Wednesday, December 18, 2013

Please Don't Tell Me I'm a Supermom

When I tell people I've gone to the store, or out to eat, or made dinner, or gotten a few hours of work done, or some other apparently monumental task while being responsible for all four of my kids, I get exclamations of amazement. "You're a supermom!", they'll say. Or, "I only have two, and I can barely manage most nights!" Or, "I don't know how you do it!" I know these are meant as compliments and are honest reactions to something outside their own frame of reference. And I appreciate them as such.

But it makes me uncomfortable just the same. Because secretly, deep down, it releases all kinds of insecurities. All I can think of is all the things I've done wrong, the mistakes I've made, the things I wish I had managed to do. I berate myself for not paying enough attention to the kids, for letting them fend for themselves while I work in another room, or, conversely, for spending a few hours with them instead of working a few more hours to pad my paycheck. Or, for neglecting both work and kids to sit on the toilet and play Candy Crush in private. I should hold my baby more, hug my five-year-old more, draw with my toddler more, and read with my seven-year-old more. I should put the phone down during dinner and make them tell me about their day. I should try harder to get the toddler to take a regular nap. I should get the middle two dressed before noon. I should take them to the park more so they can run around on sunny days. I should replace their bike helmets and let them out front to ride. I should fold their laundry. I should wipe down the kitchen counters, sweep the floor of the toddler's food-leavings, and change the baby's diaper and give him a bath.

I see other people accomplishing things I haven't been able to, and I think I have no right to those compliments. I'm not "doing it all." I'm not a supermom. And when you tell me I am, you're belittling yourself. You're negating all of the amazing things you've managed to do, like have a dance party in the living room and do an art project with your preschooler, like cook healthy meals all week long, get your car washed, and clean your toilets. Like sign your second-grader up for soccer, acquire all the gear he needs, and attend all his games. Like save up for two years to take the family to Disneyland. Like start your own business and run it successfully, work full time outside the house and still get the laundry folded and the lawn mowed, and remember to pick up a birthday present for the party this weekend.

I'm just a mom. Some things, I know I do well. Some things, I know I could improve. And, looking at you, looking at how well dressed you are, how neat and clean your house is, how you make healthy meals all the time and get your housework done regularly and limit screen time to just the weekends, and have money left in the bank at the end of the month, some things make me feel very, very inadequate. Not because I think you're judging me, but because I'm judging myself.

Please don't tell me I'm a supermom. I don't feel all that super, and I don't have a cape. Sure, I made it to the grocery store, but I nearly lost the stroller, forgot to buy half the things we needed, and left the reusable bags at home. Yeah, I got the oldest to school on time, but the other three are still in pajamas and the toddler's diaper needs changing. Absolutely, I made dinner and put the dishes in the dishwasher, but I didn't make them clean up their toys, there are shoes everywhere, and the baby is crying in his swing while I rinse the last of the dishes.

No one's life is perfect. I think as moms we only see our own shortcomings while we admire the accomplishments of all moms around us. I'm wondering how she can remember to put jackets on both of her kids and manage to keep them from running around screaming in the store, while she's wondering how I can load four kids into the car in half the time it takes her to put her two in. I'm wondering how she finds the time to make dinners from scratch every night and keep the living room free of clutter, while she's wondering how I can work part time from home with three kids in the house.

I'll tell you what, if you buy the capes, I'll wash them. But don't blame me if I forget to put them in the dryer.

Sunday, December 15, 2013

Pumping Tips for Stay-at-Home Moms

With my second and third babies, I intended to pump milk and build a freezer stash so that the baby could have a bottle once in a while if my husband and I went out. What I found was there's not much time or motivation to pump when you're with your baby 24/7, since preparing a bottle is more trouble than just putting baby to breast, and when exactly are you supposed to pump when you have to feed your baby every couple of hours?

I actually did manage to fill a few freezer bags with pumped milk with my second, which I ended up donating because we had so few opportunities to actually give the baby a bottle. My husband worked long hours, we didn't have a budget for hiring a babysitter and going out often, and the few times we did go out, the baby wouldn't take the bottle anyway!

With my third, I resolved to pump for donation and, again, so we could leave him with a sitter, and that time I found even less opportunity and motivation to pump and ended up not putting much aside. He did get some bottles of expressed milk as a newborn, but after a few months, he, too, no longer took a bottle.

