Monday, June 27, 2011

Breastfeeding Basics - Part II: The First Few Days

In the previous post, I discussed briefly some of the basic details about how breastfeeding works and what you need to know before the baby is born. If you haven't yet given birth, or if you've recently given birth but haven't read that post yet, it'd be a good place to start.

(This post is written with the assumption that you gave birth to a normal, healthy, full-term baby. Most of the advice in this series - especially the early posts - simply does not apply if you have an extraordinary circumstance such as a premature baby, a baby in the NICU, a baby with a cleft palate or other physical impediment to breastfeeding, etc.)

Now that you actually have a baby to feed, let's talk about what's going to happen in the first few days postpartum.

Hunger Cues

How will you know when your baby is hungry? Well, your best bet to start with is to offer the breast whenever the baby fusses. Even if he's not hungry, it's a great way to comfort him. If he doesn't want to suck, he won't. If he does, you'll be giving him what he needs. Pretty soon, you'll start learning his hunger cues. A hunger cue is a young baby's way of letting you know he needs to nurse. A fairly typical cue is fussing accompanied by "rooting," which is when the baby turns his head toward anything brushing his cheek and tries to suck on it. This may be your finger, a blanket, or, of course, your nipple. The rooting reflex is how the baby looks for the breast and is an excellent clue to look for if you think he may be hungry. Some babies may also open and close their mouths, wave their arms, or stick out their tongues. You'll start to recognize your own baby's cues. Remember that crying is a late sign of hunger, and by the time he starts crying, he's already been hungry for a while and is getting desperate.

Nurse That Baby!

In the first few days of life, it may seem like all you're doing is nursing. This can be frustrating, as it seems like you barely put the baby down to change his diaper, only to have him start fussing to eat again. And feedings seem to take forever. Your arms get tired. You can't find time to pee or eat. And he'll only sleep if you're holding him.

I know this is an adjustment, but I hope that you're also enjoying your new baby, taking this time to bond with him and get to know him a little, memorizing his face and his little ears, the cute little noises he makes when he sucks, and the random waving of his arms. If you're in a hospital, enjoy the fact that someone else is taking care of you. If you're at home, let your loved ones care for you while you focus on your baby.

All of this constant nursing is very, very good for both you and baby. I mentioned in the previous post that breastfeeding takes practice. Just like any other skill, the more you do it, the more you work at it, the better at it you get. The frequent nursing gives you and your baby lots of opportunities to practice various positions and holds and that all-important latch.

The most important benefit is that nursing is stimulating your breasts and your brain to produce milk, and all the colostrum and milk your baby is taking in will help him grow, pass along antibodies and beneficial bacteria, and protect him.

Avoiding Bottles

I also mentioned in the previous post that it's generally recommended to avoid any kind of artificial nipples (pacifiers and bottles) before about the fourth week of life. Sometimes you can get so overwhelmed with the constant nursing that the idea of giving just one bottle, or of offering a pacifier, so you can have an hour or two without baby attached to you is very attractive. Keep in mind that this period is only a few weeks, and that as overwhelming as it is, you are doing yourself and your baby a world of good by letting him nurse as often and for as long as he wants. This intense period will end, and things will get easier.

If you do need a break, sometimes passing the baby to Daddy or Grandma or some other caregiver for an hour will allow you to rest, go to the bathroom, eat something, or just doze for a bit. Sometimes the baby will go longer between feedings if someone else is holding him, because he doesn't smell or sense the milk nearby. Don't deny the baby a feeding, and make sure he's satisfied before handing him off, but it's perfectly okay (and healthy) for you to take an hour for yourself when you need it.

As a side note, if you are in a situation where you must supplement your baby with expressed breastmilk or formula, there are ways to feed him without using a bottle. These include a Supplemental Nursing System, finger feeding, syringe feeding, or cup feeding. You should talk with a lactation consultant about which method will work best for you and how to do it.

When Your Milk "Comes In"

For the first two to six days postpartum, your baby will be subsisting off of the miraculous substance called "colostrum," which is produced by your body before you start making mature milk. If this is your first baby, your milk may take as long as six days to fully appear. If you have had a baby before, and especially if you nursed a baby before even for a little while, your milk may come in as quickly as 48 hours after giving birth.

You can tell your milk has come in because your breasts will suddenly feel very full, very large, possibly hard to the touch, and possibly painful. This is called "engorgement," and engorgement happens when you have more milk in your breasts than you need or that your breasts can comfortably hold. Some babies have difficulty latching when you are engorged. You can relieve engorgement by squeezing out some of the milk with your hands, using a breast pump to remove some of the milk, using warm compresses or standing in the hot stream of water from the shower to encourage milk flow, and, of course, nursing the baby. Be careful not to remove more than enough milk to be comfortable, or you will stimulate more milk production and continue the cycle of engorgement.

You can also tell your milk has come in because instead of the thicker, golden substance you've been seeing, you'll see a thinner, white liquid.


The first few days or weeks of breastfeeding may be painful. While you'll hear over and over again that if your technique is good, if the baby's latch is good, then you won't feel pain, some women may have a baby with a perfect latch and yet still experience some pain. It's important to know "good" pain from "bad" pain.

First of all, engorgement itself can be painful. If the pain localizes to a "lump" or "bruised" spot on your breast, this may be a plugged duct or the beginnings of mastitis, which you want to make sure to treat right away. If it's just a general breast soreness, relieving the engorgement should also relieve the pain.

Secondly, some women experience nipple pain with nursing during times of hormonal changes, such as the first few days or weeks postpartum. Your nipples may feel sore, or you may experience some pain when the baby latches. If a lactation consultant has evaluated the baby's latch and it seems to be fine, you may be experiencing normal-for-you pain that will pass once your hormones settle down. However, if your nipples become bruised or cracked and bleeding, or if your nipple looks like the tip of a new tube of lipstick after nursing your baby, then the baby's latch is likely in need of adjustment, and you should see a lactation consultant immediately.

