Annelies Bon asked if there were a formal definition of breastfeeding
     on demand.  WHO and UNICEF tried to articulate one in the 1992 Global
     Criteria for Step 8 of the BFHI Ten Steps:

     "Mothers of normal babies (including caesareans) should have no
     restrictions placed on the frequency or length of their baby's
     breastfeeds. They should be advised to breastfeed their babies
     whenever they are hungry or as often as the baby wants and they should
     wake their babies for breastfeeding if the babies sleep too long or
     the mother's breasts are overfull."

     Demand feeding is also known as unrestricted feeding or baby-led
     feeding, or in response to the baby's cues, according to WHO's book
     Evidence for the 10 Steps to Successful Breastfeeding (1998).

     The BFHI description of exclusive breastfeeding in Step 8 is
     complemented by Step 9 for which the Global Criteria read: "Infants
     should not be fed using bottles with artificial teats (nipples) nor
     allowed to suck on pacifiers."

     Is it possible that in the Dutch families that space out breastfeeds
     as Annelies describes, there is some degree of pacifier use?  This
     would not quite be feeding on demand as defined in BFHI.

     There may also be cultural interpretations of when a baby is "hungry"
     or "wants" to breastfeed. What one woman sees as a cue of hunger may
     be taken by another to mean that the baby needs to be cuddled,
     changed, walked, talked to.... And of course there are also
     individual variations on how mothers respond to their babies.  So it
     may be important not to have rules, not even rules of thumb, and to
     ensure that everyone caring for a mother just helps her to find what
     works best for her and her baby.

     The WHO publication me3ntioned above points out that the frequency
     and length of feeds varies between infants, and from day to day for a
     single infant. There are certainly placid infants who seem to be
     quite content to breastfeed, for quite a long time, about five or six
     times in 24 hours and who flourish on that pattern. And some of them
     go right on breastfeeding well into the second year -- yet there are
     others for whom such relative infrequency of breastfeeding would
     signal an approaching end to breastfeeding.

     Four to five times in 24 hours would be a relatively unusual
     pattern for exclusive breastfeeding producing a cheerful alert baby
     and good growth. One would want to be sure this was not a situation
     in which for some reason the baby needs to be stimulated to
     breastfeed more frequently.

     Where a lot of women report that their babies are breastfeeding "on
     demand," yet with a pattern of infrequency, one would want to look
     at the exclusivity of breastfeeding, and the durations of
     breastfeeding.  Do those who start with infrequent breastfeeds
     manage to go on for two years or beyond as recommended?  One would
     also look at the growth and health or morbidity of the infants who
     are fed in this way, before drawing any conclusions about whether
     infrequent breastfeeding on demand is an effective way of
     breastfeeding in that social context.

     Where each breastfeed is a big production, with the mother sitting
     in a special place, the baby changed before and after and winded
     (burped) in between, and the mother more or less devoting herself
     to the feeding, it can happen that each breastfeeding session takes
     about 45 minutes, and the baby goes off to a deep sleep afterward.
     Where breastfeeding is more casual, quick and informal, it is quite
     likely that the feeds will not be so widely spaced out.  Some
     families breastfeed in a pattern that looks like fast food or
     snacking, never giving what someone from a perhaps more systematic
     child-rearing culture would call "a proper feed."

     So I think we need to be quite objective about what works for women
     and babies in a given culture. The American adage "if it ain't broken,
     don't fix it" applies.  On the other hand, even if growth and health
     are achieved, if the spaced-out feeds are achieved by disregarding or
     obstructing the baby's signals for attention, then mothers may want to
     consider how this is experienced by the baby and how it might affect
     their long-term relationship.

     Helen Armstrong
     Consultant, Infant Feeding and Care
     UNICEF Nutrition Section

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