It happens that I recently listened to Dr. Bergman’s “Theory on Feeding Frequency” from the 2013 ILCA Conference. Two of his references for infant stomach size are from after 1992 (abstracts below my signature). He says that the Sase article gives the stomach size as 10-15 ml, but it’s not mentioned in the abstract, so I don’t know how they got the number. Dr. Bergman’s theory is that the newborn stomach size is 20 ml, but if I understood the presentation correctly (and I admit I may not have), that was the MAXIMUM volume you could put in their stomach without undue pressure, not necessarily the OPTIMAL amount to feed them. 

He proposed these terms:

Physiological capacity - Maximal amount stomach can handle without undue stress.

“Receptive capacity” of STOMACH - maximal amount stretched organ holds

“Ingestive capacity” of BABY - the amount baby or infant swallowed (he notes that if this quantity is greater than the receptive capacity, the excess won't be in the stomach)

Sonya & Sue point out that the author of the blog started from the assumption that hospital protocols based on feeding newborns a certain number of calories per day are perfectly accurate, and that you can extrapolate from research on premature/NICU babies to healthy full term babies. She does not explain or quote any research used to develop the hospital protocols. The author simply says: "current hospital feeding protocols for formula-fed babies range from feeding 10-30 ml for newborns less than 6 pounds’ every 2-3 hours and feeding newborns over 6 pounds 10-30 ml every 3-4 hours on the first day of life.”

Here are my questions:

First, how do we know that the appropriate volume of FORMULA to give per feeding (even if that volume is appropriate, for which the only proof she gives is that it’s the hospital protocol) is automatically the appropriate volume of BREASTMILK to give? We know that breastmilk is digested & absorbed totally differently from artificial baby milk. 

Second, even if stomach volume is 20 ml rather than 5-7, why is the author ok with giving 30 ml (the upper limit of the hospital protocol), which is a full 50% larger than the largest (theoretical) stomach capacity? That still seems like over stretching the stomach (and causing more spit up & reflux) to me.

Third, even though she quotes Dr. Bergman’s 20 ml elsewhere in the article, she still assumes that babies should be fed somewhere from every 2 hours to every 4 (!) for larger babies. Dr. Bergman used the 20 ml theory to support his hypothesis that babies should actually be fed every hour. Where is the author’s evidence (other than current hospital protocol) that being fed every 2, 3, or 4 hours is physiologically appropriate for newborns? It seems to me that even if you give a baby 5-7 ml’s per feeding, but feed every time the baby cues, even if that’s every hour or less, you can meet the baby’s required calorie needs for the day without giving the maximum possible stomach capacity at every feeding. (As an aside, those of us recommending 5-7 ml’s are recommending it for the first 24 hours of life, maybe up to 48 hours, not weeks at a time!)

Finally, how much is underfeeding a problem anyway? In my personal experience, I see far more parents overfeeding than underfeeding, especially since the ready-to-use formula bottles given out in the hospital are 50 ml. Many parents assume that 1 bottle equals 1 feeding, which is reasonable; after all, if an adult is in the hospital, they don’t give him a meal 5 times larger than he really needs and then tell him to eat only 1/5 of it. Of course, that gets into why the ABM manufacturers have chosen to package it that way and their motivations for doing so, but I will refrain from giving my rant on that topic, as I’m sure most of you have the same one.

Overall, I think this blog conflated two different questions that are related but not necessarily identical. One was “What is the exact volume of a newborn’s stomach and do our current models/pictures reflect that accurately?" The other was “How much breastmilk should a newborn receive at each feeding?" Then there is the related question the author didn’t even ask, (but should have because it directly affects the answer to the second question) “How frequently should a newborn be fed?” The assumption or answer seemed to be that newborns should receive enough milk to fill their stomach to capacity (by some measurement) at every feeding, but the author didn’t show why this should be the case (other than meeting calorie needs, but again isn’t it possible to meet calorie needs without completely filling the stomach at each feeding? I’m no expert on gastric emptying so I apologize if there’s something obvious here that I didn’t understand).

The result of this conflation was a post whose main effect will be to scare parents. As others pointed out, the statement about colostrum having fewer calories that mature milk or formula seems especially likely to make parents anxious that colostrum doesn’t have “enough” calories for their newborn when we know and science knows that it has exactly the nutrition (and immune factors, etc.) the newborn needs. Obviously, if a healthy baby is breastfeeding well and gaining & stooling appropriately, it doesn’t matter what volume they consume in each feeding or how frequently they feed. If breastfeeding isn’t going well, most babies in my area (New York, USA) who are being supplemented are far more likely to be overfed than underfed by their parents, no matter how many belly balls we show them. Of course that could be different in other parts of the country or other countries. I’d love to know if there's somewhere where belly balls are causing an outbreak of underfed babies.