Some women experience let-down as a painful sensation. Let-down is when the milk is released into the milk ducts and flows down toward the nipple. While some women don't feel any sensation at let-down, for others it can be very noticeable. As your supply adjusts to meet your baby's demand, the intensity of the let-down often also decreases.

Finally, nursing your baby releases the hormone oxytocin, which is the same hormone that stimulates uterine contractions during labor. The oxytocin released while nursing will also stimulate your postpartum uterus to contract, helping to bring it back down to its normal size and limit your postpartum bleeding. While these contractions are good things, they can be quite painful for some women. Your doctor likely recommended or prescribed a pain reliever such as ibuprofen. Take it as directed to help with this pain, as there is certainly no need to suffer.

I don't want to scare you away with all this talk about pain. The pain of nursing should not be excruciating, it should not last more than a few days or weeks, and it should not make you dread nursing your baby. If the pain is unbearable or causes you to avoid allowing your baby to nurse, or if your nipples are showing signs of damage, please see a lactation consultant.


There are many comfortable ways to hold your baby while nursing. One popular way is the "cradle hold," in which you hold the baby along your forearm, supporting his head in the crook of your elbow, with your hand supporting his back, bottom, or thigh (depending on how big your baby is). Another common one is the "football hold," or clutch hold, where you hold the baby face-up on your arm, against your side, much the way a football player holds a football (hence the name). This position is popular for women who have had a c-section or who are nursing twins, as it keeps the baby off your stomach. There are several other ways to hold your baby in order to nurse him comfortably. Usually there will be someone in the hospital to help you with these different positions. You can also see illustrations online, such as here. It is helpful to find a few that work well for you and practice with them. The most important thing to remember is that the baby should not have to turn his head or strain to find the nipple.

Keep it up! The first few days and weeks can be difficult, but the hard work pays off. I hope you'll join me for Part III, which will discuss the next few weeks up to what I call the "magical six-week mark."

Wednesday, June 22, 2011

Breastfeeding Basics - Part I: What You Should Know Before You Give Birth

By the time you're about ready to give birth, you have had to make lots of decisions. You've decided where to give birth and how, you've picked out or purchased all kinds of baby gear, and you've agreed on a name or two you like. And, hopefully, you've made a decision about how you intend to feed her. You've no doubt read about all the pros and cons of breastfeeding and formula feeding. You've been "informed" by friends, family, coworkers, and the barista at Starbucks about what the best choice is. And, if you're reading this, you've probably decided that you'd like to give breastfeeding a shot. It seems like the healthiest thing for baby, and probably for mom. It's definitely got all sorts of benefits you'd like to take advantage of. And you're a bit staggered by the cost of formula.

But all those books have so much information in them! Which one do you read? What do you really need to know right now?

Before you go into labor, or lie down on the gurney to go to the OR, or arrive at the hospital for your induction, before your water breaks and you start making frantic phone calls to your family letting them know the baby's coming, you should have a few vital bits of information stored away so that you can initiate breastfeeding as soon as possible and have some idea of what to expect. When I had my first baby, despite assuming I was going to breastfeed, I found out very quickly that there was a lot I didn't know about this process that was supposed to be "natural" and "normal" and "instinctive." Sure, it's instinctive for baby, but mom actually has to learn a few things. (And, to be honest, the baby has to practice a bit, too!) I was bombarded with advice from people all around me, and, in the end, my son ended up formula-fed. I was shocked at how much I didn't know going in. I want to help you avoid that shock. Thus, this first segment in a series of posts.

Defining Terms

First, there are terms and phrases you'll hear in relation to breastfeeding. Here are a few you should know right away.

Latch: The baby's "latch" is the arrangement of the baby's lips, tongue, and gums on your nipple and areola. The quality of his latch affects how efficiently he can remove milk from your breasts and swallow it, as well as how comfortable (or uncomfortable) breastfeeding is for you. If the baby is latched well, he should be taking your nipple far back into his mouth, and his lips should be flared around your areola. He should not be chewing or sucking on the nipple directly, and his tongue should be over his bottom gums. The latch usually should be "asymmetrical," meaning the bottom jaw is farther up on the breast than the upper jaw.

Exclusive Breastfeeding: Exclusive breastfeeding means that nothing is ingested by your baby other than breastmilk - no water, no formula, no juice, no cereals, no foods of any kind. The American Academy of Pediatrics and the World Health Organization recommend exclusive breastfeeding for the first six months of a baby's life, at which point solids may be introduced. (This definition allows for the administration of Vitamin D drops, if recommended by your doctor. Some babies may need a Vitamin D supplement, but your pediatrician will discuss this with you.)

Colostrum: Colostrum is a special substance produced by your breasts in late pregnancy and in the first few days after birth. It is a thick, golden substance full of antibodies, concentrated nutrients and proteins, and other substances vital to a newborn’s health. Colostrum is sometimes called “liquid gold” because of the unique beneficial properties it contains and the short period of time in which it is produced. Colostrum is the only food your baby needs in the first few days of life.

Nursing on demand: When you hear the expression “nurse on demand,” this means that you should put your baby to your breast whenever she seems hungry and allow her to nurse for as long as she wants. You will learn your baby’s hunger cues through observation and trial and error. This is the healthiest way to feed a young baby, as it will ensure that the baby is getting enough to eat and will aid in establishing a healthy milk supply so that you can continue producing enough milk for your baby.

Skin-to-skin: Putting a baby “skin-to-skin” refers to the baby being held against the chest of a caregiver (usually the mother), with the adult shirtless and the baby naked or only in a diaper. The direct contact of the baby’s skin with the skin of a caregiver helps the baby to regulate his own body temperature, lets him hear the calming sound of a heartbeat, and helps him regulate his own breathing and heart rate. Putting the baby skin-to-skin with the mother directly after birth promotes the release of beneficial hormones in baby and mother, stimulates milk production in the mother, and calms the baby. You can request that your baby be put skin-to-skin with you immediately (or within one hour) after birth, as the baby will instinctively seek out your nipple and begin to nurse.

