A new parenting book, co-written by a Louisville doctor, is stirring up controversy with its recommendation that nursing babies be fed on the parents' schedule. Breast-feeding experts across the country worry that On Becoming Babywise may be connected to slow weight gain in infants and may disrupt the important early bond that forms between a mother and child.
Standard medical practice, as endorsed by the American Academy of Pediatrics, the World Health Organization and lactation experts, among others, is that mothers demand-feed their infant--as they define it, to feed whenever the infant indicates he's hungry.
Though Babywise is co-written by a pediatrician, Dr. Robert Bucknam, many of its ideas first appeared in a religious right parenting program called Preparation for Parenting that was developed by Babywise co-author Gary Ezzo and his wife Anne Marie. Ezzo heads a Chatsworth, Calif.-based Christian ministry called Growing Families International, whose stated goal is to establish "a biblical mindset for parenting, a mindset that can be passed from generation to generation."
In Preparation for Parenting, the Ezzos recommend that to avoid exhausting days and sleepless nights, new parents should follow God's principles and instill a sense of order in their child from the day he is born--by ideally scheduling feedings every three hours. Babywise , which was published in 1995 by Multnomah Books, a Christian publishing house, gives the same advice as Preparation for Parenting, often using Prep's same sentences.
Babywise , however, contains no references to the Bible.
Critics within the Christian church have raised concerns about the Ezzos' programs since the early 1990s, but now more health professionals are taking note. At least 27 doctors have expressed concerns about Preparation for Parenting or Babywise to the American Academy of Pediatrics, the 53,000-member national association (of which Bucknam is a fellow) based in Elk Grove Village, Ill. And an Orange County (Calif.) child abuse task force recently recommended that parents not use any of the programs developed by the Ezzos for child-rearing. The task force concluded that the Ezzo parenting approach could harm a child's psychological and emotional development.
Both programs, however, are gaining in popularity. According to the Ezzos, Preparation for Parenting has worked for thousands of parents. And to date, Babywise has sold more than 120,000 copies, been translated into four languages, and is handed out by more than 200 physicians. With a cover boasting, "how 100,000 new parents trained their babies to sleep through the night the natural way," Babywise is increasingly being passed from parent to parent and finding its way into retail bookstores.
But while Prep and Babywise appear to work for many infants, health professionals say its schedule-feeding advice won't work for all infants. Breast-feeding experts warn that even attempting to schedule-feed too early, particularly in the baby's first two months, may limit how much breast milk a mother can produce--and therefore how much food her baby can get and how much weight he gains. The mother may then need to start supplementing with formula, which usually leads to the mother having to give up breast-feeding. If the low weight gain goes unheeded, however, the baby may eventually need to go to the hospital.
Low weight gain seen
Nancy Williams, a Santa Maria, Calif.-based certified lactation consultant and, for the last 16 years, a local leader for LaLeche League International (the Schaumberg, Ill. breast-feeding support organization), says that she is aware of at least 100 cases of low weight gain connected to the Ezzo programs. Williams and Kathy Nesper, president of Apple Tree Family Ministries, based in Artesia, Calif., along with three others, have amassed 60 first-hand reports of mothers following Prep or Babywise whose infants failed to gain weight adequately; several cases resulted in hospitalizations. These reports came unsolicited from such sources as lactation consultants, nurses and parents themselves. An additional 30 cases since 1991 have been seen directly by Katharine West, a Sherman Oaks, Calif. certified lactation consultant and home health nurse who has observed Prep for 10 years; and 10 cases have been reported by Kathleen Huggins, a nurse and the San Luis Obispo, Calif. author of the popular breast-feeding guide The Nursing Mother's Companion.
One additional case is that of Bonny Williams (no relation to Nancy), a Dayton, Ohio, housewife who tried to follow the Prep program in exclusively breast-feeding her fourth child, Isaac.
Starting a few days after Isaac's birth, Williams tried to space his feedings. Friends and relatives sometimes asked why she wasn't paying attention to Isaac's cries. And Williams remembers one night when Isaac cried for half an hour, yet she did not feed him. "I thought, 'He can't be hungry,'" Williams says. "He's got to get over it."
Everything seemed to be working well, though. "Isaac was taking such long naps," Williams says. By Isaac's fourth week, however, Williams sensed something was wrong. Her son was extremely thin. He had not yet regained his birth weight. Williams discarded Prep 's advice. She also left her pediatrician, who unfortunately was unconcerned by Isaac's low weight. Williams' new pediatrician was concerned, though--and sent Isaac to the hospital.
