Approaches to Infant Feeding
From Volume 3 Issue 4 of Unless the
Lord ... Magazine
Breastfeeding vs. Formula
There was a period in the mid-1900s when breastfeeding was really "out of style" in America. The "modern" way was formula / bottle feeding. Feeding formula decreased the frequency of feedings, and allowed fathers, older children and babysitters to feed the baby. This made it much easier for women to leave their babies with sitters, whether to join the workforce or to just enjoy more social functions and cultural events. Besides, it was also thought that breast feeding would damage the woman's figure. Breast feeding was also looked down upon as somewhat "primitive." So with assurances that formula was healthy for their babies, a high percentage of young mothers began to bottle feed.
With the passing of a few decades, it became well established that infant formula did NOT measure up to mother's milk. There were many more allergy problems and there was more sickness. It was found that mother's milk provided a great deal of immunity to young babies until they could develop their own immunity to sicknesses. Mother's milk was perfectly suited to the digestive and growth needs of baby, unlike what men had been able to formulate.
So there was a return by many to breastfeeding. Besides the health of the infant, benefits were also found for the mothers (a special "bonding", a relaxation effect, a natural delay in the return of fertility, less risk of future breast cancer, etc.). Of course bottle and infant formula would continue to be used by many, either for convenience or from necessity. Mothers working outside the home had little option but to have their babies bottle-fed while they were away from home. At other times, a mother would be unable to breastfeed because of a physical problem or because of sickness. In these instances, bottle feeding became the best option available.
Today there is almost universal agreement that breastfeeding is best for both infant and mother, under normal circumstances. This is especially so in the early months of life. Many mothers nurse their babies for at least 3-6 months. Some continue to nurse until the child is 1 or 2 years old, or until the child naturally weans hisself. Others after some months of nursing, switch to bottle feeding first with infant formula and later with cow's milk (or sometimes goat, soy or rice milk), until the child is ready to give up sucking and drink from a cup. The medical experts indicate that nursing longer is best, but to a decreasing degree with the passage of time. Particularly between one and two years, the benefits seem fairly small and many children lose much of their interest in nursing.
The Chief Controversy
The real controversy today about infant feeding concerns feeding "on demand" or "by schedule". The La Leche League played a prominent role in making breastfeeding popular again. Some of the top experts on breastfeeding and nursing problems have come from this organization. Highly experienced lactation consultants are often considered the greatest experts on breastfeeding babies. The La Leche League teaches mothers to feed upon "demand", in other words, when the baby cries for food or otherwise shows signs of hunger or needing to suck. Many prefer to label this approach as feeding "on cue", meaning simply that they pay attention to the baby's cries, rooting, sucking its fists, etc. to determine whether baby is hungry. If the mother believes the baby is hungry, she feeds him, even if he nursed just a short time before.
In contrast, feeding on schedule regulates baby's feeding times based on specific time intervals between feedings. The recommended intervals increase with age, or start closer together for a premature baby, etc. Feeding by a schedule gained popularity when bottle feeding became very popular. When feeding formula with a bottle, there is no issue of needing to maintain or increase the mother's supply of milk as the baby grows and baby becomes hungry less often as the formula digests more slowly in the baby's stomach. Feeding by schedule is much more convenient for the mother.
In 1987, a new variation on schedule feeding began to be taught, which came into direct conflict with what had become the accepted way of infant feeding (La Leche League, Pediatricians, and most of the general public had come to regard "demand" or "cue" feeding as best). This new approach was being taught by Gary & Anne Marie Ezzo and was termed "Parent Directed Feeding" (PDF). (This was included in their Growing Kids God's Way, Preparation for Parenting Class, and then in 1995 in Ezzo & Buckman's book, On Becoming Babywise).
The Ezzo's define PDF as "an infant management strategy to meet the needs of the newborn and the needs of the rest of the family, and as "the center point between hyperscheduling on one extreme and attachment parenting at the other.” “With PDF, a mother feeds her baby when he is hungry but takes advantage of the first few weeks to guide the baby's hunger patterns by a basic routine." So clearly the Ezzos did not mean to teach a pure scheduling approach, but one in which a schedule plays a significant role vs. feeding whenever the baby indicates possible hunger.
Thus began a serious controversy over which method of infant feeding was best. On the one side, the Attachment Parenting advocates, such as Doctor William Sears, the La Leche League, the majority of pediatricians, and many parents (both Christian and Non). On the other side are the Ezzos, a much smaller number of doctors who have endorsed their teachings, and the many parents who have tried and benefited from the Ezzos' approach. The debate between these two often becomes very hot - we will strive to look at both as coolly as possible.
