Babywise Advice Linked to Dehydration, Failure to Thrive

 by Matthew Aney, M.D.

Expectant parents often fear the changes a new baby will bring, especially  sleepless nights. What new parent wouldn't want a how-to book that promises  their baby will be sleeping through the night by three to eight weeks?  One such book, On Becoming Babywise, has raised concern among pediatricians  because it outlines an infant feeding program that has been associated with  failure to thrive (FTT), poor weight gain, dehydration, breast milk supply  failure, and involuntary early weaning. A Forsyth Medical Hospital Review  Committee, in Winston-Salem N.C., has listed 11 areas in which the program  is inadequately supported by conventional medical practice.The Child Abuse  Prevention Council of Orange County, Calif., stated its concern after  physicians called them with reports of dehydration, slow growth and  development, and FTT associated with the program. And on Feb. 8, AAP  District IV passed a resolution asking the Academy to investigate  "Babywise," determine the extent of its effects on infant health and alert  its members, other organizations and parents of its findings.

I have reviewed numerous accounts of low weight gain and FTT associated with  "Babywise" and discussed them with several pediatricians and lactation  consultants involved. The book's feeding schedule, called Parent Directed Feeding (PDF), consists  of feeding newborns at intervals of three to three and one-half hours  (described as two and one-half to three hours from the end of the last  30-minute feeding) beginning at birth. Nighttime feedings are eliminated at  eight weeks.

This advice is in direct opposition to the latest AAP recommendations on  newborn feeding (AAP Policy Statement, "Breastfeeding and the Use of Human  Milk," Pediatrics, Dec. 1997): "Newborns should be nursed whenever they show  signs of hunger, such as increased alertness or activity, mouthing, or  rooting. Crying is a late indicator of hunger. Newborns should be nursed  approximately eight to 12 times every 24 hours until satiety."  Although demand feeding is endorsed by the Academy, WHO, and La Leche League  among others, "Babywise" claims that demand feeding may be harmful and  outlines a feeding schedule in contrast to it. The book makes numerous  medical statements without references or research, despite that many are the  antitheses of well-known medical research findings. In 190 pages, only two pediatric journals are referenced with citations dated 1982 and 1986.

Many parents are unaware of problems because the book is marketed as  medically supported. It is co-authored by pediatrician Robert Bucknam, M.D.,  who not only states in the book that the "Babywise" principles are  "medically sound," but also writes, "'Babywise' has brought a needed  reformation to pediatric counsel given to new parents." Obstetrician Sharon  Nelson, M.D., also warns: "Not following the principles of "Babywise" is a  potential health concern."  The book's other author is Gary Ezzo, a pastor with no medical background.  Ezzo's company, Growing Families International (GFI), markets the book as  "ideally written" for "obstetricians, pediatricians, or health-care  providers to distribute to their patients." (GFI promotes the same program  under the title "Preparation for Parenting," a virtual duplicate with added  religious material).

Though "Babywise" does say, "With PDF, a mother feeds her baby when the baby  is hungry," it also instructs parents to do otherwise. In a  question-and-answer section, parents of a 2-week-old baby, who did not get a  full feeding at the last scheduled time and wants to eat again, are  instructed that babies learn quickly from the laws of natural consequences.  "If your daughter doesn't eat at one feeding, then make her wait until the  next one."  Unfortunately, the schedule in "Babywise" does not take into account  differences among breastfeeding women and babies. According to one report,  differences of up to 300 percent in the maximum milk storage capacity of  women's breasts mean that, although women have the capability of producing  the same amount of milk over a 24-hour period for their infants, some will  have to breastfeed far more frequently than others to maintain that supply.

Babies must feed when they need to, with intervals and duration determined  according to a variety of factors in temperament, environment, and  physiological make-up. Averages may fit into a bell-shaped curve, but some  babies will require shorter intervals. (Daly S., Hartmann P. "Infant demand  and milk supply, Part 2. The short-term control of milk synthesis in  lactating women." Journal of Human Lactation; 11; (1):27-37).
Examples of the many other unsubstantiated medical claims in "Babywise"  include:  "Lack of regularity [in feeding intervals] sends a negative signal to the  baby's body, creating metabolic confusion that negatively affects his or her  hunger, digestive, and sleep/wake cycles." "Demand-fed babies don't sleep  through the night." "A mother who takes her baby to her breast 12, 15, or 20  times a day will not produce any more milk than the mom who takes her baby  to breast six to seven times a day." "Mothers following PDF have little or  no problem with the let down reflex, compared to those who demand-feed."  "Colic, which basically is a spasm in the baby's intestinal tract that  causes pain, is very rare in PDF babies but is intensified in demand-fed  babies." "In our opinion, much more developmental damage is done to a child  by holding him or her constantly than by putting the baby down. In terms of  biomechanics alone, carrying a baby in a sling can increase neck and back  problems, or even create them." "Some researchers suggest that putting a  baby on his or her back for sleep, rather than on the baby's tummy, will  reduce the chance of crib death. That research is not conclusive, and the method of gathering supportive data is questionable."

My review of the low  weight gain and FTT accounts associated with "Babywise" revealed several  disturbing trends. Parents were often adamant about continuing with the  feeding schedule, even when advised otherwise by health care professionals.  They were hesitant to tell their physicians about the schedule, making it  difficult to pinpoint the cause for the weight gain problems. Many elected  to supplement or wean to formula rather than continue breastfeeding at the  expense of the schedule. The parents' commitment can be especially strong  when they are using the program for religious reasons, even though numerous  leaders within the same religious communities have publicly expressed concerns.

Pediatricians need to know about "Babywise" and recognize its potential  dangers. History taking should include questions to determine if parents are  using a feeding schedule, especially before advising formula supplement to  breastfeeding mothers or when faced with a low-gaining or possible failure  to thrive baby. Lactation consultants also should be instructed to probe  this area. Efforts should be made to inform parents of the AAP recommended policies for  breastfeeding and the potentially harmful consequences of not following  them.

Dr. Aney is an AAP candidate fellow based in Lancaster, Calif.

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