So, this time, I vowed I would find a way. One of the biggest difficulties many women have with breastfeeding is the feeling of being "tied" to the baby. You can never go out without the baby because you have to feed him. It's frustrating. Pumping and storing milk toward this eventuality can help. I bought myself a Hygeia EnJoye double electric pump, revived my hand expression techniques, and promised myself and my baby that I would find one time a day to pump and that he would get bottles often enough that we could leave him with a sitter and go out.

Now, obviously the situation is different if you work outside the home and are away from your baby on a regular basis. In that case, the baby is receiving bottles almost every day, and you're pumping instead of feeding during the time you're away from baby. That's not to say it's easy! Just different.

Here are tips for pumping/expressing milk when you stay at home with baby!
  • Pick a time of day when you're pretty sure you'll be able to take 15 to 20 minutes to express milk on a nearly daily basis. Many women have more luck pumping first thing in the morning, so if that's an option, it may be a good choice. I tend to pump in the afternoon, but that's just easier for me because we're not rushing to get out the door.
  • You may not need a fancy electric pump if you're only pumping once a day. Hand expression can be very effective for many women (myself included). You may also want to try a manual pump, which generally run $30 to $50, rather than a pricey electric pump. Check out my video on hand expression (NSFW) if you're not sure how to do it.
  • You can start pumping as soon as your baby is born, if you want, but wait to introduce the bottle until breastfeeding is established, usually around 3 to 4 weeks of age.
  • Give the baby a bottle at least every other day or so. This is the mistake we made with both baby #2 and baby #3: If you don't keep giving a bottle, the baby will forget how to use it or will simply refuse to take it, preferring your breast (understandably so). Have someone else give a bottle when the opportunity arises. I had my 7-year-old feed the baby one evening while I made dinner, for example. Baby may not take a bottle from mom but might from someone else. I did manage to give him a bottle myself the other night, but it sure felt weird to me!

  • If you have trouble producing for the pump, or you have trouble finding a time between feedings to pump, you can try pumping while you nurse. Latch baby on one side and use the pump on the other side simultaneously. I find this to be extremely effective. Your baby will achieve the letdown for you, and you don't have to keep baby waiting to eat while you pump! It's a win-win. It is, admittedly, somewhat awkward, though, and it may take a few tries to get the hang of it. You can also use this method to help your body "learn" to respond to the pump if you're having difficulty getting letdown for the pump alone, and you can use it to help increase your supply if you're having supply problems.
  • Massage and do breast compressions while you pump. If you are pumping just one side, or you have a hands-free pumping bra (highly recommended if you're double-pumping), use a free hand to compress and massage the breast while you pump. Find the full ducts and put pressure there to push the milk forward. This can greatly increase the amount you extract. I find using a combination of pumping and hand expression yields the highest volume in the shortest time for me. Milk removal is the trigger for milk production, so the more you remove, the more you'll produce!
  • Remember that your supply will adjust to the demand. You can pump extra and have enough to feed your baby, but only if you pump consistently to tell your body you need that extra milk.
  • At first, you may find it difficult to express a large volume of milk. Pump as much as you can, then keep pumping for a few minutes after you've "run dry" to let your body know you want it to make more milk. You should find your milk volume increasing if you pump daily. Be sure you are hydrated!
Milk Donation

If you find you are expressing considerably more milk than you need, even after giving a bottle every couple of days, you can use that excess milk to help another baby in need, either by donating through the Human Milk Banking Association of North America (HMBANA), which provides donor milk to babies in the NICU, or through a private milk sharing arrangement. You can find local-to-you mothers in need of donor milk by visiting Eats on Feets, Human Milk 4 Human Babies, or Milkshare.

Private, mother-to-mother milk sharing is controversial and not regulated or endorsed by the FDA, but it is legal and completely up to you and your milk recipient whether you want to enter into such an arrangement. Milk donors typically do not charge recipients for their milk but may ask the recipient to cover costs such as storage bags and shipping (if applicable). Milk donation is totally voluntary. Some recipients may ask that you be screened for diseases that can be transmitted through breast milk (a simple blood test). As a donor, you are doing a great favor to a baby and mother in need, but you also have a responsibility to ensure that your milk is safe for another baby to drink, meaning you should use best practices in expressing and storing your milk to ensure it is not contaminated or soured.