Attachment Parenting Advice on Infant Feeding
The following representation of Attachment Parenting teachings comes for Dr. Sears' The Baby Book. Sears teaches mothers to breastfeeding on Cue, not on a set schedule. Some of the instruction / advice given is as follows:
There is a lot of variation in babies as to how fast they suck and how long a time of feeding is needed. You should expect on average to nurse about every 2 hrs around the clock for the first 4-6 weeks. You should, "Watch your baby and not the clock." Baby's feeding times will vary, particularly in the early weeks and during growth spurts. Often around 3 weeks, 6 weeks, 3 months and 6 months, babies will want to nurse almost constantly for a few days, building up your milk supply and getting the added nourishment they need for a growth spurt. You should also expect your baby to have an increased need for nursing during times of illness. Baby will sometimes just be thirsty and will only nurse for a few minutes and will be satisfied with foremilk. When truly hungry, baby will nurse longer and more vigorously and will get the hind-milk.
Premature babies suck weakly, feed slowly, tire quickly, and fall asleep frequently during feedings. They also need more calories to catch up on growth and have smaller stomachs. So they need small, frequent feedings. A technique to encourage a baby to eat more and get more nutrition is called "switch feeding." With switch feeding, you stop nursing to burp and switch breasts repeatedly - as soon as the baby starts getting tired and losing interest. This encourages taking more milk and encourages a creamer hind-milk to be released. This can be particularly helpful for sleepy babies who are not getting enough and growing as they should.
The key factor in stimulating production of more milk is the frequency of sucking. Longer but less frequent periods of sucking is not as effective at increasing milk production. Nap nursing and night nursing are powerful stimulators of milk production, since the milk-producing hormones are best secreted while you are sleep.
Following is some of the advice and instruction taken from On Becoming Babywise, By Gary Ezzo and Robert Buckman, M.D.
Parent directed feeding (PDF) is described as a "more user-friendly, less fatiguing alternative" to feeding on demand. PDF results in life being more predictable for the mother - she can plan her day. Also she benefits from better health and having the time to get the restful sleep and the exercise she needs.
"Healthy, full-term babies typically are born with the capacity to achieve seven to eight hours of continuous nighttime sleep between seven and nine weeks." Your philosophy of feeding primarily determines whether your baby begins sleeping through the night by this time. By week 12, baby will likely be sleeping 10 hours a night. PDF babies are also happier and more contented because they are more rested.
How to achieve these results? After the first week of the baby's birth, the mother should establish a feed/wake/sleep routine (in that order). Sleep should not conclude a feeding (Don't allow your baby to be nursed to sleep). The parents must help the baby organize his sleep into healthful patterns. "From birth onward, infant hunger patterns will either become more stable and regular or move towards inconsistency. When infants are fed on the PDF plan, their hunger patterns stabilize."
As a general rule, during the first two months, mothers are advised to space feedings 2 ˝ to 3 hours apart (from the beginning of one feeding to another), resulting in 8-10 feedings a day. There are occasions when you might feed sooner, but mothers are warned to be careful. Consistently feeding at a shorter interval may wear the mother down and even interfere with her ability to produce enough milk.
Once the mother's milk comes in, she should expect average nursing periods of 15 minutes per side. The mother should focus on delivering FULL meals, not snacks. This is achieved by keeping the baby awake by regularly burping, switching sides, stopping for a diaper change, stroking his face, talking to baby, etc. This way the baby nurses long enough to get the fat rich hind milk and to take a full feeding. If the mother feels her baby needs further sucking for reasons other than nutrition, the mother is advised to offer a pacifier (though warned not to over use it).
Essential to this feeding schedule is keeping the baby awake after feeding and then making baby take a nap (1 - 1 1/2 hours). Mothers are advised to use no "props" for baby's sleep (no rocking, nursing, or holding to help your baby get to sleep without crying). Baby should be taught to sleep by being left to himself to go to sleep, allowing him to cry.
Any "help" offered in going to sleep creates unnecessary dependence on mom for sleep. Often a period of 10-15 minutes of crying may be necessary, sometimes even an off and on cry of 35 minutes. Often babies learn to go to sleep without crying by about 3 months. Let your baby cry for reason of the goal of teaching healthy sleep patterns. But do check on your baby if he cries for longer than 15 minutes.
Attachment Parenting (AP) babies do cry very little because AP philosophies suppress crying, but many babies need to cry to go to sleep. AP practices keep baby very dependent and prevent baby from learning independence. Baby remains very insecure when detached from mom.
At about 2 months, you should expect baby to begin sleeping 7-8 hours at a time. When baby first begins to sleep through the night, the mother may feel some discomfort resulting from the longer period without feeding. It may take several days to a week for the mother's body to adjust, she may want to pump some milk to relieve her discomfort. However, breast feeding mothers are advised to always be mindful of their milk supply, adding back feedings if necessary to maintain it. At 3-5 months, you should be able to drop the late evening feeding, leaving only 4-6 feeding periods a day and with nighttime sleep of 10-12 hours.
