Quotes are from On Becoming Babywise by Gary Ezzo and Dr. Robert Bucknam, published by Multnomah, ©1998.
Let's begin: "With PDF, a mother feeds her baby when he is hungry."
p 38
Early in the book, statements like this refute concerns about the program, making it sound like the baby will be fed in response to hunger cues, as recommended by the American Academy of Pediatrics. But the meat of the book directs parents to observe clock times and clock-based intervals instead of hunger cues, as in this next quote:
"Babies learn very quickly to become snackers if you let them. If your [in context, 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" (pp175-176).
Feeding cues that occur more frequently than every 2.5 hours are portrayed negatively, and parents are instructed to observe the clock instead. The truth is that young babies often need to nurse at least every 2 hours. This is a positive situation and helps establish a strong and flexible milk supply as well as meeting the needs of a fast-growing newborn.
"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...." (p. 48)
Above, Ezzo articulates Babywise's central, unsubstantiated theory: when fed on a schedule, the baby's feeding requirements adapt and conform to the pattern imposed. This theory runs counter to the physiologically determined processes that regulate breastmilk supply. This passage reinforces scheduled clock times and feeding intervals instead of encouraging parents to observe hunger cues, and presents unsubstantiated medical "facts".
"Fact Three
"It is not what goes in the mouth as much as when it goes in." (p. 48)
"When the feeding occurs, not what the feeding consists of, has much more to do with baby's healthy sleep...." (p. 49)
Above, Ezzo dismisses breastmilk's quick digestive time or breastfeeding's physical processes as requiring frequent feedings. Instead, sticking to the approved times is reinforced and parents are reminded that this will achieve the sleep goals of the program.
"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." (p. 74)
Again, feedings are presented according to time interval. The AAP notes that newborns typically nurse between 8 and 12 times a day. Ezzo notes that his recommendations provide access to the bottom edge of the normal range, showing he's either not afraid of playing with fire or that he completely misunderstands the AAP on this point--more on that in a minute.
It's true that babies often nurse less frequently as they get older, but their hunger is influenced by the size of their stomachs, their metabolism, activity level, growth spurts, mother's breast milk storage capacity, the heat or dryness of their environment, illness coming on, etc.
The AAP says the best schedule for the baby is the one they set themselves, and that mothers should nurse the baby on demand. They observe that this typically results in 8-12 feedings daily. Awareness of the normal range allows parents and doctors to identify feeding patterns that may indicate a problem. Assigning the baby a number of feedings at the low end between 8 and 12 is not the intention 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..."p. 74
Ezzo presents an unsubstantiated medical statement (about normal nursing intervals that are associated with successful breastfeeding wearing mother down) and urges compliance with his schedule through scare tactics.
"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." (p.114)
"...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."
This guides the mother toward observing the proper interval, not the baby's hunger. This quote also illustrates Ezzo's attitude toward flexibility. Ezzo assumes that his schedule IS basically adequate, and sooner or later must be returned to--preferably sooner.
"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.
The mother in this example is presented as living according to the very sort of rigidity that is so often said not to be a part of this program. The example exhorts the parents to feed the baby for the sake of adults in earshot of the crying 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." (p.116-117)
None of the 4 examples on provided to illustrate situations that call for flexibility acknowledge hunger, and the concluding paragraph (quoted above) reinforces the point that flexibility is not for the baby but for bystanders who dislike the sound of a crying baby.
"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.] p. 117-119
A worksheet with 8 timeslots is a powerful cue to that 8 feedings a day is normal or ideal, when it is really at the bottom of normal for a healthy newborn baby.
"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." p 120
Earlier editions actually did prescribe 4 feedings at this age, and critics faced Ezzo's ire for mentioning how inadequate that was. Even though this edition adds a feeding or two, most normal breastfed 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, and consequently how much better their babies gain weight.
"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." (p 120-121)
This experiment on how few feedings a mother can offer without adverse effect 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 this 1998 edition 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. p121,122
Most breastfed babies nurse quite a bit more often at this age than 4-6 times a day.
"...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. (You may want to sleep in if your sleep is disturbed by your baby's crying during the night.) 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. On the contrary it's cruel not to help your child gain the skill of sleeping through the night...."
According to Ezzo's theory, hunger has a metabolic memory which creates the regular intervals of the routine, so babies would be hungry at the same time each night. But here this is treated as an indication that the baby is not really 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 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 permissible 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.)"
Again, feedings are presented according to clock times rather than hunger cues.
"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." 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" lead the mother away from properly interpreting the baby's problem. On the other hand, if the selected routine is not adequate but the baby does sleep throughout his nap, then his underfeeding situation may go undetected and he may seem to be adapting to his schedule--until a well-baby visit reveals his weight gain has fallen off.
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.
These numbers will be inadequate for most breastfed babies. They are also internally inconsistent and are probably a holdover from the previous edition which is also still in wide circulation.