Tuesday, December 10, 2013

Living My Life on Camera: I'm Not Making Porn

Okay, maybe that title's a little dramatic, but since my YouTube channel is growing and we've started making a lot more videos, I feel like I spend a lot of time with a camera in my face. The feature called "Life Shots," especially, is very much like having my own little reality show. Every situation becomes a video opportunity. The other day, when I was changing the toddler's diaper while simultaneously nursing the baby in the Moby wrap, all in a public restroom in a medical building because my 5-year-old had to pee, I found myself thinking what a great video that would have made and lamenting that my cameraman - my husband, who also produces and does most of the editing - was not there to record it.

It's not that I think my life is so unique or noteworthy, but enough people comment about how I "must have [my] hands full," or that my boys "keep [me] busy," or wonder "how [I] do it," I figured having four boys 7 and under is interesting to a lot of people. I also like the idea of documenting a normal life. I don't have any special secret. I'm not very organized. I'm certainly no "supermom," whatever that's supposed to mean. But I think I mostly have things under control, and I enjoy life with four boys, and I don't mind sharing that with the world.

Exposing myself (sometimes literally) and our life to the camera is a way of saying, "This is what a normal family looks like." It helps other people in normal families realize that they're normal. It makes people who have it more together than I do feel good, and it gives inspiration to people who aren't sure if they could manage.

I also enjoy using the platform to normalize breastfeeding, cosleeping, and other aspects of baby care that still aren't as mainstream as they could be. It's an opportunity for education about breastfeeding and birth, and a way of showing that I'm just a regular person who does mostly practice what I preach. Babywearing, breastfeeding, these are not out of reach for most people, and they are extremely valuable, especially when you have multiple children.

It's become a little scary, being so exposed (again, sometimes literally). At first, I wasn't sure about making videos that exposed my breasts. Though I'm not squeamish about breastfeeding in public, I'm also not likely to go around flashing people for fun. Because breasts are so sexualized, I knew that I was opening myself up to attention I wasn't looking for by making videos about expressing milk, obtaining a good latch, and so forth, that couldn't help but show quite a lot of skin and nipple. Indeed, I got a penis picture in my message inbox, for the first time yesterday. Lovely. While I know that there are men watching my videos for purposes other than learning about breastfeeding, the fact that those videos have lots of views means that women (and men) who are looking for breastfeeding and pumping help will find my videos. That's the power and magic of social media. More views means more potential viewers. And, I have gotten a few genuine comments from women thanking me for the information, so I know the videos are being watched for their intended purpose as well. And I'm not sorry that I get to generate ad income from men watching for other reasons. That's money that will help me make more videos that can help more people with their breastfeeding and other baby care questions.

I still haven't quite gotten past the idea that men other than my husband are enjoying my breasts. The fact that they are anonymous helps. The fact that some percentage of my video views are from women looking for breastfeeding assistance helps, too. And I can't help what other people do with my image once it's out there. It's the internet, and I'm not naive. My husband is very aware of the potential, of course. He's the one who films the videos, after all. He's in the same frame of mind, that we'll take the views and the ad revenue regardless of the motivation, and we're glad that at least some of the people watching are learning something.

The bottom line, for me, is that the only way to normalize breastfeeding is to show breastfeeding. And since I'm in a position, as a breastfeeding counselor with a new baby of my own, to make instructional videos about breastfeeding using an actual newborn baby, a woman's actual postpartum breasts, and her actual breastmilk, it only made sense to seize the moment and just do it. Showing a real woman breastfeeding a real baby under real circumstances makes breastfeeding attainable, normal, and tangible. My videos let other women see me struggle to latch my baby, fumble with my wrap, and occasionally get confused. They let me expose the learning process of breastfeeding, to show that it's not always easy but that it's doable, to show that it's convenient, to show how it works when you have multiple children. To me, that benefit far outweighs the ickiness that comes with knowing what else my videos might be used for.

Like my videos? Subscribe to my channel and like my Facebook page!

Wednesday, December 4, 2013

Breastfeeding a Newborn: How Often Does My Baby Nurse?

I have a confession to make: I have no idea how often or for how long my baby nurses.

That's right! Gasp! I don't keep track!

When someone asks me, "How often does he eat?" or "How many times do you get up at night to feed him?", I don't have an answer beyond, "I don't know. It's not bad."

