are a serious complication of frequent and prolonged nursing, and sore nipples are one of the top reasons why moms stop nursing.  Taking necessary pain medication while in the hospital often masks nipple pain and when a mom gets home with scabbed bleeding nipples, nursing becomes unbearable. Telling mothers to keep breastfeeding for lengthy periods of time to pacify a hungry baby is the perfect storm for a traumatic and resentful initial breastfeeding experience.  

Take-Home Message

It is important to keep breastfeeding a pleasant and gentle experience for both mom and baby. This can be achieved with preparation, flexibility, knowing the difference between a hungry and satisfied baby, and knowing the signs of when supplementation may be necessary to protect your baby and your breastfeeding relationship.

 

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Resources and additional education LINKS

If I Had Given Him Just One Bottle, He Would Still Be Alive. – Fed Is Best

How To Prepare For Supplementing When Breastfeeding Your Baby In The Hospital – Fed Is Best

Hospital Drops Baby-Friendly Program After Doctor’s Baby Was Harmed – Fed Is Best

 

 

 

The Loss Of Our Son Has Devastated Our Family – This Time I Will Be Supplementing With Formula After Every Nursing session

Hospital Drops Baby-Friendly Program After Doctor’s Baby Was Harmed – Fed Is Best

 

 

HOW YOU CAN SUPPORT FED IS BEST

 

There are many ways you can support the mission of the Fed is Best Foundation. Please consider contributing in the following ways:

1. 1. Join the Fed is Best Volunteer group to help us reach Obstetric Health Providers to advocate for counseling of new mothers on the importance of safe infant feeding.
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   3. Share the stories and the message of the Fed is Best Foundation through word-of-mouth, by posting on your social media page, and by sending our resources to expectant moms that you know. Share the Fed is Best campaign letter with everyone you know.
   4. Write a letter to your health providers and hospitals about the Fed is Best Foundation. Write to them about feeding complications your child may have experienced.
   5. Print out our letter to obstetric providers and mail them to your local obstetricians, midwives, and family practitioners who provide obstetric care and hospitals.
   6. Write your local elected officials about what is happening to newborn babies in hospitals and ask for the legal protection of newborn babies from underfeeding and of the mother’s right to honest informed consent on the risks of insufficient breastfeeding of breastfed babies.
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