A Review of Babywise (2001 edition)

by Kathy Thile

By now, many people are aware that Babywise recommendations for infants from newborn to six months of age have been associated with problems like low milk supply, underfeeding, dehydration, failure to thrive, and depression in infants. 

Babywise author Gary Ezzo has reacted to these concerns by calling attention to statements in recent editions of Babywise that are similar to advice from the American Academy of Pediatrics, such as:

These commendable ideals are stated at various points in Babywise. It is encouraging that the authors have chosen to highlight recommendations similar to those of the American Academy of Pediatrics.

Unfortunately, throughout the book, other statements and advice are in direct conflict with these ideals and sometimes even undermine them. At these points, Babywise differs from the evidence-based recommendations of the American Academy of Pediatrics. It is the differences, and not the similarities, that have been widely criticized by experts in infant feeding and child development.

The Author's Qualifications

Babywise's main author, Gary Ezzo, has no expertise in the care of infants. He has a master's degree in ministry and is the father of two adult daughters who are presently estranged from him. His co-author, Dr. Robert Bucknam, is a pediatrician. Fresh out of residency, he contributed the foreword to the original self-published Babywise (c. 1993). The rest of the book's content was drawn from an earlier infant care manual that Gary Ezzo and his wife, Anne Marie -- authored in the late 80's for use in church-based parenting classes. Anne Marie Ezzo worked as a nurse for two or three years in the 70's.

The presence of conflicting and contradictory information within Babywise may be seen charitably as the result of a layman's attempt to combine two inherently conflicting approaches: feeding the baby in response to his hunger cues as recommended by the AAP on the one hand, and the parent-directed, evenly-spaced feedings that Ezzo has promoted over the years on the other.

In recent revisions, Ezzo has obviously labored to find rhetoric to bring the two concepts together on paper, but in practice, they are uneasy bedfellows.The successful combination is further hampered by Babywise's moral subtext of parental authority versus permissiveness. Simple decisions about feeding young babies and putting them down for naps are laden with moral significance as one path is portrayed as the way of firm guidance and another the way of reckless overindulgence and permissiveness.

Double Messages

Dr. Barbara Francis, a Christian psychologist who evaluated Gary Ezzo's parenting curricula several years ago, observed that the work was difficult to analyze due to "many double messages inherent in the presentation:"

"There are often two opposing, mutually exclusive requirements of parenting behavior; what might be strongly stated on one page is refuted on another." "This inconsistency not only produces confusion, but also allows for literal justification of both sides of often-mutually exclusive concepts; one can simply "prooftext" to justify either side." (1)

Dr. Francis's observations are as true of the current edition of Babywise as they are of the religious editions she evaluated. Commendable and quotable statements in harmony with the AAP's advice can be found nearly side-by side with advice and information that undermines and conflicts with it.

Compare these messages all found within the pages of Babywise:

