The NDC model of frequent flexible breastfeeds + evidence base

"Their meals, and in my Opinion their sucking too, ought to be at stated Times, and the same every Day; that the Stomach may have Intervals to digest, and the Appetite return. The Child would soon be quite easy and satisfied in the Habit; much more so, than when taught to expect Food at all times, and at every little Fit of Crying and Uneasiness."

Dr William Cadogan, An Essay upon Nursing and the Management of Children from their Birth to Three Years of Age, 1748

The NDC model of frequent flexible breastfeeds is fundamental to the Possums or NDC approach to clinical breastfeeding and lactation support

The NDC model of frequent flexible breastfeeds is based upon cross-cultural observations, both in my own clinical and personal experience, and in anthropological research. It fundamentally informs

• Initiation and maintenance of breastfeeding and lactation

• The NDC management of breast inflammation

• The NDC management of low milk production

• The NDC approach to pumping breastmilk

• The NDC approach to paced bottle-feeding in the first four months of life

• The NDC approach to transitioning away from pumping and triple feeding.

Table: Clinical strategy and underlying biological or scientific rationale for frequent flexible breastfeeds

Clinical strategy	NDC rationale
Generous opportunities for skin-to-skin contact in the immediate postpartum and in the days after the birth.	Abundant opportunities for skin-to-skin contact in the first hours and days after birth facilitates frequent and flexible breastfeeds, which help prevent engorgement and mastitis, and promote development of prolactin receptors in the mammary gland so that milk secretion optimises(Schafer and Watson Genna 2015, Kent, Gardner et al. 2016, Moore, Berman et al. 2016)
Many women need to offer each breast about 12 times in 24-hour period (without counting or watching clock) to maintain milk supply and baby weight gain.(Kent, Mitoulas et al. 2006)	Optimises ductal dilations and milk removal. Makes daily life with infant easier not harder, once underlying clinical problems have been addressed (for example, conflicting intra-oral vectors of force, positional instability).(Douglas and Keogh 2017, Douglas and Geddes 2018, Douglas 2022, Douglas, Perrella et al. 2022)
Babies suckle to satiate both nutritional and sensory-motor nourishment needs.	Women can offer breast whenever they think it might dial their infant down, without trying to determine if he or she is hungry or not.(Crawford, Whittingham et al. 2022)
There is no expectation that baby transfers certain amounts of milk in a breastfeed.	No need to count sucks and swallows.
Women can trust that over a 24-hour period the infant will take what he or she requires if offered unrestricted access, once underlying clinical problems have been addressed (for example, conflicting intra-oral vectors of force, positional instability).(Crawford, Whittingham et al. 2022)
Breastfeed durations and involvement of one or both breasts are highly variable, both over a 24-hour period, and between women.(Kent, Mitoulas et al. 2006)	Some breastfeeds will be short or very short, depending on age of infant; others much longer. No need to offer both breasts in the one feed but the infant might also want both breasts. A woman can offer the breast again even if only a very short period of time (for example, ten minutes) has passed since a previous feed if her infant seems to want that.(Douglas 2022) Breastfeeds occur ‘on the go’ in the midst of a day which meets the infant’s needs for rich sensory nourishment and the mother’s needs for rich social life, work, exercise.(Whittingham and Douglas 2014, Ozturk, Boran et al. 2021) Breastfeeding fits in frequently and flexibly amidst a rewarding life outside the home.(Crawford, Whittingham et al. 2022) Breastfeeding dials infants down during the night, to make night-waking manageable. Excessive night-waking is not caused by frequent flexible feeds,(Smith and Forrester 2021) but by disruptions to the biological sleep regulators.(Whittingham and Douglas 2014, Ball, Douglas et al. 2018, Douglas 2018, Ball, Taylor et al. 2020, Whittingham, Palmer et al. 2020, Ozturk, Boran et al. 2021, Crawford, Whittingham et al. 2022)
Breastfed babies can’t be overfed.	Don’t wait for cues to offer a feed, knowing that the infant will communicate if not interested. Underlying clinical problems need to be addressed.(Crawford, Whittingham et al. 2022)
Never coerce at the breast.	Coercion may result in conditioned dialling up at breast.(Douglas and Hill 2013)
Don’t burp or hold upright after feeds.	Infants do not swallow significant amounts of air, even when encountering clinical problems.(Douglas and Geddes 2018, Mills, Lydon et al. 2020) Burping or holding upright after feeds unnecessarily rouses infants.(Crawford, Whittingham et al. 2022)
Don’t attempt to ‘drain’ breast so that the baby receives more cream.	Breast is never empty; trying to keep infant on the one breast decreases ductal dilations and may decrease supply. Frequent shorter episodes of milk removal are more effective than spaced, longer episodes of milk removal, due to the physiology of milk ejection.(Douglas 2022) Fat content over a 24-hour period is same between women regardless of feeding frequency and doesn’t require efforts to make baby receive cream.(Kent, Mitoulas et al. 2006)
Don’t attempt to ‘drain’ breast so that the baby receives more cream.	Breast is never empty; trying to keep infant on the one breast decreases ductal dilations and may decrease supply. Frequent shorter episodes of milk removal are more effective than spaced, longer episodes of milk removal, due to the physiology of milk ejection.(Douglas 2022) Fat content over a 24-hour period is same between women regardless of feeding frequency and doesn’t require efforts to make baby receive cream.(Kent, Mitoulas et al. 2006)
Baby is the best breast pump.	This is the case once underlying clinical problems (for example, conflicting vectors of intra-oral force, positional instability, conditioned dialling up at the breast) have been addressed.(Douglas and Keogh 2017, Douglas and Geddes 2018, Douglas, Perrella et al. 2022)
Experimentation is the key to resilience.	The breastfeeding woman is the one who has expert knowledge about her own baby.(Crawford, Whittingham et al. 2022)

