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.