Feeding a Hungry Baby and Flexibility: Babywise 1998
& 2001
Quotes are from On Becoming
Babywise by Gary Ezzo and Dr. Robert Bucknam, published
by Multnomah, ©1998, Parentwise Solution ©2001
Comments by Kathy Thile.
"With
PDF [Parent-Directed Feeding], a mother feeds her
baby when he is hungry." [1998, p.38]
This paper will illustrate
that this message is mediated by frequent references to
clock times and book-approved intervals of time which
are emphasized over and against watching for and responding
to hungry behavior the baby may display. I have also included
quotes showing suggested numbers of feedings are routinely
on the low end of what breastfed babies typically take.
"Babies
learn very quickly to become snackers if you let them.
If your [two week old] baby increasingly becomes characterized
by snacking, you must work on stretching the times
between feedings to make the 2 1/2 hour minimum"
(1998, pp175-176, 2001, pp 175).
Although many young babies need
to nurse that frequently, Ezzo defines regularly feeding
more frequently than every 2.5 hours as snacking,
and parents are instructed to respond by using the clock
as the guide instead of the baby's hunger prompts.
"With
PDF, feeding time, waketime, and naptime cycles are
both routine and predictable. Though a routine is
always predictable, what is predictable does not necessarily
establish routine. For example, Chelsea's mom follows
the principles of PDF. This means approximately the
same amount of time passes from one feeding/wake/naptime
event to the next. So interaction with baby is
both predictable and routine, an important first step
in establishing continuous nighttime sleep" [1998,
p.42, 2001 p.42, emphasis mine.]
In contrast to the information
expressed in the first quote, here PDF is defined by properly
spaced feeding intervals, not by feeding the baby when
she is hungry.
"...Healthy,
full-term babies typically are born with the capacity
to achieve seven to eight hours of continuous nighttime
sleep between seven and nine weeks. Whether or not
your child achieves this is determined predominately
by the philosophy you adopt for feeding....mothers
who follow the AP approach to parenting see completely
different behavioral results than Babywise moms...."
(1998, p. 43-44, 2001, p.43-44)
This statement presents an unsubstantiated
medical statement alleging an early capacity for continuous
nighttime sleep. Ezzo does not discuss the value and safety
of having a baby that young go that long without nourishment,
nor the impact this has on the mother's ability to sustain
an adequate long-term milk supply, nor the impact of the
probable resulting early return of menstrual cycles and
fertility. Dr. Richard Ferber, a genuine expert in the
area of children's sleep, says this long overnight sleep
(and the attendant gap in feedings) is not proven to be
safe.
"From
birth onward, infant hunger patterns will either become
stable and regular or move towards inconsistency.
When infants are fed on the PDF plan, their hunger
patterns stabilize. The reason for this is that the
hunger mechanism (digestion and absorption) operates
as if it has a metabolic memory reinforced by routine.
If Chelsea's feeding periods are regular, she will
establish a hunger metabolism that is stable and predictable.
For example, if her mom feeds her at approximately
7:00 A.M., 10:00 A.M., 1:00 P.M., 4:00 P.M., 7:00
P.M. and 10:00 P.M., Chelsea's hunger synchronizes
with those times. This happens only where feeding
periods are routine...." [1998, p. 48, 2001,
pp. 48-49]
This passage reinforces guidance
by clock times and feeding intervals instead of being
guided by the baby's hunger, and presents unsubstantiated
medical "facts". Also, contrast this interpretation
of hunger synchronized to clock times with Ezzo's
interpretation on what it means if the baby wakes
to feed at the same time each night.
"Fact
Three
"It
is not what goes in the mouth as much as when
it goes in." (1998 & 2001 p. 48, emphasis
mine)
"When
the feeding occurs, not what the feeding consists
of, has much more to do with baby's healthy sleep...."
(1998 & 2001 p. 49, emphasis mine)
"When" refers to approved
interval times rather than on feeding the baby when he
is hungry as claimed in the first quote, and moreover,
Ezzo connects the approved intervals with the book's central,
advertized goal of getting the baby to sleep through the
night, making compliance more likely.
"How
often you should feed your baby depends on your baby's
age. As a general rule, during the first two months
you will feed your baby approximately every 2 1/2
to 3 hours from the beginning of one feeding to the
beginning of the next. Sometimes it may be less and
sometimes slightly more, but this time frame is a
healthy average....With these recommendations you
can average between eight to ten feedings a day in
the early weeks. These times fall well within recommendations
of the American Academy of Pediatrics." (1998
& 2001 p. 74, emphasis mine.)