When Williams saw Isaac gobbling down formula in the hospital, "It was obvious that he hadn't been getting enough food," Williams says. Within 24 hours, Isaac gained a full pound.
Isaac spent a few days in the hospital. And with the help of a dedicated lactation consultant, Williams was able to breast-feed Isaac again (though she did need to supplement with formula). This time, Williams fed Isaac whenever he was hungry--and didn't worry about what time he was last fed.
One cannot conclude that Prep or Babywise are causing low weight gain in infants. Doctors agree on many reasons why some breast-fed infants may fail to gain weight: for example, infants may have a weak suckling reflex or may have an underlying medical problem; or mothers may innately be unable to produce enough milk. To state a cause-and-effect relationship involving Prep or Babywise would require scientific studies such as clinical trials.
And though the authors write that parents should not use their programs rigidly and should certainly feed hungry infants, critics charge that the programs are nevertheless being used inflexibly--possibly because of the books' inflexible tone.
Gary Ezzo has previously said that if a baby on the Prep program is having problems, it must be because parents did not closely follow the program or for medical reasons.
He declined to be interviewed by Boulder Weekly , citing a busy schedule. Through a secretary, he referred BW to Bucknam, who said that neither he nor Ezzo would cooperate "in anything that attempts to make Babywise look controversial, because Babywise is not controversial." But Bucknam did discuss Babywise briefly with BW , volunteered evidence and replied by fax to faxed questions.
To critics' charges that Babywise may be causing low weight gain in infants, Bucknam says, "People from LaLeche League International claim that babies won't gain weight well. That's all lies. Our recommendations are typical among pediatricians."
A body of opinion
Babywise 's advice to schedule breast-feeding appears far from typical, however.
"The infant should direct the feeding. It should not be a scheduled event, particularly early on," says Dr. Lawrence Gartner, a professor of pediatrics, obstetrics and gynecology at the University of Chicago. As chair of the American Academy of Pediatrics' working group on breast-feeding, Gartner is one of the country's leading breast-feeding experts. "Trying to force a schedule on a child will likely interfere with effective breast-feeding," he adds. Gartner says his opinion is shared by a "huge majority" of pediatricians.
In the American Academy of Pediatrics parenting guide, Caring for Your Baby and Young Child: Birth to Age 5 (Bantam, 1994), a 600,000-copy seller worked on by more than 70 doctors, the academy writes: "What's the best feeding schedule for a breast-fed baby? It's the one he designs himself. Your baby lets you know when he's hungry .Whenever possible, use (your baby's signals) rather than the clock to decide when to nurse him."
In a section on bottle-feeding, the academy writes: "As we mentioned in the section on breast-feeding, it's initially best to feed your newborn on demand, or whenever he cries because he's hungry."
In a joint 1989 statement, the World Health Organization and the United National Children's Fund wrote that one step to successful breast-feeding is to "encourage breast-feeding on demand."
At least three leading handbooks on breast-feeding--The Nursing Mother's Companion, The Complete Book of Breastfeeding and Breastfeeding Your Baby --explicitly advise against schedule-feeding your newborn. Trained lactation consultants and LaLeche League leaders also say breast-feeding mothers should demand-feed infants and not schedule-feed them.
"We've known for years that the best way to develop a long-term milk supply is to allow the baby to nurse as often and as long as he indicates he needs to nurse," says Williams, an internationally board-certified lactation consultant (otherwise known as IBCLCs). Because of their extensive experience, these lactation consultants are considered greater breast-feeding experts than most doctors. Very few doctors even see an actual breast-feeding demonstration during their residencies, according to a University of North Carolina survey. IBCLCs, on the other hand, have at least 2,500 hours of professional experience in breast-feeding counseling and must pass a qualifying examination.
According to Williams, a mother who tries to adhere to a schedule may not feed her baby frequently enough. Thus, she may have a good early supply of milk that runs out fairly quickly. With women following an Ezzo program who consulted with Williams, "Their milk was diminished within five months or earlier," she says. "That's virtually unheard of in mothers who are demand-feeding."
Trying to schedule-feed defies the breast's basic physiology, Williams says. With breast-feeding, supply adjusts to meet demand. The more a baby's suckling stimulates the mother's nipple, the more breast milk is produced. Studies have shown that frequent feedings (of 10 times a day) result in larger weight gains than feeding seven times a day.