Lactation consultant (IBCLC): A lactation consultant is a medical professional who is specially trained to help new mothers (and babies) learn to breastfeed, keep up on the latest research regarding breastfeeding, feeding techniques, and information, do breastfeeding research, provide advice and education to nursing mothers, and diagnose and treat breastfeeding difficulties and issues. International Board Certified Lactation Consultants (IBCLCs) receive thousands of hours of hands-on and classroom training in order to become breastfeeding experts. A good IBCLC is your best resource for any breastfeeding questions you may have and to help solve any breastfeeding problems you may encounter. Many hospitals now employ IBCLCs who can come to your room in the postpartum ward to help you learn to breastfeed your baby.

How Does Milk Production Work?

This is definitely something you need to understand before you actually have a baby to nurse. This is the one bit of information that I wish I'd known before my first son was born. 

In the first few days and weeks after giving birth, milk production is driven largely (although not entirely) by hormones. Toward the end of pregnancy, you start producing large amounts of prolactin and other hormones, which stimulates the breasts to start making colostrum, the thick, golden substance defined above. After giving birth, usually within two to six days, the colostrum you are already producing will be replaced by mature milk, which looks like, well, milk. This switch-over to mature milk should happen regardless of whether you've started breastfeeding, since it is hormonally driven, but if you don't stimulate continued milk production by nursing a baby or pumping your breasts, milk production will gradually taper off and eventually stop. What this boils down to is, in order to make milk and continue making milk, you need to nurse a baby and continue nursing a baby.

Breastmilk production and supply are driven by demand. As your baby nurses, he drains the milk from your breasts. This milk removal sends a hormonal signal to your brain, which sends more hormones back to your breasts to signal them to make more milk. If there is no demand placed on the breasts for more milk (i.e., no baby is nursing, or you are not removing the milk by pumping it), then the breasts will stop producing milk. The less often you remove milk from your breasts, the less milk you will produce. The best way to ensure a good milk supply is to nurse your baby whenever he is hungry and allow him to nurse until he is full. This will signal your brain and breasts to keep producing milk.

Weight Loss

It is normal for a baby to lose 5 to 7% of his birth weight in the first few days of life. Babies are born "full," meaning that they have been receiving nutrition nonstop through the umbilical cord right up until they are born. A newborn baby's stomach is about the size of a golf ball and is not elastic. This means it can only hold a very small amount of food at a time, which is all he really needs anyway. The colostrum provided by your breasts, as long as you are feeding the baby whenever he is hungry, is sufficient to provide his nutritional needs in the first few days of life. Once your mature milk comes in, the baby should start putting on weight again. The goal for most babies is to regain that birth weight by about two weeks of age.

A small weight loss (less than half a pound for most full-term, healthy, normal-weight babies) is not cause for concern, and does not mean you need to offer any supplemental feedings of formula. If you have any concerns about your baby's weight loss and gain patterns, you should talk to your pediatrician.

As an example of a normal weight loss and gain pattern, my second son was born 7lbs., 6oz. When we were discharged from the hospital less than 48 hours later, he weighed only 6lbs., 14oz., a loss of 8 ounces. However, by his two-week follow-up visit with the pediatrician, he weighed 8lbs., 1oz., which means he gained back those eight ounces, plus another 11 ounces, in two weeks.

This only applies in the first few days of life until your milk comes in. If your baby is losing weight after having started to gain, you should have the baby evaluated immediately by a pediatrician, and you should be seen by a lactation consultant to determine if you have a sufficient milk supply and if the baby is getting enough to eat.

Pacifiers and Bottles

I promised this would be short, so there's just one more topic to discuss. The introduction of a pacifier or bottle too soon in the breastfeeding relationship may cause problems with the baby's latch and desire and ability to feed from the breast. This is not true of all babies, but it can and does happen, and is called nipple confusion or nipple preference. In order to avoid  problems in the early days, lactation experts generally recommend that you wait until about four weeks of age before introducing any kind of artificial nipple. What this means is, in the hospital, you should inform the nurses immediately that you do not want your baby to be given a pacifier or offered a bottle - even a bottle of breastmilk.


Well, the reasons are different for pacifiers and bottles. With pacifiers, they can often become a crutch to allow you to delay or avoid feeding the baby. If the baby learns to comfort-suck from the pacifier, he may not give you the proper hunger cues and may even skip a feeding. In the early days and weeks of life, it is important that the baby feed as often and for however long he wants to, in order to put on weight and achieve the rapid growth that is normal and necessary for a young baby. When your baby is a bit older (three to five weeks), has established a good breastfeeding relationship, has demonstrated good growth, and knows how to latch properly and eat his fill, then introducing a pacifier is less of a problem and may even be beneficial. 

The problem with bottles is different. A bottle is generally easier to drink from than the breast. Bottles tend to drip regardless of whether the baby sucks. When the baby swallows, more milk comes from the bottle nipple, forcing the baby to swallow again, which causes more milk to flow. Because this takes so little effort, some babies will "forget" how to latch and suck properly at the breast, especially those who are already having trouble staying latched and maintaining the stamina to feed effectively. There is also evidence that even one bottle of formula can interfere with the proper population of beneficial bacteria in the gut and expose and sensitize a baby to proteins not found in human milk.

That's it! I hope this summary helped condense things for you into a manageable bite, so that when you do go into labor or give birth, you'll feel like you have the knowledge you need to get started.

The next segment in this series will address topics important relevant to the first few days of your baby's life.

