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:
"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."
"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."
- 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.
- 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.
- 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."
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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."
- 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.
- 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?
- 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.
Laurie Moody is the mother of 4 children and a certified lactation counselor.