Problems with the 45 Minute Intruder Portions in the 2001 Babywise

by Laurie Moody

First let me say that I'm not just being negative here. I'm sincerely grateful that there has been an attempt to provide some cautionary clarification with regard to feeding problems masked as sleeping problems in the Babywise book. While I applaud the effort, I would be remiss if I did not say that the effort is too little and too late.

For background information, readers should know that on the old GFI message board called "The Forum," which now exists only as a read-only format, this 45-minute intruder used to be called the "45-minute monster." While this term was not used in any of the Babywise editions that I'm aware of, this term was used regularly on "The Forum" when responding to mothers' questions about mid-nap interruptions. Until the 2001 edition of Babywise was released, mid-nap waking was always considered a sleeping problem. Not until critics began drawing attention to repeated problems with infant weight gain and loss in maternal milk supply around the 4 month mark did contact moms begin to question moms on whether milk supply was adequate when mid-nap waking was a problem.

I'm going to list the problems with the following quotes from the 2001 edition of Babywise as I see them. First the quotes from the book and then the commentary:

page 115:

"Then there is the 45-minute intruder. Most mothers tell us this intruder sneaks in around seven or eight weeks, and four-months [sic] of age, popping up all of a sudden and out of the blue. Your baby has been doing great on her 3 1/2 hour routine, feeding and sleeping like the book says. And then, all of a sudden around week seven, she wakes 45 minutes into her nap. You know that she just had a full feeding so you begin to wonder if the problem is sleep related. That might be the cause, but equally, if might be that she is hungry and in need of another full feeding. If that is the case, feed her again, and then readjust her routine over the next TWO FEEDINGS [emphasis mine]. You will know it is not hunger if she is not interested in eating or only nurses for a minute."

page 144-145

"It [waking early out of a sound nap] might also also be the 45-minute intruder mentioned in Chapter Six [quoted above]. One day your baby just begins to wakeup [sic] 45 minutes early, because she is hungry even though your last feeding was a full feeding. We find the intruder appearing between seven and eight weeks and at four months of age. It might stick around one or two days or up to two weeks. What should you do if the intruder visits your baby? Our emphasis and encouragement is to first approach the 45-minute intruder as a hunger problem, not a sleep adjustment problem. Try feeding your baby first. If the problem is really sleep-related, your baby will be disinterested in feeding or will not feed well. But if your baby takes a full feeding, you have your answer. Feed the baby during these growth spurts and adjust your daily routine to allow for a few more feedings during the day. It is important to properly recognize the intruder because it can affect more than a single sleep cycle. While more research needs to be done in this area, it appears a link may exist between the 45-minute intruder and breast-feeding [sic] problems. If your baby, whether she be at two or four months of age, demonstrates a need to feed more often by waking out of a sound nap, it may be an indicator of a decrease in your milk supply or the quality of your milk. The downward spiral begins. The baby is waking early in the nap. Mother assumes it is a sleep problem. This continues for several days. Meanwhile, the baby is not getting adequate daytime sleep so she is not nursing proficiently. The end result in a week's time is two-fold: Mother's decreasing milk supply and a fussy baby who might possibly over a week's time begin to lose weight."

1. Both portions quoted indicate this as a problem related to growth spurts within a specific time frame only: approximately 2 months and 4 months. The authors of Babywise are COMPLETELY MISSING THE PROBLEM. Every authoritative medical source I can find lists growth spurts as occurring at or near 10 days to 3 weeks of age, 6 weeks of age, 3 months of age, and 6 months of age, but also clarifies that it is normal and acceptable for them to be at other ages as well. What happens with Babywise is NOT that a growth spurt at 2 months or 4 months causes the 45-minute intruder to appear. What happens is that because of unresponsive breastfeeding, a mother likely misses a growth spurt, which eventually causes a baby to deviate from previously established patterns of sleep. Even if a mother accepts the warning offered by the 2001 edition of Babywise, her baby is likely hungry and uncomfortable for an extended period of time before the mother realizes it by way of the "45-minute intruder." In addition, the most commonly noted periods of weight loss in Babywise babies that I have documented (and others as well) show up at the 2 month and 4 month well baby checks further giving support to the conclusion that healthy growth is probably affected well before the magic 2 and 4 month age guidelines given in Babywise.
2. Babywise here gives mothers a false confidence that her greatest need for caution with regard to sleeping interruptions needs to take place only at these two "common" ages: 2 and 4 months. The newborn period is the most critical time for the establishment of milk supply and mother's responsiveness to her baby.
3. These sections also give mothers a false confidence that she only needs caution with her schedule if her baby is waking mid-nap. Yet some babies will learn to settle for less caloric intake than they need, and will shut down and sleep more, not less. In lactation literature, babies like this are referred to as "content to starve."
4. Babywise indicates that at seven weeks a baby is "doing great on her 3 1/2 hour routine, feeding and sleeping like the book says."
   