Monday, June 20, 2011

Breastfeeding: What You Need to Know, and When - Introduction

The next series of posts will be a simple introduction to breastfeeding, formatted like the popular "week-by-week" style books. Rather than throw a breastfeeding text at you and tell you to read the whole thing before your baby is born (or worse, in those rough first few weeks after the baby is born!), I'm going to give you a break-down by time period. "Read this before the baby is born," then, "Read this in the first day or two postpartum," and so on. That way, you don't have to overwhelm yourself with information, most of which you're going to forget and have to re-read anyway, and you'll have topical, targeted information for what you're actually living through, rather than something related to five months from now.

First, an introduction. Why am I writing this? Where did I get this idea, anyway?

Well, first a personal plug. I am writing a breastfeeding booklet, to be sold in e-book format, certainly for Kindle and possibly for other readers. It's not available yet, but I anticipate publishing within the next month. I hope that you will check it out, either on your behalf as a potential or new nursing mother, or on behalf of a friend or partner who is planning to nurse or has a new baby. More on that when it's out, of course.

In writing this and discussing the outline with a friend, she suggested writing it in something of a week-by-week format, but I couldn't pin down what would go where. Breastfeeding isn't as straightforward a trajectory  as pregnancy. You can't say, "In Week 1, your baby is 7 pounds. Your breasts are producing X ounces of breastmilk per day." It just isn't realistic. But, there is definitely a growth curve, especially for the mother, in learning about breastfeeding and in the act of breastfeeding itself, so it became a matter of breaking it down into logical phases.

I remember being 39 weeks pregnant with my first baby, hanging around in the soon-to-be nursery after working a half-day at work. I was spread out on the futon in the room, books about babies and breastfeeding  stacked neatly for me to read. I picked up "The Womanly Art of Breastfeeding," La Leche League's excellent text/manual on breastfeeding. It's incredibly comprehensive, offering advice and information on just about every aspect of breastfeeding from newborn to toddler and beyond. And I couldn't read it.

Reading a breastfeeding text before you are actually breastfeeding is a bit like reading the manual for a camera you don't own. It just doesn't apply. You don't know what you're going to need to know. You don't know whether you're going to have any problems. You don't know what you'll be able to figure out for yourself and what you'll need someone else to help you with. It's all theoretical, and therefore boring. Especially to a first-time mom who is already overwhelmed with all the "stuff" she needs to buy and all the "stuff" she needs to know about baby care. And, besides, if breastfeeding is natural, then who needs a manual, anyway?

And then, expecting a new mom to read such a book in the first few weeks postpartum, when she is overwhelmed by how much she didn't know but doesn't have time to go find out, is simply ridiculous.

But what if it were broken down into digestible pieces? One or two pages that apply right now. Tell me what I need to know before I give birth. Do I need to know about thrush, about weaning, about introducing solid foods? Do I need to know about nursing a toddler? Generally not. So don't waste time reading that now, when you can always look it up later. Don't overwhelm yourself with information about problems you may or may not have. No, learn just what you need to know, so that you'll know what to look for and what questions to ask when the time comes.

My next post, then, will be "What You Need to Know about Breastfeeding before You Give Birth." This will be followed by information for the first few days postpartum, then the first six weeks, six weeks to three months, three to six months, six months to one year, and then nursing a toddler and weaning. Peppered within all of this will be information that may apply at any time, about plugged ducts and mastitis, about thrush, nursing strikes, and so on.

But I intend for each section to be short and manageable, no more than, as I said, a few pages. It has to be something you can read quickly, understand immediately, and then follow up on by jumping straight to that chapter in your favorite breastfeeding book.

I look forward to seeing you all in Part I!

And here, just a gentle disclaimer that I'm just a mom like the rest of you, without any formal training beyond all the reading I've done and having nursed one child. As I'm not a medical professional, I can't diagnose or treat any problems, and I can't recommend medication or treatment regimens. For serious problems, please contact a local International Board Certified Lactation Consultant, who is a medical professional who's job it is to help you figure out what's wrong and what to do to fix it. If you have any concerns about your baby's health, contact your child's pediatrician immediately.

Monday, June 13, 2011

TV and Movies

I admit it. My kids watch TV. More than we really meant for them to.

When our older son was a baby, we were "against" TV as a baby-sitter, in that we didn't see a reason for a small child to be watching TV, and we really didn't think a baby should be propped in front of a television in lieu of playing with toys or being interacted-with by adult caregivers. When he was a baby, the TV was on a lot in our house, but it was our shows, and then when he was a toddler, we'd watch TV when he was sleeping. I didn't (and still don't, really) believe in using Baby Einstein or any of that. I think babies learn way more from hanging around with their parents than being sat in front of a TV screen, regardless of what that screen is showing.

I'm aware of the research out there that says kids under two shouldn't watch TV at all, and preschoolers shouldn't watch more than an hour, and so on. There are all sorts of theories about how TV is causing autism, or ADHD, or G-d knows what else. And it's entirely possible that exposure to the TV screen is in some way bad for the brain or eyes or something. It wouldn't surprise me if they found something definitive.

My bigger concern is how TV is becoming a crutch for me. We'll put on a 30-minute show in the morning for the kids to watch while my husband makes breakfast and I shower and get dressed. Keeps them occupied. I'll let my younger son watch a "moo-wee" so I can get work done. He knows how to open the DVD player and turn on the TV, how to handle a DVD properly, take it out of the box, put it back in its box, and put it in the DVD player. He doesn't know how to switch the TV to the proper input channel or to start the DVD, but I'm sure he'll work that one out eventually. Then, when his brother comes home from school, I sometimes let them watch some more TV, say a 30-minute show or two, so that I can get a little more work done, or cook dinner, or something, while they wind down. Many days, I refuse to let them, and if they don't ask, I don't suggest it unless they've already been playing well for a long time and I want them to start calming down.