This was meant to be short but apparently I had a lot to say on this topic! ;-)

Jennifer Sokolow, IBCLC
Long Island, New York, USA

* * * 

Pediatr Res. 2001 Nov;50(5):629-32.
Rapid maturation of gastric relaxation in newborn infants.
Zangen S1, Di Lorenzo C, Zangen T, Mertz H, Schwankovsky L, Hyman PE.
Abstract
We studied gastric volume, wall compliance, sensory perception, and receptive relaxation during the first postnatal 80 h in 17 healthy term infants, using a computer-driven air pump and simultaneously measuring pressure and volume within a latex balloon placed through the oropharynx into the stomach. To evaluate gastric compliance, we measured pressures while we infused air into the intragastric balloon at different rates (10, 20, and 60 mL/min) in random sequence. In all infants, there was a linear relationship between intragastric pressure and volume to the maximum pressure tested, 30 mm Hg. Gastric compliance ranged from 0.2 mL/mm Hg to 3.8 mL/mm Hg. Different infusion rates had no effect on compliance. We calculated gastric receptive relaxation by measuring the volume needed to maintain a constant pressure of 10 mm Hg within the balloon for 5 min. Gastric receptive relaxation ranged from 0.5 mL/min to 54 mL/min. Gastric compliance and receptive relaxation increased with postnatal age (r = 0.70, p < 0.005; r = 0.79, p < 0.001, respectively) and with number of feedings (r = 0.80, r = 0.88, respectively, both p < 0.001). There was no correlation between weight or type of feeding (breast versus formula) and either gastric compliance or relaxation. In conclusion, these results may explain the small feedings that neonates ingest in the first days of life. During the first 3 postnatal d, the newborn stomach becomes more compliant and develops more receptive relaxation, associated with a larger volume capacity.

* * * 

Am J Obstet Gynecol. 2005 Sep;193(3 Pt 2):1000-4.
Gastric emptying cycles in the human fetus.
Sase M1, Miwa I, Sumie M, Nakata M, Sugino N, Okada K, Osa A, Miike H, Ross MG.
Abstract
OBJECTIVE: 
Fetal swallowing contributes greatly to amniotic fluid homeostasis and fetal somatic development. Despite the absorption and recirculation of significant volumes of amniotic fluid, little is known about the rates of fetal gastric emptying or gastrointestinal absorption. We sought to determine the patterns of human fetal gastric emptying cycles across gestation.
STUDY DESIGN: 
The gastric emptying cycle of 80 normal human fetuses at 12 to 39 weeks of gestation was studied. Real-time ultrasound examination of the fetal stomach (defined as the largest gastric area inclusive of the pylorus) was recorded continuously for a minimum of 1 hour (60-112 minutes). Images were replayed with measurements of gastric size every minute. The gastric area ratio was defined as the ratio of the fetal gastric area divided by the area of the fetal abdominal transverse section. The changes in gastric area ratio of all subjects were analyzed with the discrete Fourier transform method. The calculable maximum cycle was 60 or 112 minutes, and the minimum cycle was 2 minutes. The highest and second highest peaks of all power spectrum were recorded, and each cycle was converted from frequency of each peak.
RESULTS: 
The gastric emptying cycles of the highest peak before 24 weeks of gestation were scattered between 30 and 100 minutes with low power. At 32 to 35 weeks of gestation, cycles were focused at approximately 40 minutes with increased power. At term, the cycles increased to >80 minutes. The gastric emptying cycles of the second highest peak were constant at 20 minutes, with stronger power after 24 weeks of gestation.
CONCLUSION: 
Fetal gastric emptying cycles normalize during the early third trimester. The near-term evidence of delayed emptying may contribute to newborn infant feeding satiation.

> On Nov 15, 2016, at 5:26 PM, Sue Jacoby, IBCLC <[log in to unmask]> wrote:
> 
> Sonya,
> 
> Yes!  Good points.
> 
> Also, while the author claimed no research has been done since 1992.  But in my files I have this:
> 
> J Pediatr. 2010 Jan;156(1):29-32. doi: 10.1016/j.jpeds.2009.07.009.
> Colostrum ingested during the first day of life by exclusively breastfed healthy newborn infants.
> Santoro W Jr1, Martinez FE, Ricco RG, Jorge SM.
> Author information
> Abstract
> OBJECTIVE:
> To determine the mass of colostrum ingested by exclusively breastfed newborn infants during the first 24 hours of extrauterine life.
> STUDY DESIGN:
> Milk ingested during the first 24 hours of life by 90 healthy newborn infants was evaluated by use of a scale with high sensitivity. The masses were measured during 8-hour periods. Associations of the mass measured with prenatal and postnatal variables were tested.
> RESULTS:
> The mass of colostrum ingested was evaluated in 307 feedings, with 3.4+/-1 feedings recorded per 8-hour period of observation. Mean gain per feeding was 1.5+/-1.1 g. The daily mass of milk ingested by newborn infants was estimated at 15+/-11 g. This volume did not show a tendency to increase during the first 24 postnatal hours, nor was it related to perinatal or postnatal factors or to breastfeeding time.
> CONCLUSIONS:
> During the first 24 hours of life newborns ingested 15+/-11 g of milk
> 
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