Again, Ezzo missed an opportunity
to say,"how often you should feed your baby depends
on how often your baby is hungry."-- He could then
educate parents that hunger has less to do with the baby's,
and more to do with the size of his stomach, his metabolism,
his activity level, his mother's relative breast milk
storage capacity, and the daily fluctuations of her milk
supply. And again he focuses the parents' attention on
feeding according at certain intervals of time.
The
AAP says the best schedule for the baby is the one they
set themselves, and that mothers should nurse the baby
when he cues that he is hungry, which on average will
result in 8-12 feedings daily. Picking a number between
8 and 12 is not in keeping with the spirit and intent
of the AAP
recommendations.
"While
2 1/2 to 3-hour feedings are a healthy norm, there
may be occasions when you might feed sooner. But take
heed. Consistently feeding exclusively at 1 1/2 to
2 hour intervals may wear a mother down....As stated,
there will be times when you might nurse sooner than
2 1/2 hours, but that should not be the norm. At the
other extreme, going longer than 3 1/2 hours in the
early weeks can produce too little stimulation for
successful lactation..." (1998 & 2001 p.
74)
Ezzo presents an unsubstantiated
medical statement (about wearing mother down) and urges
compliance with his schedule through scare tactics. This
undermines the advice about the value of feeding more
often, and makes it appear optional.
"Summary
of Phase One
By the
end of eight weeks, the stabilization phase is usually
complete. By this time, your baby should be sleeping
through the night on a regular basis or very close
to achieving the skill. If she is not, don't worry.
Approximately 15 percent of PDF babies will start
sleeping through the night between weeks ten and twelve....
The number
of feedings in a 24 hour period will be seven to
nine before your baby is sleeping through the
night, and seven to eight feedings afterwards....
You may need to maintain a seventh or eighth feeding
period for four to five days after your baby initially
begins sleeping through the night. Sticking close
to a 2 1/2 hour to 3 hour routine will help facilitate
that goal....Most PDF moms are comfortable alternating
between a 2 1/2- and 3 1/2-hour routine, getting in
six good nursing periods." [1998 &
2001 p.114 Emphasis added]
"...The
point is this: it's okay to deviate from the 2 1/2-
to 3-hour feeding norm. But do not deviate so often
that you establish a new norm." [1998 p. 115,
2001 p. 116]
Another warning that feeding is
primarily associated with clock times (to guide the mother
toward the proper interval) not with the baby's hunger.
This quote illustrates Ezzo's attitude toward flexibility.
Ezzo's flexibility does attempt to meet the need but assumes
and that his schedule IS basically adequate, and sooner
or later must be returned to--preferably sooner. Real
flexibility adapts to whatever is appropriate for the
circumstances, turning away -- sometimes permanently --
from preconceived plans.
"Here
are some examples of context and PDF flexibility:
"...2.
You are on an airplane and your infant daughter begins
to fuss. The fussing grows louder. You fed her just
two hours earlier. Yet failure to act will stress
you, not to mention the entire jet full of people.
What should you do? Your solution is simple: consider
others. Don't let your baby's routine get in the way
of being thoughtful toward others. You can either
attempt to play with your baby and entertain her or
you can feed her. Although you normally would not
offer food before three hours have passed from
your last feeding, the context of the situation dictates
that you suspend your normal routine. When you arrive
at your destination, you can get back to basics. There's
your flex. [1998 p.116, 2001 p. 117]
The mother in this example would
apparently normally not offer to feed the baby until three
hours have passed, regardless of the baby's cues. This
rigidity is often said not to be a part of this program,
yet here it is mentioned in passing as normal, and the
flexibility which the example illustrates, comes to allay
the discomfort of those around the crying baby, not to
meet the fluctuating need of the baby.
"...Most
of your day will be fairly routine and predictable.
But there will be times when you may need more flexibility
due to unusual circumstances. Your life will be less
tense if you consider the context of each situation
and respond appropriately for the benefit of everyone.
Right parental responses often determine whether a
child is a blessing to others or a source of discomfort."
[1998, p. 117, 2001 p. 118]
None of the 4 examples of "flexibility"
given in the text deal forthrightly with the issue of
the baby's hunger, and the concluding paragraph (quoted
above) reinforces the idea that flexibility is not driven
by compassion for the baby, as would be normal and appropriate,
but out of consideration for others who might find the
sound of a crying baby to be a "source of discomfort."