What's nice about my kids is that they do self-police what they watch. My older son is, pardon my brutal honesty, a wuss. We've tried to have him watch age-appropriate movies other than "Toy Story" and "Cars," and most of them have him whimpering in fear during mildly scary sequences. My husband and I don't really get it, and we're never sure what will scare him or give him nightmares. My younger son is more open to watching new movies, but he hasn't reached the point of anticipating what will happen or being afraid of something bad happening. It's possible that when he's 4-1/2, he'll be a "wuss," too. He's already been exposed to far more TV and movies than his brother had been by this age, though, by virtue of, well, having an older brother!

So how do we choose and police what we allow them to watch? Well, first of all, thank G-d for the DVR. My sons don't even understand that there was a time when you couldn't just choose what to watch, whenever you wanted to watch it. We picked out mild shows from PBS and Nick, Jr. that we felt were inoffensive, fairly calm, had some educational value, and didn't annoy us too much. Since they choose from what's been recorded, we have total control! (I know that won't last, but we'll enjoy it for now.)

My kids' favorite shows are, now, "Calliou," "Curious George," "Thomas the Tank Engine," "Sesame Street," "Sid The Science Kid," and "Martha Speaks." I'm not sure why they like the shows they do, but I don't particularly mind any of these. I don't feel like the kids are learning anything they shouldn't, and sometimes a lesson gets through.

As far as movies, we mostly stick to Disney/Pixar. We've found, in trying other studios' fare that it's less truly kid-friendly. At least, not little-kid friendly. They like "Shrek," though. They definitely prefer animated to live-action, cartoon drawing to CGI, except they love all three "Toy Story" movies and "Cars." In fact, we've decided that our older son's first theater movie will be "Cars 2" in a couple weeks. Lucky guy!

I guess as they get older they'll start watching more "mature" stuff, but hopefully not for a while. I never understand how parents can let their young kids watch things like horror films or thrillers or action movies. My husband and I saw "X-Men First Class" last weekend (good movie!), and there was a family there with fairly young kids. That movie has some very disturbing imagery. I wouldn't take my kids anywhere near that stuff for years yet. I mean, if "Wallace and Gromit," which says right on it that it's intended for ages 5 to 7 years, gave my son nightmares, who knows what Holocaust imagery would do to him. I don't see any reason to find out!

I don't know how you know when a kid is old enough for a particular show or movie. I know that my brother, at four-ish, was afraid of "Star Trek: The Next Generation," while I, at seven-ish, loved it. So maybe seven is a magic cut-off age? I suppose if you know your kid, you know what he can handle. It's just, there are movies and books I really look forward to sharing with my kids, like "The Princess Bride," that I know we need to hold off on for years yet. I first saw "The Princess Bride" when I was about eight, and it scared me! I still remember that, despite how much I adore that movie now.

I also don't care for them to see shows or movies that will bring up questions I'm not ready to answer. I'll never forget watching some sitcom with my mom - I don't remember which - in which the word "orgasm" came up. Naturally, I asked her what it meant. I don't think she enjoyed answering. I don't remember how old I was, but probably not quite old enough to need to know what an orgasm is. I was pretty sheltered, TV-wise, as a kid. I watched "Mister Rogers" and "Square One" after school, and that was good enough for me for a long time. To give you a sense of my "shelteredness," I was about 9 when "Terminator 2" came out. Some of my friends went to see it. I was horrified that someone my age would see an R-rated movie! I remember saying, "I don't watch R-rated movies!" I think I saw my first R-rated movie when I was about 13. I remember being haunted by the violence of "The Last of the Mohicans" for years, and being shocked when we were treated to Olivia Hussey's breasts in the 1968 Zeferelli version of "Romeo and Juliet," which we watched (with parental permission) in ninth grade. I'm happy enough for my kids to be equally sheltered.

For now, while we still have control, I won't worry too much about what TV my kids are exposed to. Soon enough, they'll be going to friends' houses and probably watching TV there. They'll be able to turn on the TV and channel surf on their own (although right now we don't have cable, so there won't be much to see!). They'll want to go see movies in the theater with friends instead of parents. My main hope is that they also will do their homework and read books, because while I don't think TV is evil or to be completely avoided, I also think it definitely gets in the way of other valuable pursuits.

And who knows? Maybe they'll figure out that TV really does rot the brain, and we'll all turn our TVs in for healthy organic snacks and, um... haha! Just joking!

Monday, June 6, 2011

Sleep: Part III

If you read my last two Sleep posts looking for advice on getting your child to sleep better, you were probably disappointed. But this post might help. This is not a method, or a technique, or even a general overview of various techniques. But it is a list of things I'm beginning to feel are "truths", and knowing them might help you come up with a plan of your own for handling your current sleep situation, if you feel it needs handling, or reassure you that maybe you don't need to make any changes, if that's the direction you're leaning in.

All kids are different. This is always true, regardless of topic. All people are different, all kids are different, all babies are different. Yes, even ones within the same family. Yes, even twins. Some kids will sleep better if left alone, while others won't sleep unless they have company. Some kids will wrap themselves around you when they sleep, while others need their space. Some kids will only sleep once you put them down, while others will only fall asleep while you're holding them. Some kids will hardly move at all when they sleep, while others might end up in the toy box by midnight. Some like to be covered; others like to be unencumbered. Some like their feet free; some like footed pj's in the depths of summer. The point is, what worked for one of your kids might not work for the next. What works for your friend's kid might not work for yours. Or might work differently.

Consistency is key. Whatever you decide to do, you need to stick with it. If you decide you're going to let your baby cry it out, you have to keep letting him cry it out. If you decide to refuse to nurse at night, you have to keep refusing. Once you relent, you're back to square one. That's not to say you can never try it again later. And, if you start a process and decide it's not for you, of course you can (and should!) stop. But if you intend to do it, then you have to do it. Consistently. The same way every time, every night. (Variables happen - if the baby is sick, everything goes out the window. If you're traveling, things will change. But be as consistent as you can.)