   In my opinion this part of Babywise inadvertently reveals a predilection for young babies to be on long-interval feeding schedules early on, which is consistent with overt directives in earlier versions. Read carefully: to be "doing great" AT seven weeks, this indicates that the baby would likely be moving into a 3.5 hour schedule at the end of the newborn period. The AAP recommends that a newborn be fed 8-12 times in a 24-hour period. A baby being fed every 3.5 hours is only being fed at most 7 times.
5. Babywise indicates that at seven weeks a baby is "doing great on her 3 1/2 hour routine, feeding and sleeping like the book says."
   
   Yes, MORE from this one quote. It says "feeding and sleeping like the book says." This is just ONE OF MANY statements throughout the book that lead moms to think that the patterns described in the book are normative and should be expected. When the baby ISN'T doing it "like the book says" the mother is told to find out what is causing the baby's "uncooperative stance". Babywise doesn't indicate that the method itself could be flawed, it blames the mother or the baby.
6. Babywise says, "You know that she just had a full feeding."
   
   JUST had a FULL feeding is a dangerous statement to make for a few reasons. First of all, "just" would indicate by most definitions to be a relatively recent event. In the 3.5 hour routine as described by Babywise, the baby waking 45 minutes into a nap would have been fed anywhere from 2 hours and 15 minutes earlier to 2 hours and 45 minutes earlier depending on waketime. By any reasonable definition of "just had," that time interval is NOT recent. Secondly, Babywise says "a full feeding." Babywise gives moms a false confidence about this idea of "full feedings." Babies whose cues are being ignored cannot adequately tell a mother's body how much milk to produce (which will eventually cause a decrease in milk supply). Not all moms can store the same amount of milk and not all babies can take in the same amount of milk to satisfy them for certain feeding intervals. Not all moms have the same caloric or fat content to their milk, and not all babies have the same metabolism for how quickly they use up calories. It stands to reason that quieter, calmer babies will not use up calories as quickly as fidgety, active babies.
7. Babywise says, "you begin to wonder if the problem is sleep related. That might be the cause, but equally, if might be that she is hungry and in need of another full feeding... Mother assumes it is a sleep problem."
   
   This is another example of "blame the mother." Moms are told that if they follow the book they will get the stated results. Mothers are told to evaluate cries and figure out what the baby needs before responding. I see this section for some moms as one that would lead them to doubt their ability to evaluate what the baby needs, especially for a mother who begins losing her milk supply or who has a baby who isn't gaining weight adequately. The Babywise book is not the problem, but the mother's apparent inability to determine what the baby really needs. HOGWASH.
8. More on this quote, "you begin to wonder if the problem is sleep related. That might be the cause, but equally, if might be that she is hungry and in need of another full feeding."
   
   Why is it ONLY possible that hunger is causing sleeping "problems" at 2 months and 4 months. Why isn't this 45-minute intruder considered earlier in the newborn period as well? Could it be because the authors of Babywise don't really believe in true routine but really believe in a schedule instead? Could it be that they really don't want moms to be "too flexible?" Consider this quote from the 2001 edition of Babywise, page 109.