But the big reason schedule-feeding doesn't always work, Williams says, is that it ignores basic differences among mothers in milk capacity and differences among infants. Given all of these variations, it's difficult to trust that schedule-fed infants are getting enough food when, at the same time, breast milk is rapidly digested and a newborn's stomach is only the size of a walnut, she says.
All of the advice against schedule-feeding contradicts that given by Ezzo and Bucknam, who write in Babywise : "The infant who is (breast-fed) on a basic three-hour routine will demand more milk, thereby stimulating greater milk production as compared to the child who feeds more often but demands less." Demand-fed babies only receive partial meals, or "snacks," which causes them to feed more often, while parent-directed-fed babies have more complete meals, Ezzo and Bucknam write.
"The experts say one thing," Williams says. "Ezzo and Bucknam say another."
Williams' breast-feeding expertise has been recognized by Gary Ezzo himself. In 1993, Ezzo asked Williams to provide breast-feeding advice to the fourth edition of Preparation for Parenting . In asking for Williams' help, Ezzo admitted (according to Williams) that neither he nor his wife had read any book or journal article on human lactation, but that God's truth stood apart from the information in those texts. Williams turned down Ezzo's offer. "We were worlds apart," she says.
Babywise credits no one as the book's primary lactation expert. Bucknam says he was not at liberty to give her name. "But, yes, she is certified and highly regarded in her area of expertise," he adds.
As evidence that Babywise works, Bucknam points to satisfied parents. Bucknam also says that University of Virginia and University of Arizona research, soon to be published in major medical journals, will support Babywise 's principles. (When asked twice, Bucknam would not divulge the names of the principal researchers or the journals where this research will be published.)
To show that Babywise is consistent with standard medical knowledge about infant feeding and sleeping patterns, Bucknam provided Boulder Weekly excerpts from pediatric textbooks and American Academy of Pediatrics guidelines. According to these excerpts, newborns usually establish a feeding routine of every three to four hours, on average. But none of the texts specifically recommended that healthy infants be schedule-fed at these average intervals.
Bucknam says many pediatricians, certified lactation consultants and other medical professionals served as advisers to Babywise , among them Dr. Eleanor Womack, a former professor of cardiology at Harvard University. But with the 198-page Babywise providing just three citations of medical evidence (the most recent being a 1986 study) to support its far-ranging medical claims, the question arises whether Babywise is based less on prevailing medical knowledge and more on Gary Ezzo's interpretation of the Bible. When directly asked whether the support for Babywise 's principles came primarily from medical literature or from the Bible, Bucknam replied, by fax: "I know of no reference in the Bible which addresses infant feeding, sleeping, or growth."
Ezzo, a pastor of family ministries for 10 years, started Growing Families International with his wife, Anne Marie, in 1986. Together the Ezzos have created a birth-to-college parenting series that is taught in more than 3,500 churches and in 34 countries.
For groups like GFI, the battle for the family has taken on particular importance in the 1990s, as the vast political gains that the Christian right anticipated in the late 1980s have failed to materialize. In the GFI catalog, the Ezzos state their hopes in the ministry's fifth and final goal:
"We desire to capture the hearts and minds of the next generation. it takes two generations to affect change. We gave the last over to the ideological humanists; they have our tax dollar and the public classroom to bring about their agenda. We cannot collectively capture the minds of the next generation without educating the minds of today's parents. Establishing a biblical mindset for parenting, a mindset that can be passed on from generation to generation, is our fifth goal."
Like many Christian right parenting groups, the Ezzos strongly emphasize that God is a God of order--best demonstrated by the orderly way in which he created the world in the book of Genesis. The Ezzos also believe that children are born in sin, and only in homes where parents maintain order and authority can children grow up with strong morals and a strong love of God.
The Ezzos' materials have been well-received by Christians frightened by the moral decay they perceive in today's society: high divorce rates among adults, teen pregnancies and gang violence, for example. The Ezzos attribute such moral chaos, in part, to non-structured parenting styles, first championed by Dr. Benjamin Spock, in the 1950s, that moved the parenting pendulum away from maintaining parental authority and more toward serving children's needs.
Thus, Babywise explicitly warns against attachment parenting, or "child-centered," practice, such as sleeping in the same bed as your infant or carrying around your infant in a sling ("You are not a marsupial, and your baby should not be treated like a kangaroo joey!"). Continuing in this parenting vein may lead to "teenage rebellion and broken families," Babywise notes.