Bedtime routine is very important. One thing you'll see in all the sleep books is to create and stick with a bedtime routine. I agree with this 100%. Pick a bedtime, build a routine around that bedtime, and don't waver from it. Try to get your baby to bed around the same time every night, within about 30 to 60 minutes of that time. This helps to set his internal body clock so that he'll know when to be tired. The bedtime routine will help him know that bedtime is coming and will signal his body to start releasing all those lovely hormones that help you relax and fall asleep. If you're starting this process for the first time, I recommend starting on a Monday night. This gives you five nights to enforce the same weekday routine, so that when Saturday comes and the day is different, you'll already have a head start. Then maybe for that first weekend, try to stick as closely as you can to the same routine. By the following Friday evening, a blip here and there shouldn't matter as much (for example, if you go over a friend's house for dinner and are there later than the usual bedtime), as long as you go right back to the routine as soon as possible. You can also try to do the routine as closely as possible in your different situation. For example, bring the baby's pajamas, music, book, or lovey, whatever you've begun to establish, and get the routine started. That way, if the baby falls asleep in the car on the way home, you can just put her to bed.

Don't miss the sleep window. There's about a 20 to 60 minute window of time where your baby's body is primed for sleep. This happens around his usual bedtime. If you get him to bed within that window, he is likely to fall asleep peacefully and easily. If you miss it, you'll probably have to wait another hour and a half, at least, before he'll be able to fall asleep. This is a biological phenomenon which happens for everybody, adults and children alike. If you don't go to sleep at your usual time, your body assumes that there is some kind of stressor or danger that requires you to be awake. You get a flood of adrenaline and other hormones that will help you stay alert. We usually call this the "second wind," and we take advantage of it when we want to stay up later, pull "all nighters" in college, party, or finish one more chapter of a book before going to bed. You'll notice that you have a great deal of trouble falling asleep during that second wind, even if you want to. The same is true of babies.

It takes about four nights. For babies and toddlers, it takes about 3 to 5 nights for a new sleep "rule" to kick in. The first night, he may seem bewildered by the whole thing. The second night may be worse than the first night, because he starts to protest the new rule. By the third night, he should start to get the idea that you mean it. And by the fourth night, you'll know whether your new "rule" is working. If there is no change for the better by the fifth night, either this method simply won't work for your baby, or you're not being consistent enough.

Different parents can handle different levels of sleep "problems." You may be the type of person that, once awakened, takes an hour to fall back asleep. You may be the type of person who can't function on less than six solid hours of sleep. You may be the type of person who just keeps chugging along regardless of how you slept. You may be someone who can practically sleepwalk through the nightly feedings and barely remember waking up and feel quite refreshed in the morning. If you are functioning at a level that is acceptable to you during the day, then your night time sleep is fine. Just because your baby is waking up three times a night to nurse or your toddler wanders in every night to climb into bed with you doesn't mean that you're doing something wrong by allowing it to continue if it doesn't bother you. Your friend, however, might find this to be intolerable because she finds herself falling asleep at her desk at work, or, G-d forbid, while she's driving. Remember "If the solution is worse than the problem, then you don't have a problem"? Yeah. If you think whatever sleep changes you might "need" are going to be harder on you than just leaving things the way they are for now, then leave things the way they are.

Some changes are more possible at some ages than at others. There's a fantastic book out there called Bed Timing, by Marc Lewis, Ph.D., and Isabela Granic, Ph.D. They are developmental psychologists who have broken down the zero- to five-year-old brains and pinpointed developmental ages at which their brains are better able to handle changes in their sleep habits. They make suggestions as to when to "sleep train," rather than how. From my observations, I agree with this general thesis. There are definitely times where making changes to sleep habits will go very easily, and other times where you'll fight for weeks to set a new pattern, even if you use the same techniques with the same kid. I think my success with my two kids at 16 months has something to do with them having been in "stable" periods of development at that age.

Sleep regressions will happen. There are certain ages where everything you've worked for, sleep-wise, will seem to vanish. There are classic "sleep regressions" at four months, eight months, 13 months, 18 months, and usually on the "halves" after that - 2-1/2, 3-1/2, like so. At those ages, for a few weeks, your baby/toddler will suddenly start sleeping even worse. (If you have a particularly "poor" sleeper to begin with, you may not notice a dramatic change. However, if you have a baby who previously slept four hours at a time, you may notice she suddenly starts waking every hour for no apparent reason.) Usually, once the sleep regression has passed, sleep will return to basically the patterns you had established pre-regression. There's not much you can do about this. You can stick to your guns or you can let it all go, whichever works better for you. I do think that if you have made sleep changes in the stable period before a regression, it will be easier to return to those established patterns afterward. Also, you may notice poorer sleep in the days or weeks leading up to a major developmental change, such as crawling, walking, or talking. The baby will be "practicing" the new skill even in bed, and it will be hard for her to sleep. Once the new milestone is reached, sleep should improve. And don't forget things like teething, illness, or change in environment can have an effect on sleep.

You'll have to sleep train more than once. This isn't a one-shot deal. First of all, you may make one change at a time, over time. Secondly, after developmental milestones, sleep regressions, vacations, major changes such as moving house or adding another baby to the family, and so on will probably necessitate a "retraining" of sorts, although the retraining typically only takes a night or two to reestablish what you've already done.

How your baby sleeps now is not an indicator of how she will sleep as an adult. Sleep is natural for all humans. Eventually, your child will fall into the normal human pattern of nocturnal sleep and diurnal activity. (Until he becomes a teenager? Haha.) Some kids need a little push to learn to stay in bed and go back to sleep on their own, but just because you have a nine-month-old who wakes four times a night to nurse does not mean that your son will be getting up four times a night as an adult to raid the fridge. Don't worry about it.