Responding promptly to a newborn's hunger cue is a central part of "Parent Directed Feeding" (p. 64)	"Erratic feeding periods" determined by the baby are emotionally and developmentally harmful (p. 42, 48).
The baby's hunger cues determine feedings (p. 112)	Parents must "regulate" the infant's hunger patterns through the use of predictable feeding cycles. (p. 47).
Responding promptly to the infant's hunger cues is portrayed positively as part of following Babywise. (p. 64)	Responding to the infant's cues is portrayed in negative terms on page 113: "without a routine, you are subject to the irregular needs of the child.” (p.113)
Parents should turn the clock around for the first week to ten days (p. 107)	"Day One" is the best time to start thinking about the baby's routine (p. 107)
Flexibility is basic to success in using Babywise. (p.109)	"During the critical first weeks of stabilization...too much "flexibility"...is viewed by a baby as inconsistency." (p. 109)
Hunger is "always a legitimate reason to feed in less than two hours' (p. 115),	Nursings every two hours or less can cause hunger rather than solve it. (p. 14, 68, 74).
The infant's hunger cues determine feedings	Parents should identify whether they personally prefer a disciplined, scheduled lifestyle or a more relaxed lifestyle. This will determine whether a "tighter routine for baby" or "feeding periods with some flex to them" will be established in their home. Either way, the book declares, "your baby soon learns to fit with your personal style." (p. 109)
"Hunger cues, not the clock, determine feedings" (p 112)	Hunger cues that are observed between scheduled feedings may be interpreted as a desire for a snack, and snacking should be discouraged. "If your baby increasingly becomes characterized by snacking, you must work on stretching the times between feedings to make the 2 1/2 hour minimum" (p. 175)
"Hunger cues, not the clock, determine feedings" (p 112)	If the baby isn't making it to the scheduled feeding time, eventually parents must "stretch" the time between feedings to conform to "the 2 1/2 hour minimum" (p. 175).
Babywise babies will sleep through the night "without disruption to lactation" (p. 49)	Establishing nighttime sleep patterns may "risk a challenge to long-term breastfeeding" (p. 64)
Babywise facilitates breastfeeding success . (p. 94)	Before their baby arrives, parents must determine whether the Babywise routine or breastfeeding is their highest priority, because in order to attain their goal, a tradeoff of one or the other may be required. (p. 64)

Emphasis on the Intervals

The AAP's feeding advice puts the emphasis squarely on the natural linkage between hunger and feeding. According to the AAP, mothers should nurse their babies whenever they show signs of hunger, and this will usually be about 8 to 12 times a day. Feeding cues in a newborn include increased activity, rooting, sucking motions or putting hand to mouth, and crying. (2) The AAP urges mothers, "not to wait until your baby is overly hungry before you breastfeed." (3) As a practical matter, it's much easier to coax a newborn to latch on when they are rooting and making sucking motions than when they are so hungry they're crying. Newborns will usually nurse at least every couple of hours around the clock. (4)

In Babywise, the weight of the feeding advice is not on the natural link between hunger and feeding, but on cultivating the proper intervals between feedings, the proper order of activities and the discipline of "full feedings." Instructions throughout the book refer to "the next scheduled feeding" and examples provided in the text link feedings to clock times.

Babywise even offers a worksheet with 8 fill-in-the-blank slots so parents can pre-plan the daily feeding times of infants over two weeks old in accord with the book's "general rule" for that age range of feeding every 2.5 - 3 hours (p. 119).

Problems attributed to "unevenly spaced feedings" are vividly described. These are purported to include delayed development (42), years of sleep dysfunction (44), confused memory and insecurity (48) insufficient RSP sleep (50), reduced milk supply (68), mother's body worn down (69), and extreme fatigue in the mother (74). Problems associated with not feeding often enough or not recognizing and reinforcing feeding cues are seldom, if ever, mentioned.

Meanwhile, the purported benefits of parent-directed, evenly spaced feedings are enumerated throughout the book, supported by an appeal to the contrasting experience of the two fictitious babies, Chelsea and Marisa, and by descriptions of the private, unpublished studies of the authors.

Hunger and Proper Feeding Intervals

"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...." (pp. 48-49 emphasis added)

 

According to Babywise, it all works out well because the baby's times of hunger will begin to line up with mealtimes.

However true to experience this patterning may be for many adults, for rapidly growing breastfed babies, hunger and feeding are much more dynamic processes that change in response to factors like growth spurts, fluctuations of milk supply, illness, thirst brought on by hot weather or dry indoor conditions, activity levels and so on. The infant's stomach size and gastric emptying rate, and the mother's breastmilk storage capacity and rate of milk synthesis also affect how often an individual baby needs to feed.

Babywise, however, connects the issue of feeding frequency to age:

"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....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." ( p. 74, emphasis added.)