In their parenting books, the Ezzos suggest many methods for establishing order in the family. As one means of keeping older children in line, for example, the Ezzos suggest corporal punishment (using a firm rubber stick). The Ezzos also teach that toddlers may require a swat on the hand to learn not to play with their food.
Their most controversial belief, however, is that, from a child's first week of life, parents must establish a routine of scheduled feedings and sleep. To get infants feeding roughly every three hours, parents should simply follow common sense, Ezzo and Bucknam write. Instead of feeding a baby whenever he cries, parents need to properly assess the cry. After all, the baby might not be crying because he's hungry, but because he's tired, because his diaper needs to be changed or because he's sick, among other reasons.
"Certainly, we do not advocate just letting a hungry baby cry without being fed," Bucknam says.
In other passages, Bucknam and Ezzo write that parents should be flexible: for example, a mother may feed a crying baby on a plane, regardless of when he was last fed, so not to disturb other passengers. In addition, both Babywise and the latest edition of Preparation for Parenting contain chapters that teach parents how to track their infant's weight gain; with this information parents are supposed to be able to spot if their infants are running into trouble. For these reasons among others, neither Prep nor Babywise can be blamed for any problems in infants, Ezzo and Bucknam have said.
"My first goal as a pediatrician is to ensure a healthy, thriving child," Bucknam says.
A question of flexibility
But critics like Nesper and Williams say that from the cases they've been informed about, many parents are not being as flexible as they need to be in following the instructed routine. At the same time, these parents are missing or ignoring signs of low weight gain. One reason, the critics say, may be that the few passages urging parents to be flexible are overwhelmed by the overall tone of the Ezzo books, which tends to be inflexible and judgmental. For example, Babywise states:
- A demand-feeding mother "in a sense is in bondage to her daughter's unpredictability."
- "How tragic. With all sincerity and unmatched sacrifice, (demand-feeding) mothers, in hopes of meeting every need of their psychologically fragile child, too often create such a child."
- "Demand-fed babies don't sleep through the night." Yet in reality, few demand-feeding mothers feed their babies at every cry (or sometimes, as the authors write, "three times within twenty minutes"). And according to the American Academy of Pediatrics book, parents should expect demand-fed babies to fall into a routine on their own--without needing the help of a parent-directed schedule. The academy writes: "As time passes (your newborn will) begin to develop a fairly regular timetable of his own. As you become familiar with his signals and needs, you'll be able to schedule his feedings around his routine."
Many parents have used Babywise flexibly and deemed it successful. Jennifer Wilger of Lafayette, Colorado, says her son Micah was sleeping through the night by 5 1/2 weeks and seems "so well-adjusted so early." At the same time, Wilger was able to breast-feed Micah for his first year without having to supplement with formula. Since then, Wilger and her husband have taught a Preparation for Parenting class at their church. "As first-time parents, it was good to have guidelines," Wilger says. "But we were flexible in using them. We allowed the principles to serve us, rather than having us serve the principles."
Babywise does appear to work for a large number of breast-fed babies, generally those with birth weights above eight pounds, says Katharine West. Babywise also may work fine for formula-fed babies because formula takes longer for babies to digest and because mothers can monitor how much food their babies are getting, Williams says.
But Williams says many women are giving up breast-feeding prematurely after trying to follow Prep or Babywise , believing they are not "milk-sufficient," as Ezzo and Bucknam express it. And that saddens her. Breastmilk is so universally recognized as being superior to formula (as Ezzo and Bucknam note in Babywise ) that mothers will want to avoid supplementing with formula unless they truly need to.
The psychological effect
Williams also believes mothers are hurt psychologically when they think they are milk-insufficient. "It leaves women believing they are inadequate at providing milk for their children, and consequently, leaves them feeling inadequate in general," Williams says. "It's not a great start to their mothering careers."
It is not only the mother who can suffer emotionally. A member of the Orange County (Calif.) child abuse task force wrote (in May 1996) about Prep and other Ezzo parenting programs: "The issues of control and authority seem to override the elements of compassion, child advocacy and real developmental needs."
Margie Deutsch, who has a master's degree in early childhood education, also wrote: "Setting routine at birth without taking into account the individual needs of the baby may set up conflict and the inability for communication to occur between parent and child."