   " But what is flexibility? Many times we hear new moms say they want to be flexible. What does this look like? The word flexibility means the ability to bend or be pliable. When you think of a flexible item, you think of something with a particular shape that can bend and then return to its original shape. Returning is perhaps the most crucial element of flexing. During the critical first weeks of stabilization you are giving your baby's routine its shape. Too much flexibility in these weeks is viewed by a baby as inconsistency. Routine must first be established. After that, when necessary deviations are made, baby will bounce back to the original routine. Doing so, however, may require your firm guidance. The flexibility you desire will come, but give yourself time to develop your child's routine. And remember, true flexibility is not a lack of routine, but a temporary alteration of what you normally do."

   Considering that parents read this statement FIRST, before reading about the 45-minute intruder, it is reasonable to believe that most moms would be focused then on "normal" sleeping patterns as defined by Babywise up until the possibility of a 45-minute intruder sometime after 7 weeks.

9. The solution Babywise suggests is inadequate. Both quoted passages suggested temporary modification of the feeding schedule by adding in a few feedings. This idea of the temporary alteration of the "routine" is based on the assumption that only feeding at certain predefined, acceptable intervals is safe for every mom and baby to start with. Yes, adding in more feedings temporarily may solve the short-term problem, but it may not solve the problem long-term. Why? Restating what I said in #6 above: Babies whose cues are being ignored cannot adequately tell a mother's body how much milk to produce (which will eventually cause a decrease in milk supply). Not all moms can store the same amount of milk and not all babies can take in the same amount of milk to satisfy them for certain feeding intervals. Not all moms have the same caloric or fat content to their milk, and not all babies have the same metabolism for how quickly they use up calories. It stands to reason that quieter, calmer babies will not use up calories as quickly as fidgety, active babies. Additionally, the mother may not be able to consistently produce enough milk after weeks and months on end of giving her body mixed signals. The AAP says that the best schedule for a breastfed baby is the one he/she designs for him/herself. Babies can develop a pattern or routine and parents can work with baby to influence that pattern, but it can and should be done with more medical safety and more respectfully than the Babywise approach.
10. Both passages say this in one form or another, so I'll just quote one of them. Babywise says, "If the problem is really sleep-related, your baby will be disinterested in feeding or will not feed well." I have personally worked with moms during my former Contact Mom status with GFI whose babies were so conditioned to be fed only at certain intervals or times of day that they were unwilling to nurse at other times. These were babies who were losing weight and clearly needed to be fed more often, yet were unwilling to do so. Along the same line, there have been babies who were so conditioned to only receive a small amount of breastmilk at a time and were unwilling to take more at once. The story of the Hseigh baby (see the story at http://www.ezzo.info/Voices/hsieh.htm ) is probably the most serious one of which I'm aware that illustrates my point. Weight loss and interruption in typical sleeping patterns are evidence of a problem that has already existed for some time. Babywise ignores this in its suggestion of a solution and its cursory dismissal of a possible response by the baby to the "solution."
11. Babywise says, "If your baby, whether she be at two or four months of age, demonstrates a need to feed more often by waking out of a sound nap, it may be an indicator of a decrease in your milk supply OR THE QUALITY OF YOUR MILK." [emphasis mine]
    
    Notice the conjunction OR. Here the authors of Babywise introduce, not so subtly, that the problem could, after all, just be the QUALITY of the mother's milk. No, the method cannot possibly be at fault, just the mother's ability to analyze her baby's needs and the quality of her milk. When all else fails, blame the MOTHER. MORE HOGWASH! There are no peer reviewed medical studies to back up this assertion by Babywise that in the midst of not following the AAP's recommendation for cue feeding her baby, a mother should assume the quality of her milk could be at fault in her baby's inability to follow the Babywise method.
12. Babywise says, "While more research needs to be done in this area, it appears a link may exist between the 45-minute intruder and breast-feeding [sic] problems."
    
    In America we don't do this kind of research--purposely withhold food from babies to see what kind of problems it causes! This kind of proposal for research would never make it past a peer review board. It could only be done by a retrospective study, which as those who have done serious research know has its own set of problems (very difficult to sort and define variables, very difficult to establish how much of the protocol was followed and how it was actually implemented).
    