Sleep begets sleep. Being "overtired" is real, and being overtired makes it harder to sleep well. The more sleep-deprived or sleep-confused your baby is, the harder it will be to fall asleep and stay asleep. The healthiest sleep (for anyone, not just babies!) is to go to bed and wake up at the same time every day, and to get enough sleep. Babies need a lot of sleep, generally around 12 hours in a 24-hour period (this changes depending on age and on the particular child - some kids need less sleep; others need more). If they are getting significantly less than what they need for more than a couple of days, they will become so tired that they will find it difficult to fall asleep, difficult to stay asleep, and the cycle will perpetuate until they become so exhausted that they can't help but sleep. It's messy. If you're as consistent as you can be about getting your baby to sleep at the same time each night, she should start waking up naturally at the same time each morning, and then if you are consistent about naps as well, you should end up with a well-rested, happier baby who sleeps better for it.

One thing I think helps put all this in perspective is if you think about yourself. Most of us feel better and sleep better when we're sleeping consistently. If we have too many nights in a row of poor sleep, we get "hyper" and find it harder to sleep well when given the opportunity. If we mess around with our sleep cycles, we basically get "jet-lagged," without the vacation, and it takes a few days to get back on track. Babies are the same. Babies are people. The only babies I would say this doesn't apply to is very young ones - newborns naturally and biologically do have different sleep patterns than adults and older babies, simply because of their need to feed often and grow rapidly. But once you've come out of the newborn stage, or probably by about six months of age, babies basically follow the human need for enough sleep, most of it at night, and to follow a consistent sleep/wake schedule.

One last thing before I think seriously about getting some sleep myself. Whatever you decide to do, whenever you decide to do it, and however you decide to proceed, keep in mind that you need to do what you believe is healthiest for your family. You make all kinds of decisions for your child, even before he's born. How he "should" sleep is just another in a long line of decisions you make that will impact how he grows. I'm not here to tell you what will happen if you do a "cry-it-out" method versus cosleeping until he's five. I'm not here to tell you if you're doing any psychological damage by having him sleep alone or letting him sleep between you and your spouse. I'm not here to judge you for needing eight hours of uninterrupted sleep, and I'm not here to judge you if you're willing to walk around in a zombie-state just so that your child can get eight hours of uninterrupted sleep with his head on your chest. Honest. Any of those things are your choices to make.

As for me, I personally am uncomfortable with leaving a baby alone in the dark to cry, as you may have gathered. I think feeling secure is the most important aspect of good sleep. Even if it means a lot of sleep interruptions in the early days, I think the security of knowing that Mommy and/or Daddy are nearby and will respond when he feels he is in distress can only be beneficial as the child grows.

Friday, June 3, 2011

Sleep: Part II

And then there's Son #2...

I considered Son #1's sleep "training" to be generally successful, so I was quite confident that I would know what to do when Son #2 was ready for the same kind of treatment. I knew I wouldn't do it before six months of age, but I thought I would surely do it earlier than 16 months this time around. I was happily dispensing sleep advice to other friends (and random people on the internet) based on the technique that worked with Son #1.

But when Son #2 came along, there was a very important variable I hadn't considered: breastfeeding. Son #2 was a nursing fiend. I've mentioned before that he nursed every hour. I'm not really exaggerating. I swore I wouldn't have him in my bed at night. I swore I wouldn't nurse him to sleep, so I wouldn't fall into the "trap" of having no other way to get him to sleep. I swore this up and down until I got home from the hospital, snuggled up in bed with him to nurse... and fell asleep that way. When I attempted to put him into his crib in our bedroom, he woke up.

And that was that. I would nurse him to sleep in our bed, fall asleep along with him, and wake up sometimes an hour later with him still happily attached to my breast. I'd then flip over, move him to the other breast, and go back to sleep.

He wasn't attached to my breast all the time while sleeping, but he woke often to nurse himself back to sleep, or because he was actually hungry. I actually felt quite well-rested for the first 10 weeks or so, because I didn't have to wake up all the way to nurse him, and I didn't have to get up out of bed when he awoke.

The interrupted sleep did start to catch up to me, but by 11 weeks or so, I could see no alternative. It was just so easy! Baby sleepy? Great! I'd nurse him to sleep, leave him on the bed, come back when he got hungry again. Then, when I went to bed, I just curled myself around him with a boob exposed and let him have at it while I slept.

Granted, I'd often wake up to milk-soaked sheets. Once I had a hickey on my breast where he'd latched in the wrong place. It didn't really hurt, but it was a little weird to look at until it healed. And it got a little wearing that only I could get him to sleep, and that whenever he woke up, I had to drop whatever I was doing to go upstairs and nurse him, sometimes for 30 or 45 minutes.

Because I was already so strict with Son #1's bedtime routine, Son #2 just tagged along for all the steps of the routine. I'd basically just nurse him while I read books, sang songs, etc. When he was very small, he'd hang out on the floor outside the bathroom while I bathed his brother. As he got older, he'd crawl around and explore. At some point, we decided he was old enough for the two boys to take their baths together, and they still do to this day. That's the nice thing about having two kids of the same gender, I suppose.

The point is, Son #2 just started to fit naturally into an already-established bedtime routine. This was a great blessing, because he seemed to decide on his own that 8:00 was bedtime for him, too. I'd finish up with Son #1's bedtime, say goodnight, take the baby to my bedroom to nurse him to sleep on my bed, and then leave him there (girded with pillows so he wouldn't fall if he happened to roll) while I continued to have my quiet evenings. Except having to return every so often to nurse him back to sleep. This got a bit annoying when I had company over or something and had to leave for half an hour to nurse; I admit that.

When he was six months old, I decided to try a modified Ferber method again, hoping to sleep train the baby sooner than I had his brother. On the night that I decided to start the process, I decided also that it was time that Son #1 stay in his bed instead of falling asleep on the landing against the gate (as mentioned in the previous post). I figured, why not do two sleep-trainings for the price of one?