"Sample
Schedule
Below
we have provided a sample schedule which can be personalized
for you and your baby. Remember the basic rule: feed
every 2 1/2 to 3 hours after the beginning of the
last feeding. Then the baby needs waketime, which
is followed by naptime. This work sheet is based on
eight feedings in a 24 hour period and is a guide
for your first six to eight weeks."
[Worksheet
with 8 fill-in blanks for feeding times.] [1998, p.
117-119, 2001, p. 118-120]
This powerfully communicates that
8 feedings a day is normal or even ideal. Yet 8 is actually
the fewest number of feedings in the normal range the
AAP recommends for newborn babies (8-12 on average).
"Phase
Two: Extended Night
Weeks
Nine through Fifteen
....By
the end of the thirteenth week, your baby should average
five to six feedings a day, but never less than four."
[1998,p 120, 2001, p. 121]
Editions prior to 1995 prescribed
4 feedings at this age. ("By the end of week thirteen,
your baby should be on four feedings a day if he isn't
already".) Be glad your baby wasn't born then! 5-6
or "never less than 4" feedings will be inadequate
for many babies. Most demand fed babies nurse much more
frequently than this. Mothers switching from PDF have
commented on how shocking it is to see how much more their
babies eat once they allow a more hunger-driven and less
schedule-driven approach.
"Phase
Three: Extended Day
Weeks
Sixteen through Twenty-four
Usually
between the sixteenth and twenty-fourth week, you
will introduce your baby to solid foods....By the
twenty-fourth week your baby's mealtimes should begin
to line up with the rest of the family's: breakfast,
lunch and dinner, with a fourth, fifth and for some,
a sixth liquid feeding at bedtime....As a breastfeeding
mother, try to maintain four to six feeding periods
as long as you are nursing. Any less may decrease
your milk supply." [1998, p 120-121, 2001, p.
121-122]
This experiment on how few
feedings a mother can give the baby without adverse
effect on her milk supply is still in progress. An earlier
edition declared: "As a breastfeeding mother, we
suggest you maintain these four feeding periods as long
as you're nursing--anything less may decrease your milk
supply." By 1998, Ezzo learned that 4 is too few.
My observation is that many mothers using the 1998 and
2001 editions also have trouble with milk supply. The
experiment is still in progress.
The American Academy of Pediatrics differs
with Ezzo on when to add solid foods to the diet of a
breastfed baby. The AAP states: "Exclusive breastfeeding
is ideal nutrition and sufficient to support optimal growth
and development for approximately the first 6 months after
birth....Gradual introduction of iron-enriched solid foods
in the second half of the first year should complement
the breast milk diet." Later introduction is especially
preferable for babies at risk for allergies. It's been
observed that mothers who use PDF may turn to solid foods
earlier than 6 months in order to make up for a diminishing
milk supply.
Phase
Four: Extended Routine
Weeks
Twenty-five through Fifty-two
Between
the ages of six months and twelve months, your baby
will continue to be fed on three meals a day. Each
meal is supplemented by baby food with an optional
fourth liquid feeding before bed....Continue with
four to five nursing periods during the day....The
process of moving a child to three meals a day should
be nearly completed by the beginning of this
phase....plus a fourth nursing period just before
bed. [1998, p121,122]
Most breastfed babies nurse quite
a bit more often at this age than 4-6 times a day.
The following quote shows the
changes to this section in the 2001 edition of Babywise
(which are offered without apology or explanation):
Phase
Four: Extended Routine
Weeks
Twenty-five through Fifty-two
Feeding
times continue the same between the ages of six to
twelve months. By now each meal will include a liquid
feeding, breast or bottle, and should be supplemented
by baby food with an optional fourth or fifth liquid
feeding in the late morning, or mid afternoon, and
a required liquid feeding at bedtime....Continue
with four to five nursing periods during the day...Keep
tracking the healthy baby growth indicators during
the entire time and you and your baby will do just
fine....The process of moving a child to three meals
a day should be completed by the end of this
phase. [2001, p. 122-123]
Most breastfed babies nurse quite
a bit more often at this age than 4-6 times a day (still
the bottom line in spite of improvements.)
"...There
are some little ones whose internal clocks get "stuck"
at the nighttime feeding. Parental guidance can help
reset that clock. If
you have a digital timepiece and notice that your
baby is waking at nearly the same time each night,
that's a strong indicator that his or her biological
clock is stuck. To correct the problem, wait for a
weekend when no one has to get up early for work....
When your baby awakens, don't rush right in to him
or her. Any crying will be temporary, lasting from
five to forty-five minutes*. Remember, this will be
temporary! Some parents fear that failing to respond
right away will make their baby feel unloved or insecure."