This instruction allows for about 8 to 9.6 feedings per day. Targetting a subset at the low end of the normal range is setting some parents and babies up for failure or frustration--and is not an appropriate application of the AAP's discussion of a normal range of 8 to 12 feedings for breastfed babies.

Inadequate feedings past the newborn stage

“By the end of the thirteenth week, your baby can be average [sic] five to seven feedings a day, but never less than four.” (p. 121, emphasis added) "Between weeks twelve and fifteen, most babies go easily to a combination 3- to 4-hour routine and drop the late-evening feeding." (p. 123, emphasis added)

Experts continue to recommend demand feeding for this age group. The AAP indicates that once breastfeeding is well established, babies may take about 8 feedings a day, increasing whenever they need more milk. A recent study published in Pediatrics showed babies between one and six months old took an average of 11 feedings a day, plus or minus 3 feedings and the number of feedings did not change with age. (5)

Conflicting Messages about Flexibility

Babywise endorses flexibility, but the book takes particular care to define its usage, stating that returning to the original plan is "perhaps the most crucial element of flexibility" (p.109). The book does not advocate an open-ended approach to flexibility.

Warnings not to be too flexible pepper the material:

"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." (p 109, emphasis added)

 

"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. Extreme fatigue reduces her physical ability to produce a sufficient quantity and even quality of milk. Add post-partum hormones into the mix and it isn't any wonder some women simply throw in the towel....As stated, there will be times when you might nurse sooner than 2 1/2 hours, but that should not be the norm." (p. 74, 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." (p. 116, emphasis added)

These produce a double message: muted permission--it is "okay" to be flexible, you "might" feed sooner, but stern warnings not to overdo it. The feeding advice contained in the quotes above conflicts with advice from the American Academy of Pediatrics. Feeding more frequently is often desirable and does not, in and of itself, wear a woman down.

After defining flexibility with the emphasis on returning to the plan, the book provides four scenarios to illustrate the flexibility Babywise offers--and none acknowledge hunger.

For example:

"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!" (p. 117, emphasis added.)

The concluding sentence of the passage on flexibility observes that "Right parental responses often determine whether a child is a blessing to others or a source of discomfort." (p.118)

Nighttime Policies Redefine Feeding Needs

"Between seven and nine weeks, Chelsea's parents can expect her nighttime sleep cycles to be a continuous 7-8 hours. After three months of age, that time is extended to 9-11 hours each night." (p.47)

Dr. Richard Ferber, who directs the Center for Pediatric Sleep Disorders at Children's Hospital in Boston, commented: "Parents shouldn't expect babies to sleep that long that early, although a very few will on their own and in that case, you may sometimes need to actually wake them to feed them. There is no good evidence that babies that young can go that long without a feeding." (6)

Although Babywise portrays the baby naturally extending his nighttime sleep to seven or eight hours within the projected time frame, babies who continue to wake for feedings may find their cues redefined as a stuck biological clock, even if they cry for forty-five minutes:

"There are some little ones whose internal clocks get "stuck" at the nighttime feeding. Parental guidance can help reset that clock.... When your baby awakens, give him a chance to resettle. You really do not need to rush right in right away. Any crying will be temporary, lasting from five to possibly forty-five minutes. Remember, this will be temporary!" ( pp 124-125)

 

Naptime Policies Redefine Feeding Needs, Too

"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." (p. 133)

In the Babywise plan, babies are not fed before going down for their naps. Naptime occurs after a wake time which follows a feeding. (The cycle is feed, then wake, then nap--then the next feeding.) Thus, no matter how flexible parents are prepared to be, if hunger does emerge prior to the next feeding, it is likely to occur during the nap. A baby who is a sound sleeper might sleep through his hunger and appear to be adjusting to the naptime rules very well, although not gaining weight as he should. A light sleeper would cue his hunger, but the rules above would lead the parent to view the crying as a naptime battle.

The 2001 edition retained the naptime rules but apparently heeded warnings of critics who frequently observed this misinterpretation of hunger cues among Babywise users. The book now states that if the baby wakes and cries partway through the nap, parents should approach the situation as a hunger problem, and try feeding the baby (p. 144).