Look, this is my fourth kid and my third nursling. I've never been a "charter." I've never kept very careful track of diaper changes or when feedings started and ended. But now, fourth kid, time has no meaning. Sometimes an hour between feedings can seem luxuriously long. Other times, an hour can seem like, "Hey, didn't you just eat?"

I know a given nursing session doesn't take long. For example, today, I fed him for five minutes at one point. I happen to know because I happened to have glanced at my watch when he started, so I figured, hey, let's see how long this actually lasts. It was five minutes. It seemed awfully short, so I tried to offer him more. He didn't want it. When did he next feed? I don't know. Was it long enough to get something done in between? Yes, I think so.

The thing is, I tend to be doing other things while he nurses. For example, he nursed yesterday at my oldest's dentist appointment. He nursed in the Moby wrap while I watched N get his teeth cleaned, shepherded S to the bathroom, and changed G's diaper. (Yes, I nursed and changed a diaper simultaneously...standing in the middle of a single-use public restroom in a medical building. That now qualifies as the weirdest nursing situation I've been in.) So how long did that feeding last? I have no clue. I was busy watching my oldest get his teeth cleaned, taking another one to the bathroom, and changing a diaper!

Usually, my multitasking isn't quite that exciting, though. Typically I've got my phone in one hand while I support the baby with the other, and I play Candy Crush and check Facebook 14 times while I nurse. Sometimes I read a book. A real one. Other times, I read a book on my Kindle app. Lots of times, I'm tending to one or more of my other kids while poor Y hangs on for dear life.

The great thing about breastfeeding is you don't have to meter it. You don't have to measure anything. You don't have to time it or schedule it or worry about whether he'll want just a little more. When the baby is hungry, you feed him. It's that simple. As long as baby is growing, producing plenty of wet and dirty diapers, is alert and interactive, and otherwise seems healthy, then you don't have to know exactly how long every feeding lasts and how often you're nursing. There will be times when he nurses for five minutes several times in an hour and other times where he sleeps three hours and then nurses for 20 (or more!). There's no rule for any given baby, and there's no general rule, either, except, "When the baby is hungry, you feed him." Check for active sucking and swallowing and watch him expand practically before your eyes. (If your baby has any health problems, has slow weight gain, or was premature, your doctor may ask you to track feedings and diapers to ensure that your baby is taking in enough calories. This is important in a situation like that. Also, if feedings seem to last an hour or more, your baby may have problems with his latch that makes it difficult to efficiently extract milk. In that case, it is probably a great idea to make an appointment with a lactation consultant to see if there's anything else going on.)

So how often is my six-week-old eating? I have no idea. How long does it take him to finish? No clue. Doesn't seem long, though. Is he happy? Reasonably. Is he growing? Heck, yeah (he's already in 3-month clothing and filling those out nicely)! Does he eat well? Yep!

Enjoy your baby. Don't be obsessed with the clock or the calendar. Watch your baby. Get to know him. Learn what his cries mean and figure out what he likes to do. Follow his lead. Follow his cues. Time has no meaning for him, and it shouldn't matter so much to you, either. Get a book, or your phone, or your e-reader, or the TV remote, sit back, relax, and nurse that baby!

Check out my YouTube channel for lots of breastfeeding videos!

Monday, December 2, 2013

Guest Post: Baby N's Birth from His Father's Point of View

Today's special guest post is from my husband! He wants to tell our kids' birth stories from his point of view. Often the man's role in and feelings about birth are underplayed or downplayed, and in a series of articles, my husband will explore his own impressions and experiences during the births of our sons. So, to celebrate 100 likes on the Facebook page, here is his perspective on N's birth! 

(Notice his challenge at the end. To continue the series and hear about S's birth, let's keep pushing forward to 200 likes! Share the blog with your friends, and if you haven't done so, please like the Facebook page!)


I've been wanting to tell the birth stories of our 4 kids from my perspective, the husband’s. I've had this idea for a while, but it’s hard to find the time to write it. You read many stories from women about their birth experience, but I can’t say I read many from the father’s point of view. So, I’m not expecting many men to read mine. But who knows? Maybe I am the strange one.

Each one of my kids' births was very different, an amazing experience by itself. Some were more exciting for me, others not as much. This is simply meant to put down in writing what I experienced and how I felt during those times. Take it as you will.