(1998, p 123, 2001, pp 124-125)
*in 2001
the wording changes to: "five to possibly forty-five
minutes"
According to Ezzo's
theory that hunger has a metabolic memory which creates
the regular intervals of the routine, a hungry baby
would therefore be hungry at the same time each night.
But here parents are instructed to view it as an indication
that the baby is not hungry. Note also that Ezzo gives
specific approval to as much as 45 minutes of crying.
"....Sometimes
in the process of eliminating feedings, bending a
guideline may be necessary. If we assume your baby
[as young as two months old, in context] is on a 4-hour
schedule (6:00 A.M, 10:00 A.M., 2:00 P.M., 6:00 P.M.,
and 10:00 P.M.), and you think he or she is ready
to drop the last feeding, then instead of eliminating
the 10:00 P. M. feeding completely, try backing it
up fifteen minutes per day until you arrive at the
time you desire. For a while, your baby's last two
feedings of the day may be less than three hours apart,
which is permissable during this transition time.
The rest of the day's schedule may need to be adjusted
so that you end up with a new 4-hour format which
looks like this: feedings at 8:00 A. M., 12:00 P.M.,
4:00 P.M., and 8:00 P. M. (or whatever times best
suit your family.)" (1998, p. 124)
Again the assumption of
clock times and measured intervals rather than feeding
according to hunger.
The following quote shows the changes to the section
in 2001:
"When
your baby is ready [around three months of age] you
can eliminate the late evening feeding by gradually
adjusting your feeding times. If your late afternoon
feeding is around 6:00 p.m. for example, feed your
baby again at 9:30 p.m. for a couple of days. Then
feed him at 9:15 or 9:00 p.m. for a couple of days.
Continue gradually adjusting the time backward until
you reach your goal, whatever your goal is. Dropping
the late evening feeding will necessitate that your
baby's last two feedings of the day may be less than
three hours apart. That should not be a problem. Getting
that last feeding into your baby, even if it has been
only three hours, is important." [2001, p. 125]
Parents begin moving feedings closer--first
to 9:30, and then earlier, showing that the three-month
old baby in the example is on at least a 3.75, if not
a 4 hour schedule, though in this revision Ezzo does not
to say so directly. The improvement is that the feeding
is not actually dropped as in 1998, but merely moved to
a more convenient time.
"Your
baby's disposition can be happy and content when you
follow three basic rules for naps.
Rule 1:
Mom, not baby, decides when the nap starts.
Rule 2:
Mom, not baby, decides when the nap ends.
Rule 3:
If your baby wakes up crying or cranky, it's most
often because he or she has not had sufficient sleep.
Other factors to consider are a dirty diaper, a noisy
neighbor, sickness coming on, or an arm or leg stuck
between the crib slats." [1998 & 2001, p133]
In Ezzo's method, naptime
falls at the far end of the feeding cycle. (Feed--wake--sleep)
If the selected routine is not adequate, and baby awakens
with hunger pangs, these "rules" divert the
mother from the baby's real problem. Or, if the selected
routine is not adequate but the baby does sleep
throughout her nap, then her underfeeding situation may
go undetected and she may seem to be adapting to her schedule--until
a well-baby visit reveals her weight gain has stalled.
The 2001 edition addresses this elsewhere in the book.
Those quotes and comments on them are
found here.
"Principles
for Starting Late...General Guidelines
"Review
chapter 6, "Establishing Your Baby's Routine,"
to determine how many feedings are appropriate in
a 24-hour period, given your child's age. For example,
at three months of age your baby should be receiving
four to five feedings a day. If he or she is six months
old, your baby should be receiving three meals a day
with a nursing period or a bottle just before bed.
If you have been in the habit of rocking or nursing
your child to sleep at bedtim, now is the time to
eliminate that practice. [1998 & 2001 p. 210]
4-5 feedings a day will be inadequate
for many if not most breastfed babies and their mothers.
"2.
Review chapter 8, "When Your Baby Cries,"
and be prepared for some crying. You are moving from
a high-comfort style of sleep manipulation to basic
training in sleep skills. Initially your baby will
not like this change, but it is necessary. In moments
of parental stress, be comforted knowing your baby
won't feel abandoned because you have decided that
the best thing for him is learning how to fall asleep
on his own....[1998 & 2001, p. 210]
Throughout his books, Ezzo narrowly
interprets the baby's crying for the parent and also attributes
to the baby the ability to divine the parents' motives
and adjust his feelings accordingly.
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