    If more research needs to be done to determine the relationship of the "45-mintue intruder" and the Babywise method, then WHY are the Ezzos continuing to publish their book? If only a few babies injured due to defects in a car seat involved in an auto accident results in the recall of that car seat, then WHY don't the Ezzos see their own liability with regard to the problems many families have had with the Babywise method? Why don't they act responsibly and remove the Babywise book from the shelves in a full recall?
13. Babywise says, "Meanwhile, the baby is not getting adequate daytime sleep so she is not nursing proficiently."
    
    I believe this statement is meant to express something similar that I said to the Ezzos when I resigned as a contact mom: that poor feeding can lead to poor sleeping which can in turn lead to poor feeding, thus creating a vicious cycle. I'll give the benefit of the doubt on that portion of material I quoted. Babywise is still neglecting to consider with this statement that the method itself could be at fault.
    
    I've already said it once and I'll say it again. The added cautions in the book are offset by admonitions to mothers to not be "too flexible too often." I don't see the paragraphs about the 45-minute intruder to be enough of a change in the overall pattern of the book to make it a safer method to follow.

Analysis of GFI's information on co-sleeping and SIDS

"Untold Dangers" in the Family Bed?

An article in the Spring 1997 issue of "The Community Perspective," a newsletter published by Growing Families International (GFI), claims, "Sleeping with your infant, as recommended by controversial attachment parenting advocates, can often result in infant suffocation…" (emphasis added). The article cites studies that supposedly prove "overlying," or a parent’s body unintentionally suffocating a baby, is "more common than the ‘family bed’ or ‘attachment parenting’ advocates are willing to admit."

It is important to remember that Sudden Infant Death Syndrome was initially called "crib death," for good reason. Far more babies die alone in cribs than from overlying in the parents’ bed, even though literally millions of parents around the world sleep with their babies, and have done so throughout history. In fact, the cultural shift from babies sleeping with their parents throughout the centuries, to sleeping alone in cribs was just that: a cultural shift. It was never studied and determined to be safe, or even wise.

It is simply not the case that one practice is 100% safe, while the other is not. Research strongly suggests, however, that when proper precautions are taken, sharing sleep is safer than leaving a baby to sleep in a crib, alone.

Does overlying happen "often" as GFI claims, so parents should be concerned?

The GFI article cites a number of studies that supposedly prove overlying is a serious risk but several of the studies date from the 1960s and 1970s and have been contradicted by more recent studies.

More recent studies from Australia and New Zealand, also cited in the article, have been re-evaluated, notably by respected SIDS researchers James McKenna and Peter Fleming. Though at first these studies seemed to implicate co-sleeping as one risk factor for unexplained infant death, the re-evaluation discovered a significant proportion of Maori Indians among the subjects of the studies. Once the common Maori practice of smoking was adjusted for, the studies were found not to implicate co-sleeping as a risk factor after all. In other words, increased risk is due not to co-sleeping per se, but to unsafe sleeping conditions, with maternal smoking first and foremost among them. In fact, Dr. McKenna states, "There is no controlled epidemiological study which shows that co-sleeping is dangerous, except where mothers smoke." This revision of the studies' conclusions is widely known among professionals, so to cite these studies as proof that co-sleeping is dangerous reveals, at best, ignorance of current research.

Two of the journals cited in the GFI article are considered in the professional community to be less scientific and less subject to peer review than the leading journals. Even so, they did not give sufficient information to support GFI’s conclusions. The GFI article itself mentioned that in one, "information concerning the parents’ alcohol and drug use was scanty," and some of the deaths may have been "intentional," i.e. murder.
For all these reasons, it cannot be "assumed" that overlying deaths are common, as the GFI article suggests. Since the few studies GFI cites are from lesser known medical journals, and even those studies don't fully back up their claims, one must wonder whether they are citing all the information they view as being "friendly" while ignoring the bulk of scientific research.

Do babies sometimes die because they are "overlaid," or suffocated by the parents? No one can say this never happens, because the cause of death often cannot be explicitly determined. Revising past opinion, expert pathologists now say suffocation as the cause of death cannot always be determined. In other words, a particular death may be thought to result from "overlying" or suffocation, as is claimed in the GFI article, but experts agree that in many cases this is simply a guess. And guesses, of course, often reflect the biases of the people doing the guessing.