Baby N

First child! I was an exemplary husband, or so I thought. I went to all the birthing classes, went to the tour of the hospital. I don’t think I missed a single OB/GYN appointment. I knew a lot about what was going to happen; well, I thought I knew. I mean, reality… well, I think most of us know how that is.

When the day came and we went to the hospital, we figured we would take along my wife’s mother. It would be a great experience and be helpful. I am very thankful for my mother-in-law for all her help, but this made for some awkward moments and made it difficult to talk to my wife in private. I was very nervous, but I thought I knew it all. We were joking about not taking an epidural, about why you would suffer pain when you do not have to. I was very casual about it; hell, at some point we ordered pizza to the delivery room. She pushed for a long time. It was nice for me at that time, I got really involved. The nurse had me help. I felt it was great. I got to hold a leg up, and look at the entrance to see if someone is coming out. I don’t think I thought too much about her pain and how she was feeling in all of this. At the time I thought I was great; today, I realize I was rather inconsiderate.

When the doctors “finally” offered a c-section, I was happy. Great, they will take him out, he won’t have a squishy head, and my wife parts will remain intact. Yes, men think about that. Well, some of them. Got all scrubbed up, the nurse asked me if I had a camera. I thought that was funny. I went in to the OR to find my wife lying in a crucified position (thankfully, my mother-in-law was not invited to this occasion). It was still all cool. I sat by her head, trying to make my usual silly jokes. I was in a huge adrenaline rush. Everything was happening pretty quickly. Pretty soon I got to hold the baby. I got to hold him first. Well, she couldn’t, being that she was crucified to an operating table and half numb. Looking at him, hearing his cry… the newborn cry is great. It hits me in a soft place every time. But the first one, it was amazing.

Then they took him away to the nursery and took us to another room to recover. Apparently she lost a lot of blood. I did not realize it then, not even when they sent a specialized trauma nurse to see her. I think it is a good thing I was high on adrenaline, or I would have freaked out. That one took a long time to settle.

At the stay at the hospital, for the next five days, I was also being great. I came by, fed the baby, and changed him. I was rather happy she did not breast feed. I got to play with my new baby a lot. This continued after she got home. They sent us home with a bili light machine, to treat his jaundice. Still, I was being cool, letting her sleep and rest while I took care of him. Every day I would change him, feed him, and wash him. All she needed to do was rest. I was supportive of her attempt to breast feed, but when she couldn’t, I was not upset. I get to keep playing with him, feeding, feeling so helpful. What a great husband I was being. This continued for about 3 months, until we moved to California, where I suddenly had to work more, and leave her alone with him.

Only much later, as she was getting ready to have Baby S, did I realize how bad I was at the time. I distanced her from her baby. I felt I was being helpful. She felt I was being helpful. But, that was not the right way to do things. I pushed what I wanted, and at the same time thought to myself, “Why is so distant from him?” There are ways to be helpful, but I do not think this was the right one. Now, I know I was being selfish. I did not see how she was unhappy, how this had made her feel.

It took me a while to change my way of thinking, and see how important it is to her. I can’t say I quite understand it yet. But, with Baby S, things were different.

That’s the first story. I think this post has gone long enough, so I challenge you to help the Facebook page get 200 likes to hear so I can tell you what comes next! 

I will say this to any men out there who are about to have a baby: It is indeed a lot about her, and not because she carries all the burden of the pain, pregnancy, delivery, etc. It is because, in the end, I do think the outcome will affect her a lot more. So, get involved, but also remember that the best help you can give is to push her to achieve what she wants. To quote Coupling, “Ask her three times” if she’s sure. But when you do ask her, make sure you mean it.

Monday, November 25, 2013

Coming Home with Baby: What to Expect on Days Three and Four Postpartum

Assuming you had an uncomplicated, vaginal birth in a hospital, you'll be going home on day two or three postpartum. Legally, in the United States, insurance is required to pay for 48 hours postpartum in the hospital, and it's up to you, your family, your doctor, and your baby's doctor whether you want to stay for that long or if you want to go home sooner. This will depend on your health, your baby's health, and how confident you feel about taking full responsibility for your care and your baby's care weighed against how much more comfortable you'll be at home compared to the hospital environment. Many first-time parents prefer to take the full 48 hours in order to have assistance with breastfeeding, diapering, and general baby care, while more veteran parents are often in a hurry to get home to the older kid(s) and back into an already-established routine. (On the other hand, if you have several children, you may enjoy the relative quiet of your hospital room!)