Criticism of Attachment Parenting & On Demand Feeding
Ezzo and Buckman's book, On Becoming Babywise, makes many comparisons of PDF teachings to those of attachment parenting and is highly critical of the attachment parenting style. Some of the primary criticisms directed at the "On Demand/On Cue" feeding advice of AP are as follows:
With AP, every cry is interpreted as a need for breast food or breast comfort. Demand feeding results in nonstop feeding every two hours around the clock - resulting in exhaustion. Many AP households are characterized by exhausted moms, dad's sleeping on couches, and baby being stressed, exhausted, frustrated or insecure.
Questions are raised as to whether demand feeding is the cause of many women giving up on breast feeding after a short time. Concerns are also raised that feeding strictly on cue with babies that are weak or sickly, may lead to "infant dehydration, low weight gain, and frustration and fatigue for both mother and baby."
Dr. Sears is also critical of the Ezzos' advice on feeding infants. However, there are many others much more outspoken than Dr. Sears who take serious issue with PDF. A number of reporters for Christian magazines, a variety of pediatricians and lactation consultants, and many other Christian parents have taken serious issue with the Ezzos' PDF. Some of the key criticisms are as follows:
Failure to Thrive. It is claimed that PDF endangers many babies by advocating a fairly rigid schedule and feedings spaced too far apart for some babies to thrive. Many examples are given of "Ezzo babies" admitted to hospitals because of not getting enough to eat. Though these represent only a small percentage of babies on PDF, yet they are claimed to represent a high percentage of babies found to be "failing to thrive."
However, a careful review of the current edition of Babywise and other recent materials by the Ezzos, show numerous cautions about not being too rigid with the schedule, about adjusting for premature or unhealthy babies, and monitoring birth weight and diaper wetting to be sure baby is getting enough. To which the critics reply that the tone and emphasis of the teaching still encourages parental inflexibility in this area and that earlier materials did not have these cautions and advocated even longer periods between feedings. The constant focus on the goal of getting baby to sleep through the night, encourages inflexibility and ignoring signs that the baby may not be geting enough.
Insufficient Milk Supply. A second major criticism is that the PDF program makes it difficult to breastfeed your baby for very long. Eliminating the nightly feedings at an early age, and minimizing the frequency of nursing works against the way the woman's body was made to respond to her infant, producing the quantity and type of milk needed at each stage. PDF is claimed to frequently result in women having an inadequate milk supply at some point within the first year.
Ezzo denies that this has been the case in their own studies of PDF families. However, Babywise does repeatedly warn mothers to carefully monitor their milk supply to make sure baby is getting enough. As a remedy, mothers are advised that they may have to reintroduce an earlier dropped feeding to rebuild the supply.
Many experts find potential problems with PDF and the way a mother's milk supply is developed and maintained. However, many PDF mothers have been reported to successfully breast feed for up to a year or more, so these problems may not be serious for most women. A related criticism is that nursing in the way prescribed by PDF tends to result in a quicker return of fertility to the mother. The critics claim that more "natural" (i.e. on demand) feeding usually delays the return of fertility for quite some time, ensuring a healthier break between children.
Following are a number of quotes from lactation consultants concerning PDF and maintaining your milk supply:
"Trying to schedule feed defies the breast's basic physiology. With breast feeding, supply adjusts to meet demand. The more a baby's sucking stimulates the mother's nipple, the more breast milk is produced. … Schedule feeding ignores basic differences among mothers in milk capacity and differences among infants. 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."
Concerning women following an Ezzo program who consulted with Ms. Williams: "Their milk was diminished within five months or earlier - That's virtually unheard of in mothers who are demand-feeding." (Nancy Williams, Lactation Consultant, quoted from Eric Patterson's Article "Wise Advice for Babies?" - Boulder Weekly 3/20/97)
"In traditional cultures, anthropologists report that babies are never fed according to a schedule. Mothers in these societies do not generally have easy access to a clock and do nothing by a schedule and pay no attention to how long it has been since baby last nursed. However, they do work very hard during the day and may sometimes feed a baby before it is really hungry or delay a feeding slightly while finishing a task. No one outside of industrialized/western culture nurses children on a schedule. They incorporate frequent and irregular nursing into their lives without missing a beat." (Kathrine Dettwyler, PhD, www. prairienet.org/community/health/laleche/detisrael).
Following is a statement by the American Medical Association (AMA) concerning infant feeding:
"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 feed. You will discover these things for yourself as you and your baby get to know each other."
