Wednesday, October 19, 2011

The Things They Don't Tell You...

There's a lot of things people will "warn" you about when you are pregnant or thinking about having kids. They'll talk about the sleepless nights, their worst "poop" story, the endless diapers, illness, worry, expenses. They'll talk about the joys, the highlights, and the lows. They'll tell you all about the births, the pregnancies, and the pain. So, you'll go into pregnancy and childbirth thinking you're prepared for what life with kids will be like. You'll be expecting incredible feelings of love, stressful nights of crying, and worry worry worry.

But there is one thing no one ever warns you about when it comes to kids, and it's something that will become a major part of your life. I am here to fill you in!

The number one thing people should warn you about when it comes to having kids is laundry. You probably have a laundry routine for yourself. Maybe you do laundry once or twice a week, or maybe you have enough underwear that you can go two weeks between loads. You probably have a load or two of clothes, plus the occasional load of sheets and towels. Once in a while, you run a delicates cycle. My point is, laundry is not a major part of your week.

Until you have kids.

Now, granted, babies' clothes are small and don't take up too much extra space. But I've had days where my newborn goes through three outfits in 12 hours, so they generate way more than one or two additional items of clothing per day to your laundry basket. Then there's the burp rags, the receiving blankets, the bibs, and your clothes that get pooped on, spit-up on, or peed on (or, if you're very lucky, all three!). If you have the baby in a crib, you have his sheet to wash in addition to your own. If he's in bed with you, you'll probably be changing your sheets more often, due to various bodily fluids he will be kind enough to emit all over your bed. You have his bath towels and washcloths to wash.

And after the infancy period, you have a toddler. Toddlers get DIRTY. You'll have food-covered shirts, mud-covered pants. And the socks! Let me tell you about the socks! You can tell your socks from your spouse's, presumably. You can tell yours and your spouse's socks from your baby's. But can you tell your three-year-old's socks from your five-year-old's socks? Word of advice about socks: Give each kid completely different kinds of socks, or you'll forever be hearing, "Mom, why are my socks in his drawer?" or "Mom, I don't have any socks!" even if you've just done the laundry. (Although this phenomenon may also be attributed to the problem of socks jumping off of feet and landing directly under the couch, rather than ending up in the laundry basket. We have this problem at our house. Do you?)

And, with each additional kid, you have all of this additional laundry! Suddenly, you can't do all the sheets in one load; you need two. Suddenly, you have two loads of kids' clothes to do, not just one. And the guilt you'll feel if you go one too many days between loads of laundry and your son runs out of school uniform shirts (not that that could ever happen at my house...)!

So yeah. Laundry. Lots and lots of laundry.

Thursday, October 13, 2011

Just One Bottle?

The latest hullabaloo in breastfeeding blog-land is the controversy over hospitals' supplying formula freebies to new moms, specifically in the context of the take-home bags. There are two issues under discussion here.

The first is that by handing out free formula, hospitals (and doctors) are advertising a product, which many feel they should not be doing. The reason hospitals give out free formula is that they have agreements with the formula companies that if they give (read: endorse) free formula to outgoing new moms, then the formula company will in turn provide free formula to the hospital to use in the nursery. The idea is that once a family starts using a particular brand of formula, they'll stick with that brand for fear of adverse reactions from switching (despite all formulas being essentially the same, and generics costing approximately half of what the identical brand-name product goes for). So, by giving a mom $30 worth of formula as she walks out the door, Enfamil or Similac or Nestle has just gained a new customer for at least the next 12 months, or so the formula companies' thinking goes.

The second issue is that studies show that mothers who have formula readily available at home are more likely to stop breastfeeding sooner or to supplement when it isn't necessary. Thus, mothers who are sent home with formula samples endorsed by the hospital are less likely to breastfeed exclusively for six months and are less likely to continue to breastfeed to a year and beyond, just because the hospital or pediatrician gave them a can of formula.

The first point is more of an ethical argument: Should hospitals be endorsing or advertising one brand over another (essentially identical) one? The second is a health issue: If the goal is for women to breastfeed their babies, then hospitals are undermining their own efforts at promoting breastfeeding by handing out formula as patients walk out the door. An associated problem is that if the hospital gives you formula, then the hospital is tacitly stating that you "can" or "should" use it, even if said hospital is otherwise trying to promote exclusive breastfeeding. It sends mixed signals.

There is one more, less controversial, issue as well. If you go home intending to breastfeed but decide to use formula for whatever reason, simply being handed a can of powdered formula with the hospital's blessing isn't enough. You need to know how to properly prepare and use formula, and if you don't do it correctly, it can be unsafe for a young baby. So if a hospital or doctor is going to give formula freebies, they should also give instructions on formula's proper use.