Leaving the Hospital
When you're getting ready to leave the hospital, make sure you collect everything you brought. Don't forget small things like your cell phone charger, eyeglasses or contact lenses, jewelry and watch, and so forth. Go over the room a few times and collect everything that belongs to you.

Then, collect everything that the hospital gave you. Sanitary pads, ice packs, peri bottle, mesh underwear, diapers, alcohol wipes, bottles, pacifiers, thermometer, bulb syringe, breastpump parts, baby wipes, samples of baby shampoo, water bottle - anything they gave you that's consumable, they have to throw away when you leave. You're paying for it, one way or another, so you may as well take it with you. The only things they'll ask you to leave behind are typically the hospital gown, the baby shirts, and the receiving blankets (although we've ended up with more than a few hospital receiving blankets over four kids, so somehow quite a few of those have slipped through...). Often the nurses will offer to bring you more of anything you might need, such as another pack of diapers. Accept it! The less you have to worry about running out to buy the minute you get home, the better. (The only thing I'd recommend leaving behind, if offered, are formula samples if you're breastfeeding. See my "Just One Bottle" post for more on that topic. Or, take them with you but don't make them easily accessible.)

Have your partner or whoever is taking you home bring up the infant car seat (if you're using one) from the car so you can take your time buckling your baby securely. See my videos (here and here) on properly buckling your newborn in the car seat for instructions on keeping your precious new baby safe on his first car ride. (If you're starting out with a rear-facing convertible car seat, obviously you'll have to carry the baby down to the car and buckle her in there. I'm not suggesting that you wouldn't be using a car seat at all!)

Baby Blues
Whether you're still in the hospital or back home, days 3 and 4 postpartum will be very difficult. There's a major hormonal plunge at three days postpartum, which usually coincides with your milk supply increasing dramatically. Your progesterone levels, which were kept high by the placenta, finally plummet, now that the placenta has been delivered. Progesterone inhibits milk production, so when the placenta is delivered and progesterone levels fall, milk production suddenly increases. This is when you'll see the changeover from small amounts of colostrum to a much larger volume of milk.

While a welcome change as far as feeding your baby, this increase in milk production can cause new problems. Even if breastfeeding was going well up to this point, your milk volume increase may result in engorgement, making your breasts bigger, hard, and painful to the touch, which can make it difficult for your baby to latch, even if there were no problems with her latch before. The speed and force with which your milk may emerge from your breasts may confuse or upset your baby, who was used to the slower, thicker flow of colostrum. These combined issues may cause frustration for you, adding to the hormonal and emotional roller-coaster of the first week or so postpartum.

The result of this perfect storm of hormonal and physical changes is often inconsolable, irrational sobbing. Many newly postpartum women find themselves crying over nothing. I remember dissolving into tears because I couldn't figure out what to do about feeding my two older kids lunch when my third was three days old. Sometimes, your crying may be triggered by nothing at all, while other times small stressors can result in big sobs.

It's important to know to expect these "baby blues," because at least if you know it's coming, you can be prepared to ride out the crazies. Make sure your partner and other support people know about this phenomenon so that they'll know that your crying is not something they did wrong and so they can remind you that it will pass. You may feel overwhelmed, incompetent, or confused. Having someone there who can remind you that you're doing great, that this will pass, and to help you with all the little things that suddenly seem monumental will be vital. And if you do need to cry, go cry. Let it out. Crying releases toxins and is very freeing and cleansing, even if it's not much fun. Better to sob it out than try to hold it in.

Ask for Help
Ask for help. Ask for help. Ask for help. If you need assistance with breastfeeding, with housekeeping, with meals, with shopping, with simple baby care, a ride to the doctor, a cup of coffee, or someone to keep you company, ASK FOR HELP. If someone says, "What can I do?", tell them. If they offer, accept the offer. Be kind to yourself. Don't expect to be able to do everything yourself, even if you're used to being in charge and handling it all. You cannot handle everything at three days postpartum, and no one, including yourself, should expect you to. Your postpartum time is just about universally accepted as a time to rest, bond with your baby, and learn about parenthood (even if you're a parent for the second or third or fourth time!). Your body is healing, your brain is changing, and your life will never be the same. Lie down and let someone else take care of the mundane stuff.