Unhelpfully, the same passage informs parents that the situation may indicate low milk supply or poor quality of milk, frets that without getting good sleep, the baby won't nurse proficiently, and blames a downward spiral involving these factors on the mother! She started the problem, the book explains, by misinterpreting an early waking from a nap as a sleep problem. Yet only ten pages earlier, the book itself stated:

"Remember, if your baby is waking up cranky or crying, he or she most likely is not getting enough sleep. Even though he or she may cry, your baby will probably go right back to sleep in ten minutes for another thirty to forty minutes of rest." (p. 134)

 

Crying Policies Redefine Hunger and Emotional Needs

Babywise differentiates "normal cry periods" from "abnormal cry periods" by stating that the latter always require prompt attention. In contrast, "normal cry periods" are those which are "normal and should be expected" (p. 145). Ezzo includes "just before feeding" among the list of "normal cry periods"

"Crying Just before Feeding. Under normal circumstances, any crying that occurs just before a feeding should be limited, since the next event for the baby is mealtime. If the baby is hungry, feed him or her." (p. 145)

Grammatical lack of clarity leaves open the question as to whether parents are to view this crying as a normal, expected part of the baby's pre-feeding routine which will end when feeding time comes--or whether parents should actively limit the crying. "If your baby is hungry, feed him or her" is reassuring on that score. Yet the previous sentence may cause some parents to hesitate. The baby might, after all, simply be having his normal, pre-feeding cry period.

Narrowly interpreting crying when parents retrain a baby to fall asleep in isolation, Ezzo writes:

"Don't feel the necessity to check on your baby every five minutes while he or she is crying....If you feel you must soothe the child, go in briefly and pat him or her on the back. With a soft voice, say, "It's all right," then quietly leave. As a result your baby will do one of two things: be comforted and fall asleep or roar even louder. If the baby chooses the latter, don't be discouraged! The crying only means he or she has not yet developed the ability to settle himself or herself." (pp. 210-211)

Ezzo consistently waves off concerns that lengthy spells of crying may be physically or emotionally or neurologically damaging--concerns that might be better addressed by professionals. Ezzo writes:

"Any crying is temporary, lasting from five to possibly forty-five minutes....Some parents fear that failing to respond right away will make their baby feel unloved or insecure....[it will not] leave your baby with a feeling of abandonment." (p. 125)

 

"When settling for a nap, crying for 15 to 20 minutes is not going to hurt your baby physically or emotionally. Your baby will not lose brain cells, experience a drop in IQ, or have feelings of rejection that will leave him manic-depressive at age thirty." (p. 131)

And believes that letting the baby cry brings a surprising benefit:

"Without knowing your child's cry patterns, you will always be second-guessing his or her real need. You will never know how long your baby's cry period should last." (p. 148)

Even further, Babywise warns of serious problems related to answering cries promptly:

"A child like Marisa has been conditioned to expect immediate gratification. What will happen to Marisa when her parents can no longer satisfy her immediately? What happens when a second or third child comes into the family? Think of the emotional trauma both Marisa and mother will endure....Now the child is emotionally fragile, rather than emotionally stable....Over time this parenting attitude creates negative propensities. These inevitably spill over into pretoddler and toddler development." (pp 140-141, emphasis added to remind readers the discussion is about young infants.)

Overall, Ezzo tends to narrowly interpret the reason for the baby's crying, pointing parents away from possible hunger and emotional needs, while attributing to the baby the ability to adjust his feelings according to his parents' motives.

"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." (p. 210)

It is ironic that this is framed as an effort to comfort the parents in their emotional distress.

The moral subtext

Babywise aspires to be more than a way to get your baby to sleep through the night at an early age. The problems of permissiveness and the value of parental authority form the subtext of the book's advice.