Okay, leaving that third bit aside, I want to talk about the other two problems from my own experience.

I've mentioned a few times now, if you're a long-time reader, that I had gone into the birth of my first son with the intention to exclusively breastfeed him. However, a difficult birth and lack of preparation on my part led to his being formula-fed. They asked us which kind of formula they should give the baby, and we, not having looked into formula at all, shrugged and asked what they suggested. They told us many moms liked the Enfamil Lipil, so we said sure, why not. When we left the hospital, they were "kind" enough to give us as much free formula as they could (a case of ready-to-feed bottles). When we ran out of those, we hesitantly bought a can of powdered stuff from the store and read the instructions carefully on how to prepare it. Naturally, we bought the Enfamil Lipil, because that's what they gave us in the hospital. He wasn't super-happy on it, so we eventually tried Enfamil Gentlease, which he did very well on. It wasn't until the baby was about 4 months old and I saw that Walmart carried a generic version of the Gentlease for about half the price that we got savvy and started using the generic, especially when we saw that the baby didn't care what brand was in his bottle! It didn't ever occur to me to buy Similac or Nestle, because, by golly, they'd given us Enfamil in the hospital, and that's what we were using! In fact, we were even convinced by Enfamil's excellent marketing that our son needed the additional nutrients found in their toddler formula, and continued using formula until our son started refusing it at about 16 months, at which point he was weaned to exclusively solid foods and cow's milk.

My second son was born at a hospital that gave out custom bags with no formula branding or free formula. I did get some free samples in the mail from Similac, and Enfamil and Gerber generously sent coupons regularly. I kept the Similac samples around but never touched them and eventually gave them to a friend who was formula-feeding. I was so gung-ho and had so few problems with my second son's breastfeeding that, even when I was frustrated, the thought of using formula never even crossed my mind. So having it in the house was not a temptation for me, but only because I was so committed (and obsessed? Maybe). If I had been slightly less so, the difficult times might have been just difficult enough to make "just one bottle" seem very attractive.

My third son was born at the same hospital as my second, and, as mentioned in his birth story last month, the breastfeeding support there was stellar. I again received a very nice, custom bag with no formula branding or freebies. I had intentionally signed up with some baby products mailing lists so I'd get free stuff, but the only free stuff I've gotten is formula. (I was hoping for a diaper bag or something!) There was a can of Similac sitting on top of my fridge for a while, until I moved it to the garage. I have to figure out who to give it to. So far, I don't have any formula-feeding friends this time around! (Not that I'm complaining.)

We brought our third son home on a Tuesday afternoon in September, on the first day of an awful, four-day heat wave. It was 92 degrees and humid. (This is quite unusual here in southern California, especially in September!) We don't have A/C, and the house was sweltering. The baby wouldn't stop nursing, probably because he was uncomfortably hot. His latch was not very good, and my nipples hurt so badly every time he latched on. (If that hadn't improved promptly, I would have gone to a lactation consultant for help!) And he latched on a lot! If I put him down, he'd scream. This went on into Wednesday, also 92 degrees and humid. I asked a friend to come over to meet the baby and keep me company, because I was all alone. She was a Godsend. She played with my other two boys, got us lunch - in the midst of my postpartum hormone surges, figuring out how to handle lunch actually had me in tears - held the baby, and was generally awesome. (You know who you are. THANK YOU for saving my sanity that day!) And the baby just kept on screaming whenever he wasn't nursing. We decided he was just so thirsty because it was so hot, and I had nothing but colostrum.

It was in that moment, the 674th time he latched on that day (okay, I may be exaggerating), that I understood the temptation of "just one bottle." I hadn't understood it with my second son, probably because it was December, I had fewer problems with his latch, and I was so worried that something would go wrong that I was afraid even to think about formula. This time, though I knew I wouldn't actually give him a bottle of formula, I understood why someone might. I needed relief. The poor baby wanted something to drink. If he had something other than my colostrum, maybe he would be happier, and my nipples could recover for an hour or two. Just one bottle... just one bottle...

Another friend of mine, who has a four-month-old, came over briefly to drop off some food for me and held the baby for a minute. He started rooting and screaming (of course). She jokingly said that she did have what he was looking for, but she wasn't sure how his mommy would feel about that. Truth be told, I actually almost asked her to nurse him for me!

Thank G-d, my milk came in Wednesday afternoon, and the baby got a good, long, satisfying feed, and he was suddenly the most content and happy baby you could ask for. It was a miracle. I had started to think that he would be a screamy, hungry monster for six months, and there was no way I could handle that, not with two other kids. I was in tears just thinking about it.