Postpartum Depression
Baby blues should not last more than a week or two and should not be accompanied by severe anxiety, thoughts about harming yourself or your baby, hallucinations, or extreme paranoia. If you experience any of these more severe symptoms or if your "blues" last more than two weeks, contact your OB or midwife immediately. These are signs of postpartum depression, postpartum anxiety, or even postpartum psychosis, which are serious but can be treated with therapy and/or medication. Many psychotropic medications are compatible with breastfeeding and can help you feel like yourself again. Don't be afraid or ashamed to reach out for help if you suspect there's something more than hormonal changes going on.

Uterine Cramps and Bleeding
Especially if this is not your first baby, the cramping caused by your uterus shrinking back to its prepregnancy state can be fairly painful. If you were prescribed pain killers, take them! Ibuprofen (Advil/Motrin) and acetaminophen (Tylenol) are both compatible with breastfeeding, and even narcotics such as Percocet and Vicodin used sparingly are relatively safe (although narcotics may make your baby sleepy - if you don't need them, it's probably better to avoid them). If you are in pain as well as having emotional symptoms, you will find it hard to enjoy your baby and your rest. Your postpartum bleeding should have slowed but will still be relatively heavy. Don't overexert yourself. If you soak through a maxipad in less than an hour, see clots larger than the size of a golf ball, or have a fever, contact your provider, as these may be signs of postpartum hemorrhage or infection.

Vaginal Symptoms and Hemorrhoids 
If you had a vaginal delivery and tore at all or had an episiotomy, this will still be healing. Don't squat or try to lift anything heavy, as this may tear your stitches and cause additional damage. If you're still experiencing swelling or any external pain, using ice packs and witch hazel on the area may help. Also, taking a sitz bath may speed healing and relieve pain and swelling. If you were given a cooling or numbing spray or foam, use it as directed. Drink plenty of water and avoid constipating foods to keep your bowel movements soft and help your hemorrhoids heal. Hemorrhoidal creams can be soothing as well. Use your peri bottle to clean your perineum after using the bathroom so that you don't have to wipe too aggressively with toilet paper.

After a C-Section
If you had a c-section, you'll likely still be in the hospital at three days postpartum. After my c-section, on day three, I woke up in the middle of the night crying. My nurses insisted that I was in pain and brought me more pain pills, but I knew that wasn't it. It turned out it was the aforementioned baby blues, which I had no idea existed! I was resentful that the nurses also didn't seem to know what was going on and that no one had warned me to expect them. A c-section will also cause different physical issues as well. Your incision is still very new at three and four days postpartum, and laughing, sneezing, and coughing will be painful. Hold a pillow against your middle if you need to do any of these things to help support and protect your incision. Watch for signs of infection such as smelly discharge from the incision site and fever. Follow your doctor's and nurses' instructions for keeping the incision site clean and dry. Some of the treatment will depend on the type of incision and the type of sutures used. You will still experience postpartum bleeding and cramping, and if you had the c-section after pushing for any length of time, you may also experience some perineal swelling and hemorrhoids.

Breastfeeding Help
As alluded to above, day three and four may present new breastfeeding challenges, as your milk volume increases and you experience engorgement for the first time. If you are so engorged that your breasts are hard and painful, or the engorgement causes your nipples to flatten out such that your baby cannot latch, it may be helpful to express some milk prior to feeding. Use warm compresses or take a warm shower to help start the milk flowing, then use hand expression (NSFW video) or a breast pump to remove some milk. If you are in severe pain, taking pain medication can sometimes relieve some of the pain so that you can express. Pump or express just enough to soften the breast so that the baby can latch and to relieve the rock-hard feeling. Removing more milk than necessary will signal your body to produce more milk, which will perpetuate the cycle of engorgement. You want to train your body to make the amount of milk your baby needs, so feed the baby on demand and let him nurse as long as he desires, and pump only enough for comfort. (Do save whatever you pump, either for later bottle-feedings or to donate.)