"On Becoming Babywise is more than an infant-management concept; it is a mind-set for responsible parenthood." ( p 17)

 

"Chelsea's parents understand that virtues must be nurtured into her tiny heart. The virtues are not inherent in her life or any new life. Therefore, Chelsea's parents must govern and monitor her until they are assured she bears the self-control and moral awareness needed to govern herself....They set the pace in Chelsea's life and insist on her compliance." (pp 19-26, emphasis added)

Chapter 1 establishes the idea that Babywise's plan supports marriage and builds character in the babies--setting "the pace and insisting on compliance", while demand feeding (which appears here under the name "child-centered parenting") endangers marriage. Marisa, the fictitious demand-fed baby is portrayed as suffering from her parents' dedication to giving her everything she demands. "This is devastating both to the family and to Marisa". (p 23-24)

"Is the parent's job simply to respond to an infant's demands? When, then, would this concept switch over to allow the parents to direct the child? Toddler years? Preteen or teen years? Hardly. By then you've missed the boat, and your child sails full speed ahead oblivious to fundamental skills like falling comfortably asleep alone. That's only the beginning." (p. 46)

Ezzo attempts to drive up the stakes, revealing confusion over basic issues of child development. Parents who rock their babies to sleep need not fear they'll need a larger rocking chair to continue the practice into the teen years. Feeding a baby in response to hunger cues is age-appropriate, as well as being the specific recommendation of the American Academy of Pediatrics, the American Association of Family Physicians, the Academy of Breastfeeding Medicine, and all other experts on breastfeeding management. But feeding a baby on demand does not tie parents' hands with respect to setting appropriate limits at older ages.

The AAP says the best schedule for the baby is the one he sets himself. (7) Ezzo criticizes the attitude of parents who go along with this: "Marisa's parents wrongly believe their baby should regulate her own routine and that their job is simply to respond" (p 46).

Double messages throughout the book, the inherent conflict between heeding the baby's feeding cues and setting parent-directed feeding intervals, as well as this subtext of authority as parental control over feeding all work against Babywise's occasional hat tips to the American Academy of Pediatrics' recommendations for breastfeeding.

Footnotes:

1. Barbara Francis, Ph. D., "Growing Kids God's Way?: A Critique of Growing Families International"
http://www.ezzo.info/Francis/index.htm. "These double messages...are used to support whatever argument necessary to answer criticisms of the overall model: 'Yes, but, it says right here not to be legalistic,' 'Yes, but the book specifically says there's a difference between scriptural principles and applications,' 'Yes, but the book warns you to feed your baby if she's hungry,' ... 'Yes, but it's people misusing the program, not the program itself.'"

2. AAP Policy Paper: Breastfeeding and the Use of Human Milk
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496
The AAP's advice to feed newborns whenever they cue hunger is immediately followed by the recommendation that non-demanding newborns should be awakened and fed periodically (advice mirrored by La Leche League and other experts who help mothers breastfeed). Babywise's straw man portrayal of demand feeding omits this fact, allowing Ezzo to portray demand feeding as dangerous, and his own option as the only safe alternative.

3. AAP Publication: Breastfeeding: Commonly Asked Questions
http://www.aap.org/pubed/ZZZORSNYKRD.htm?&sub_cat=1

4. AAP Publication: Common Concerns While Breastfeeding http://www.aap.org/pubed/ZZZ2PX7YKRD.htm?&sub_cat=1

5. Volume and Frequency of Breastfeedings and Fat Content of Breast Milk Throughout the Day
http://pediatrics.aappublications.org/cgi/content/full/117/3/e387 Pediatrics. 2006 Mar;117(3):e387-95.

6. "Getting Wise to Babywise" Katie Allison Granju, Salon, Aug. 1998
http://www.salon.com/mwt/feature/1998/08/cov_06feature.html

7. AAP Media Alert
http://www.ezzo.info/Aney/aapmediaalert.pdf