But once he had something to drink, he was fine, and he's actually been incredibly easy-going as a newborn nursling, giving me as much as two to three hours between feedings sometimes, which feels like a great luxury. My second son nursed, almost literally, every hour, so two hours feels like an eternity sometimes! It's nice.

But those first two days, with that can of Similac sitting up there on top of the fridge... Yes. I understand. Just one bottle. Just one. Just two hours of relief. Give me time to shower, apply some Lansinoh, close my eyes. Just one bottle. Just one. You know what the problem would have been if I had decided to give him that one bottle? I didn't have any bottles! (Ironic, eh? I had the formula but not the bottles.)

So, about those free formula samples interfering with breastfeeding in the early days? Yes. They can. Because another mom who had two days like I did, whose baby wouldn't stop screaming when he wasn't nursing, whose nipples were on fire, who had two other boys at home, who was all by herself on her newborn's third day of life, another mom who wanted to breastfeed but maybe didn't know quite as much as I do about how bottles can be a problem early in the breastfeeding relationship, that mom might give in and use "just one bottle."

Now, obviously, anyone can run to the store and buy some formula in such a situation, but it's less convenient, and she might be scared off by the price of a can. Or, in my case, she actually might not be able to run to the store, because she's all alone! But a free sample already in the house, given with the implied endorsement of the hospital, is very easy to tear open and use.

I'm not trying to paint formula or formula companies as evil. It's just business. And if a mom decides she does want to use formula, or wants to try to combination feed, or must supplement because of supply problems or weight-gain issues, then those free samples can be really helpful to have around! But if we're talking about supporting exclusive breastfeeding, which I am, then free formula samples really do get in the way.

Tuesday, October 4, 2011

Breastfeeding Support: The Disconnect from the Hospital to the Pediatrician

I promised a post about the hospital after my third son was born, and I might actually have found some time to sit down and write it. You forget pretty quickly what a time-suck having a newborn is. Everything takes longer, from getting out of the house to doing laundry. Just when everyone's got their shoes on, or just when you've finally found the energy to fold that pile of clothes, oops, baby's hungry! Be ready in 20 minutes (if we're lucky). It goes by so fast, though. He's four weeks old already, if you can believe it (I can't)!

I was very, very impressed with the breastfeeding and normal-birth supportive environment at the hospital where I gave birth. If you read my second and third sons' birth stories, you know that I was very pleased with my treatment. Both were at the Kaiser Foundation Hospital/San Diego Medical Center. Before giving birth to Son #3, I could only hope the hospital experience would be at least as good as it had been when I had Son #2, and I was pleasantly surprised to find it even better. The first improvement, and the one I liked the most, was that they are converting to all private rooms on the postpartum floor. I had a roommate for a few hours after Son #2's birth, and I didn't like the feeling of intrusion (I'm sure she didn't like it either!). The second improvement, and by far the most important, was the amount of breastfeeding training they had given all the maternity nurses.

From the moment my son was born, I truly felt he was under my care, not the hospital's. They were there to help me. They let me hold him and nurse him until I was ready for them to take him to be weighed. They didn't even give him a bath or dress him until I said it was okay (later in the day, in my hospital room!). They didn't take him out of my sight except for the hearing test, and then only for a few minutes. I was encouraged to keep him skin-to-skin. Every nurse who came to my room was able to help me with breastfeeding, armed with up-to-date information. Not one nurse gave me "bad" or "wrong" advice. The most negative thing any nurse said to me (and only if you take it in a negative context) was a fairly neutral, "He's using you as a pacifier!" I didn't exactly take it as discouragement - she didn't say, "Don't become a human pacifier!" - but I still felt it was an unhelpful comment. The nurse on duty both mornings was clearly well-trained in breastfeeding support, even had a lanyard saying as much, and was able to give me very helpful, hands-on advice about positioning. She was very supportive. When I half-complained about how often he was nursing, she said, "He's just doing what he needs to to get your milk in!" No comments about supplementing or hunger. No comments about pacifiers or taking a break. Just a "this is normal," and "you're doing great" attitude. I was very pleased.

When we were getting ready to leave, I had to detach him from my nipple so we could put him in the car seat. He wasn't too happy about this and started to cry piteously. We had a 45-minute drive, and I was so afraid he would scream the entire way. We tentatively asked the person who was helping us get ourselves ready to go if we could have a pacifier to try to calm him. She said they actually didn't have pacifiers, because giving a pacifier that early can interfere with breastfeeding (which is absolutely true!). I was disappointed but happy at the same time. As it turned out, he calmed down after a few minutes and slept the whole way home, so a pacifier wasn't necessary anyway.