References

Ball, H., P. S. Douglas, K. Whittingham, K. Kulasinghe and P. S. Hill (2018). "The Possums Infant Sleep Program: parents' perspectives on a novel parent-infant sleep intervention in Australia." Sleep Health 4(6): 519-526.

Ball, H., C. E. Taylor, V. Thomas, P. S. Douglas and Sleep Baby and You Working Group (2020). "Development and evaluation of ‘Sleep, Baby & You’ - an approach to supporting parental well-being and responsive infant caregiving." Plos One 15(8): e0237240.

Crawford, E., K. Whittingham, E. Pallett, P. S. Douglas and D. K. Creedy (2022). "An evaluation of Neuroprotective Developmental Care (NDC/Possums Programs) in the first 12 months of life." Maternal and Child Health Journal 26(1): 110-123.

Douglas, P. (2022). "Re-thinking benign inflammation of the lactating breast: a mechanobiological model." Women's Health 18: 17455065221075907.

Douglas, P. S. (2018). "The Possums Sleep Program: supporting easy, healthy parent-infant sleep." International Journal of Birth and Parent Education 6(1): 13-16.

Douglas, P. S. and D. B. Geddes (2018). "Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support." Midwifery 58: 145–155.

Douglas, P. S. and P. S. Hill (2013). "A neurobiological model for cry-fuss problems in the first three to four months of life." Medical Hypotheses 81: 816-822.

Douglas, P. S. and R. Keogh (2017). "Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer." Journal of Human Lactation 33(3): 509–518.

Douglas, P. S., S. L. Perrella and D. T. Geddes (2022). "A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series." BMC Pregnancy and Childbirth 22(94): https://doi.org/10.1186/s12884-12021-04363-12887.

Kent, J. C., H. Gardner and D. T. Geddes (2016). "Breastmilk production in the first 4 weeks after birth of term infants." Nutrients 8(756): doi:10.3390/nu8120756.

Kent, J. C., L. R. Mitoulas, M. D. Cregan, D. T. Ramsay, D. A. Doherty and P. E. Hartmann (2006). "Volume and frequency of breastfeedings and fat content of breast milk throughout the day." Pediatics 117(3): e387-e395.

Mills, N., A.-M. Lydon, D. Davies-Payne, M. Keesing, S. A. Mirjalili and D. T. Geddes (2020). "Imaging the breastfeeding swallow: pilot study utilizing real-time MRI." Laryngoscope Investigative Otolaryngology 5: 572-579.

Moore, E. R., N. Berman, G. C. Anderson and N. Medley (2016). "Early skin-to-skin contact for mothers and their healthy newborn infants." Cochrane Database of Systematic Reviews(Issue 11. Art. No.: CD003519): DOI: 10.1002/14651858.CD14003519.pub14651854.

Ozturk, M., P. Boran, R. Ersu and Y. Peker (2021). "Possums-based parental education for infant sleep: cued care resulting in sustained breastfeeding." European Journal of Pediatrics 180: 1769-1776. Schafer, R. and C. Watson Genna (2015). "Physiologic breastfeeding: a contemporary approach to breastfeeding initiation." Journal of Midwifery and Women's Health 60: 546-553.

Smith, J. P. and R. I. Forrester (2021). "Association between breastfeeding and new mothers' sleep: a unique Australian time use study." International Breastfeeding Journal 16(7): https://doi.org/10.1186/s13006-13020-00347-z.

Whittingham, K. and P. S. Douglas (2014). "Optimising parent-infant sleep from birth to 6 months: a new paradigm." Infant Mental Health Journal 35: 614-623.

Whittingham, K., C. Palmer, P. S. Douglas, D. K. Creedy and J. Sheffield (2020). "Evaluating the 'Possums' health professional training in parent-infant sleep." Infant Mental Health Journal: doi:10.1002/imhj.21885.