Further, it has been shown that in the majority of cases where a child was apparently suffocated, some abnormal sleeping arrangement was present, such as too many people in too small a bed, parents under the influence of sleep-altering drugs or alcohol, or unsafe sleeping surfaces such as couches or bean bags. There are certain basic principles for safe sleep sharing, and these are covered in scientific detail, and very highly referenced from leading journals in SIDS: A Parent’s Guide to Understanding and Preventing Sudden Infant Death, by William Sears, M.D. In that book Dr. Sears cites more than 250 current, reputable, scientific studies on the safety of sleep sharing when properly practiced.

It is also worthy of note that research (including the New Zealand and Australia studies cited by GFI) has shown one particular practice reduces Sudden Infant Death Syndrome by 30-50%: placing a baby to sleep on his or her back, rather than tummy. For this reason, the American Academy of Pediatrics recommends back-sleeping for infants. Yet Growing Families International continues to advocate tummy sleeping because babies "sleep better" and suggests those same studies cannot be trusted on this point. [Note: this information was correct at the time this article was written. However it should be noted that the Ezzos began to back away from overtly recommending tummy sleeping at some point in the late 90's.] In other words, they choose to believe the New Zealand and Australia studies on a point that has been refuted (co-sleeping), and choose to disbelieve them on a point that has been verified (back-sleeping).

The bottom line: it is not unusual for research to produce conflicting results. That is why studies must be published in reputable sources and subjected to peer review, verification, and duplication. No choice is 100% "safe," but the best current research indicates that sharing sleep, when practiced correctly, is best for babies—and safest overall.

This paper was compiled from an interview with William Sears, M.D., and with reference to his book SIDS: A Parent’s Guide to Understanding and Preventing Sudden Infant Death (New York: Little, Brown and Company, 1995). James McKenna, Ph.D. was also consulted on some points.

Letter to Church Elders about Preparation for Parenting Class

by Steven R. Rein and Kateri Allison Rein

This HTML document is essentially a letter to an elder at St. Giles Presbyterian Church in Richmond, Virginia about our experience in the Preparation for Parenting class we took.

To close out this WWW introduction to the letter, we say to all those reading, don't trust our interpretation of Growing Families International's materials and don't trust GFI but pray for discernment while looking through the evidence and weighing the issues.

Conclusion

It has been a few weeks since we have written this letter. We have received many thanks as well as the cold shoulder from some. We felt we should write a follow up most specifically to those who have taken the PFP course and found that it has worked well for their families. We believe that as God has made us all different, it is ok for there to be differences in the styles of how we parent. Of course there are Biblical principles that we are all to follow, but these do not include how often an infant eats, where or how much an infant sleeps, etc. We are saddened by the stories of how families have felt ostricized even in their own churches because they have chosen to parent their infants in a way other than the Ezzos' method.

We are also saddened by the judgmental questions (not honest inquiries or sharing of infant stories) asked by some about when our child slept through the night and how we chose to feed her. We do not consider these markers as to whether she will grow to love and serve Jesus. We feel that getting caught up in such specifics detracts from really supporting one another as parents.

We have felt that our letter has the potential to be misunderstood. We are not promoting one method over another in infant care, rather, we tried to ask some serious questions about the PFP program after doing some research into the methodology. This does not mean that we disagree with the whole of the program or that we pass judgement on those who have chosen it to parent their children. There is too much against us in our society for Christians to get caught up in whether our children are fed too often or not enough. We need to be a support system to one another. We understand that the Ezzos have some good advice in raising children according to those we respect in our church who have taken the Growing Kid's God's Way course; however they have made some ungodly claims in their PFP course as we have shared and we feel it is necessary that there be an awareness made of this. More importantly, God reveals His will to us as individuals and while we must support one another in Biblical parenting, we must remember that God has made us different and it is ok to have different styles of parenting.

References

(this link goes to an archived version of the reference page on Steve's original site.)