By responding to their infant's needs, parents teach their child that she can trust them. This builds an important foundation for their relationship, according to leading child development thinkers such as Erik Erikson and T. Berry Brazelton. Yet Babywise , by teaching a mother to cautiously assess every cry, may "harden her heart and turn her ear" and cause her to miss many cries of need, says Marvin Warman, a Burbank, Calif. marriage and family therapist, as well as an ordained minister.
"The child's basic trust in his parents is undermined, and a distance between them is created," Warman adds. "So how does that child learn to trust God when his earliest needs are not met by his parents--who are supposed to be reflections of God?"
Division among Christians
Though GFI's materials are based upon the Bible, not all Christians agree with Ezzo's teachings. The "vast majority" of family ministers attending a national conference last year said they wouldn't teach Preparation for Parenting or any Ezzo materials in their churches, according to Doug Haag, associate pastor of family ministries at the Evangelical Free Church of Fullerton (Calif.). And the Colorado Springs organization, Focus on the Family, started by James Dobson, the Christian parenting leader and Dare to Discipline author, states in a position letter about the Ezzo parenting programs: "We do not recommend this material to our constituents."
Many theologians find Ezzo's interpretation of the Bible misguided--starting with the Ezzos' own admission in Preparation for Parenting that "when it comes to method of feeding, the Bible is silent."
"If the Bible is silent, why did the Ezzos write entire books on infant feeding?" asks Haag, who wrote a theological analysis of Prep for the Orange County report.
While agreeing with much of what the Ezzos draw from Scripture, Haag nonetheless believes Preparation for Parenting is an exercise in "proof-texting." That is, Haag believes the Ezzos approached the Bible with their own ideas about parenting and looked for particular verses that seemed to support their point-of-view.
Regardless, many churches teach Preparation for Parenting and other Ezzo programs. But too often, these programs are taught as God's only way to parent--and create divisions within many churches, Nesper says. "Many people have been made to feel they aren't committed Christians because they disagree with the Ezzos' ideas or have chosen to parent in a different way," Nesper says. "For many Christians, this is very offensive and very hurtful."
Publicly, the Ezzos have vehemently attacked critics of their programs, perhaps because they believe they are teaching God's way. After ABC News aired a July 1996 report containing criticisms of Preparation for Parenting , Gary Ezzo posted a response on GFI's Web site titled "The War Against Moral Truth," where he wrote: "The people who set (media) stories in motion are not motivated by virtue but pride, popularity, and most importantly, ratings .Secular media is decidedly anti-God and anti-God's people." (Ezzo failed to mention that everyone interviewed in the ABC piece, as well as the ABC reporter, were evangelical Christians.)
Similarly, Ezzo has launched largely ad hominem attacks against two Christian periodicals, Christianity Today and World magazine, that published articles critical of Prep . Ezzo has also personally attacked attachment-parenting advocates such as Dr. William Sears, the Christian author of more than 24 parenting books, and LaLeche League International, the mother-to-mother breast-feeding support organization started by Catholic women in the 1950s.
"I'm embarrassed that you should have to see this," Williams, a devout Christian and the wife of a Baptist pastor, told Boulder Weekly . "I wish that the flaws to this program could have been worked out within the church, as within a family, rather than in the public arena."
In personal discussions with the Ezzos, Williams and West have civilly expressed their breast-feeding concerns. So far, their discussions have resulted in the chapters on tracking weight gain and a reduction in the programs' feeding intervals (in earlier editions of Prep , it was four hours). Yet the core philosophy of schedule-feeding remains, as well as the programs' inflexible tone, Williams and West say.
Many Christians hope that the Ezzos and Bucknam will patiently examine the specific criticisms of their programs and stop the personal attacks. "I don't question the Ezzos' commitment to their faith. I don't question their good intentions," Nesper says. "But I don't think they've been as careful as they need to be."
In painting other philosophies to extremes, the Ezzos and Bucknam miss what they share in common with their perceived ideological enemies. Every demand-feeding mother wants routine. Every demand-feeding mother wants a sense of order. But for these mothers, that order arises as they come to understand their babies' particular needs.
For new parents, adjusting to a newborn can be unsettling. But in seeking advice on how to feed your infant, the American Academy of Pediatrics recommends the following in its book: "The most important thing to remember, whether you breast-feed or bottle-feed, is that your baby's feeding needs are unique. No book can tell you precisely how much or how often he needs to be fed. You will discover these things for yourself as you and your baby get to know each other."
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