Leaving Baby to Cry. The Babywise practice of having babies cry themselves to sleep receives a lot of criticism from both AP advocates and many other parents. Many mothers particularly have a hard time listening to a baby cry for long without trying to offer comfort or help. AP proponents argue that this is as it should be - the way God made mothers - that there is actually a physiological response in women to a baby's cry. They also say that little babies are usually crying for a good reason (not with intent to manipulate parents). The reason may just be needing to go to sleep but not knowing how to settle down and drift into sleep. Or it may be fear of being left alone with parents nowhere in sight, etc. AP advocates helping your baby get to sleep by any of a number of means (nursing, patting or rubbing on the back, rocking, etc.).
The critics say that leaving the baby to cry hard and sometimes long, seems cruel and unkind. They are also concerned that sometimes the baby's cry may be due to a more serious problem, even a life threatening one. If parents have been so well taught that they must leave the baby to cry himself to sleep, they may neglect the cautions about periodically checking on baby and watching the clock to see that baby does not cry for too long.
Babywise defends the practice saying that fifteen to twenty minutes of crying will not do any harm and that many babies need to cry for a while before they can go to sleep. The crying is essential for baby to learn how to get himself to sleep without you.
Parents are advised to remember what is "truly important" - the goal of "teaching healthy sleep habits."
Both sides offer some potentially valuable information and advice on feeding babies. However, on some points they completely disagree concerning basic facts. So we must examine each position carefully and try to validate key factual issues from other reliable sources.
Some of the criticisms tend to the extreme, focusing on the worst cases rather than looking for the normal. Much of the description of AP in the Babywise book does not match up well with what Dr. Sears explains in his books. On the other hand, the critics of PDF sometimes seem to imply that most PDF babies experience serious problems as a result of this program. Though they may preface their concerns with saying “some babies”, they fail to also say that many babies to not appear to suffer harm from PDF.
With the more serious health threats reported with PDF, we usually find parents who took some teachings to an extreme, ignoring common sense. In addition, there have been improvements in the PDF teaching materials over the years, helping to address some of the prior criticisms. For example, the suggested feeding schedule has been revised (a reduced interval between feedings for young babies) and information has been added encouraging the tracking of the baby’s weight gain.
In spite of the many examples given by critics of problems resulting from each method, we need to remember that these are often the exceptions rather than the rule. For many years, many parents have used "cue-feeding" very successfully, without the severe problems that Mr. Ezzo attributes to it. Likewise, more recently, PDF has been used by a large number of parents who have deemed it highly successful.
Many parents just develop their own style of parenting babies. They may do some things similar to AP and some others similar to PDF. When they make liberal use of common sense and flexibility, they often do reasonably well.
Both methods can be taken to extremes and used too inflexibly. In these cases the results are more likely to be bad, occassionally resulting in tragedies. It is not entirely fair to fault the method for the misapplication of some of its students.
Neither method appears to be perfect. AP literature on feeding babies does seem to put almost 100% of the focus on what the baby needs with too little consideration for the problems the mother faces.
PDF, though claiming to be the midpoint between hyper-scheduling and AP, in practice sometimes looks much like hyper-scheduling. There is so much focus on the mother’s need for rest and the goal of sleeping through the night by a certain age, that the baby’s needs seem to become secondary. Parents too focused on the “goal”, can be overly strict with a feeding schedule and ignore warning signs.
On the other hand, parents too concerned with attachment, can also lose their perspective in a way that can be harmful to mom, baby and the whole family. Some moderation and balance are called for!
If you plan to use a PDF "routine" for feeding, remember that all mothers and all babies are NOT the same. Be careful not to hold too strictly to a schedule. Be sure you are nursing enough to maintain and build up your milk supply as needed and that baby is truly getting enough. Be attentive to your baby and any special needs that may arise. Make the goal of ”sleeping through the night” very much a secondary one, to the goal of ensuring your baby is getting what he needs for healthy growth.
If you plan to "cue" feed, do so with some reasonability and plenty of common sense. Some judgment is always required of mothers in order to determine just what baby needs. Nursing is not the answer to every problem that the baby has. Even Dr. Sears advocates reasonableness and not feeling that you must instantly drop everything to nurse the baby. Sometimes baby just has to wait a little, especially as he gets older. Learn how to meet baby's needs while also fulfilling most of your normal responsibilities. Learn how to make things easier on yourself rather than unnecessarily hard.
Where is the balance point? It may be a different point for different families. Your baby needs adequate nutrition, loving care and attention. If you are nursing, you need to maintain an adequate milk supply. Mom needs to get sufficient rest and not experience excessive stress and frustration in trying to meet her family's needs.
Some mothers have accomplished this result using
Babywise / PDF, others have done so using AP / cue feeding, still others with borrowing some principles from each. Neither method has a corner on the market for producing healthy, happy babies or for healthy, happy and reasonably rested mothers.