Well, I got Son #1 to stay in his bed, sure, but Son #2 would have none of this nonsense. He wanted boob, and he wanted it now, and I didn't have the heart to refuse him. He was just a little baby. He didn't understand "Lie down and go to sleep now." He wanted to NURSE. I gave up quickly on that idea and decided to try again when he was older.

It was at that point that I realized something very important. If what you're doing just doesn't feel right, it's really okay to trust that instinct. Listening to the anguished cries of my six-month-old baby alone in the dark for the first time in his life, in a crib instead of on Mommy's bed, cold and lonely instead of snuggled up to Mommy, I knew he wasn't ready for this. I knew he couldn't handle what he saw as abandonment. I knew he didn't understand that it was "for his own good" or any such nonsense. No. He was a baby, and he needed his Mommy.

To be honest, those months and months of sleep deprivation took their toll on my short-term memory. I don't have as clear a memory of exactly how and when we finally transitioned Son #2 to a crib in his brother's room. I believe I got to a point where Son #2 would start out the evening in his crib in our bedroom and that I would then bring him into our bed when he woke up to nurse. I know that at 12 months, we put his crib in his brother's room, but I couldn't figure out how I was supposed to night-wean him without his crying waking his brother up. So I gave up on that for the moment and brought him back into our bed. Son #2's sleep saga was much more convoluted than Son #1's was.

I did finally read Ferber's actual book, and I have to tell you, Dr. Ferber has a lot of really good information about sleep in general in that book. His sleep advice doesn't only apply to babies, but to kids, teens, and adults as well. I agreed with almost everything he said about everyone except babies. He claims that babies no longer need to eat at night at five months of age. I think this is a blanket statement that isn't true for all babies. I think some babies stop night-nursing on their own at a young age, while others do still need it longer. I do think his method of "controlled crying" is better than just leaving the kid to scream in the dark until he falls asleep from sheer exhaustion, as the parent's continual return does reassure him that someone is nearby. I also think he has good tips for how to gradually night-wean from bottle or breast, if you choose to go his route. Be aware that Ferber's methods do involve crying.

I believe it was at around 16 months that we finally got Son #2 to sleep in his crib in the room with his brother, rather than in our bed at all. I was stubborn enough by then, and fed up enough with sharing my bed with a squirmy toddler, to decide that he was not coming back into our bed even when he woke to nurse, which I knew he inevitably would. I felt there were more advantages than disadvantages at that point to his sharing a room with his brother and to my having to go in several times a night to nurse him. Remember "If the solution is worse than the problem, you don't have a problem"? Well, the solution was no longer worse than the problem by then.

It's not in any of the developmental books I've seen, but I truly think something magical happens at 16 months that allows you to make changes to sleep habits that you couldn't make before. Maybe some great leap happens around 15 months that leaves them with a greater capacity to adjust to change, but what I couldn't accomplish at six or 12 months, I was able to accomplish at 16. With both kids. Go figure.

I got Son #2 sleeping in his crib the whole night, although not through the night, through simple persistence. Whenever he woke up, I'd go in, take him out of the crib, nurse him lying on the floor of his room, then, once asleep, I'd put him back in the crib, haul myself back to my bed, lather, rinse, repeat until morning. I believe at some point, I found I was able to put him back in his bed while still awake, as long as he'd finished nursing, and he'd go back to sleep. It was usually three times a night that he woke me. For a long time. I got so tired of lifting him over the side of the crib that we decided to convert the crib to a toddler bed long before we had expected to, oddly enough, also at 19 months, the same age at which we had made the change with Son #1.

We bought a house and moved, and the pattern continued for a week, when we decided to buy Son #2 a twin bed for his second birthday, just as we had done for Son #1. Then, at least, I was able to nurse him lying in his bed instead of on the floor!

After about two months of that, I hit that "I've had enough" point, where sleep for me became more important than anything else. I figured that I wouldn't be able to night-wean him without completely weaning him, so, as I described in my nursing story, one night I simply refused to nurse him. He woke several times asking to nurse, and I simply refused, told him there was no more milk and that he didn't need to nurse anymore. It only took about three nights of this for him to stop asking for it.

From there, things gradually improved, sleepwise. First, I would lie with him, my back to him, in his bed, until he fell asleep. I had to go in a few times a night for another month or so. I realized at some point that I was no longer being awakened quite so often. But sometimes it was taking him 45 minutes to fall asleep at first, and I was getting very antsy lying there with him every night until he would finally fall asleep. The next step in the sleep-improvement project was to get him to fall asleep without me in his bed. I think this was the key to getting him to sleep through the night, because if he did awaken, he'd know how to go back to sleep on his own. Again, it just took gentle persistence and consistency from me. I just got up from his bed and told him to go to sleep, returning every so often to remind him that he was supposed to be, you know, going to sleep. A few nights of this, and he did.

So I'd stay for a few minutes - say, 5 or 10 - and then leave. And then Son #1 caught on that, hey, wait a minute, how come I always stay with Son #2 and never with him. So I started staying with one for 5 minutes, then the other for 5 minutes, and then leaving. I do kind of miss those days where I'd say good night and leave the room, but I suppose I can give them 10 or 20 minutes to snuggle before bed. :) Anyway, I'll have to see how things change once the baby is born.

All I can say is, thank G-d for smartphones and booklights.

By about the three-month mark (April or so), I was ready to say that we pretty much were sleeping through the night. Certainly there are nights where one or the other (or both) wakes for no apparent reason, or because one or the other is sick, or because one or the other has a bad dream, or because they're cold (I can't get either of them to stay under a blanket, or to get back under a blanket when they get cold. Grr.)

I guess I get about another 3 months (until Son #3 is born!) to enjoy this general sleeping-through-the-night thing. As you can see, the sleep trajectories of my two sons has been quite different, but the end result is the same. It's kind of interesting.

In Sleep: Part III (still to come), I'll expand on what did seem to be the same for both kids, and what I think is true for most kids. The test will be what happens with this next kid!