Kaiser has a custom-made diaper bag that they give out. It's a very nice, high-quality bag. (We still regularly use the one we got when Son #2 was born, and now we have a new one to use as well!) It doesn't contain anything remotely formula-related. They gave me some samples of Lansinoh lanolin, lots of diapers, baby soap, alcohol wipes (for his umbilical cord), and anything else we wanted to take from the bassinet. They gave me discharge instructions with more breastfeeding information. And, a really nice baby blanket! No pacifiers, no formula samples, no bottles.

I don't know how I would have felt about the push for breastfeeding if I had not gone in intending to breastfeed. Perhaps it would have felt too pressuring, or I would have felt ashamed if I decided not to breastfeed, but I don't know. I'm actually curious to know how other new mothers feel about the way breastfeeding is presented there. I'm sure that my nurse-midwife and the maternity nurses all got the vibe from me pretty quickly that, (a) I was going to breastfeed, and (b) I pretty much knew what I was doing.

I fully intend to write to the hospital expressing my delight about my experiences. But I also intend to write to the Kaiser general offices about my disappointment upon taking my newborn son to the pediatrician for his 3-day checkup.

The hospital was so supportive of breastfeeding, and the OB/GYN offices were full of breastfeeding literature and posters (and no references to formula), and so I naturally assumed that that breastfeeding-supportive environment should also continue into the pediatric offices.

The breastfeeding support that had so impressed me through my pregnancy and delivery completely evaporated when I entered the pediatrician's office. The initial form I was given to fill out asked me if I was feeding my baby formula in such a way that I felt like I ought to be. The nurse asked how often he was feeding, and when I told her it had been basically nonstop, she said, "Oh, getting sore already, Mama?" The doctor informed me that breastfed babies needed Vitamin D supplementation (which is true, according to the latest research), but that if I started giving formula, and at least 50% of his diet was formula, then I didn't have to give extra Vitamin D anymore. What? Throwing around the words "formula" and "supplementation" next to a mother who had had as rough a second day home as I did might have been enough to drive her to start using formula right away, since the doctor had implied it was "okay." (That's not to say it isn't "okay" to use formula if that's what you need to do. It's just that it is not supportive of breastfeeding to imply that formula would be in any way "better" than breastmilk.)

At the two-week checkup, upon seeing that my son had gained over two pounds in two weeks, the doctor (a different one this time) said, "Whatever you're doing, keep doing it!" So that, at least, was encouraging. But I wouldn't have made it two weeks if I wasn't me, in the sense that I was already well-educated and gung-ho about nursing my babies. I wouldn't have made it two days if I wasn't me. I get the feeling that the pediatricians at Kaiser are fairly autonomous, so support for breastfeeding (and knowledge about breastfeeding) will vary from doctor to doctor. I happen to very much like and respect the doctor I usually take my kids to there, the one I saw at the two-week appointment. The doctor I saw at the first appointment was very personable and friendly, but his breastfeeding support was not good. One positive comment I have, though, is that when my baby turned out to have jaundice, they didn't jump right to suggesting formula supplementation to clear the bilirubin; all of the doctors (three!) I saw over those few days just said, "Feed, feed, feed!" So there was some trust in breastfeeding!

A few days ago, Kaiser sent me a survey asking me to rate my experience at the hospital. I gave them very good marks. It is clear that breastfeeding initiation and continuation is very important to them, as several of the questions on the survey asked about the breastfeeding education and support offered during prenatal visits and in the hospital.

If they are truly so invested in Kaiser members breastfeeding their babies (as well they should be), then that support needs to continue into the pediatric offices. They need to have lactation consultants on staff. They need to train the pediatrics nurses in basic breastfeeding education, just as they did for the postpartum nurses. And they should insist on a uniform attitude toward breastfeeding among their pediatricians and possibly offer basic breastfeeding classes to the MDs, so that mothers who come in desperate for help will be able to get the support they desire.

For those who are unfamiliar with Kaiser Permanente, a brief explanation so this post will make sense: Kaiser Permanente is an HMO health insurance plan. If you are a member of Kaiser, all of your healthcare needs are attended to within the Kaiser system, which includes general practitioners, specialists, hospitals, physical therapy, pharmacy, etc.

It seems to me that if Kaiser as a whole has a philosophy of care, such as with breastfeeding support, then that philosophy should carry over from practitioner to practitioner, from prenatal care all the way through to pediatrics. If enough mothers write in with my above suggestions, maybe we will continue to see positive change throughout the Kaiser system.