If you are having any breastfeeding difficulties, contact a lactation consultant, La Leche League Leader, or an experienced breastfeeding friend for help. Many breastfeeding issues can be solved with a little intervention, but if they are not addressed, they can become big problems. Some techniques that can help in the meantime are making sure your baby is latching well, keeping baby skin-to-skin as much as possible, and trying different breastfeeding positions to see if any of them are more effective or more comfortable for you or your baby.

For a proper latch, make sure baby's lips are flared outward, that his mouth is opened very wide, that his tongue is over his lower gums, and that your nipple is far back in his mouth; some of the areola should be in his mouth as well - he should not be sucking just on the nipple.

Follow these four rules to help with positioning:
1. Tummy to tummy: Keep your baby facing you, with ear, shoulder, and hip in a straight line.
2. Nipple to nose: Align your baby's head so that your nipple points to her nose. Brush your nipple down across her lips to her chin, then drop the nipple in when she opens her mouth wide.
3. Allow the baby to tilt his head back slightly: Don't crunch your baby's chin down toward his chest, and don't put your hand on the back of his head. Instead, support his head at the base of the skull so that he can tilt his head back slightly. This will help get a deep, asymmetrical latch.
4. Bring the baby to your breast, not your breast to the baby: Don't be afraid to pull your baby in close. Support your arms and back with pillows if you need to. You don't want to be hunched over and stretching your breast toward the baby's mouth. Rather, pull the baby close to you and straighten your neck and shoulders.

See my "Breastfeeding a Newborn" (here and here) and "Breastfeeding Positions" (here) videos for more help.

If your nipples are damaged, talk to a lactation consultant about using a nipple shield to protect your nipples and help your baby latch. Also, you can use lanolin to help them heal. Hydrogel pads can assist with pain and healing as well.

What surprises did you encounter in the early days postpartum? What other tips or advice would you add?

Monday, November 18, 2013

Tips for Your Postpartum Hospital Stay

If you choose to give birth in a hospital, which is the norm in the United States, I think it's important to distinguish your postpartum hospital stay from being hospitalized for illness, injury, or surgery. Obviously, if you've had a c-section, you are recovering from surgery as well as having a postpartum stay, but some of this will still apply. If you had an uncomplicated vaginal birth and you and your baby are healthy, the hospital stay can actually make recovery more difficult by making you feel like you're in a sick environment when you are not, in fact, sick. I hope some of these tips help you make the most of your postpartum hospital stay.

The Hospital Bag
I'm in favor of "less is more" when it comes to packing for the hospital. Here's what I recommend you bring:
- Some comfortable clothes - pajamas or sweats, for example, and maybe a bathrobe - to wear in place of the hospital gown
- The outfit you want to wear home. You'll be able to fit into clothes that fit you at about mid-pregnancy, but you won't have your pre-pregnancy shape back at one or two days postpartum. Wear something comfortable.
- Something for the baby to wear home. Most people pick out a "going home" outfit for the baby.
- Bring a blanket for the baby if the weather is cool, in case the hospital doesn't let you take any receiving blankets with you.
- Bring something to occupy your time but doesn't take much brainpower - my phone was really the only entertainment I needed (for Facebook, Reddit, and games). Most hospitals have Wi-Fi and will allow you to use your phone whenever you want. Don't forget your charger! A book to read, some puzzles maybe, music to listen to if you find that relaxing. But you'll be groggy, and busy with the baby, and trying to rest, and you probably won't be as alert as you're used to being.
- Toothbrush, toothpaste, and any toiletries you can't do without. The hospital can provide most toiletries, but they'll be cheap "all-in-one" items, so if you need your certain body wash, lotion, etc., be sure to bring it with you.
- Deodorant/antiperspirant - You'll sweat a lot. Postpartum hormones make your body do crazy things. Bring deodorant.
- Glasses, contact lenses, contact lens solution. If you wear contacts, don't forget this stuff. Really.
- Hairbrush, hair ties, other basic hair care products you can't live without. You probably won't need to be styling your hair or going through your whole morning routine, but no one wants to go two or three days without brushing her hair. At least, I don't.
- Food. You'll be hungry, and the food the hospital provides may just not be enough. Bring some snacks.

Personal Hygiene
As soon as you feel strong enough - and this may take 24 hours for some of you (it did for me), take a shower and get out of the hospital gown and into a comfortable outfit you brought. I like wearing the gown and using the hospital-provided pads and such the first day, because you'll be bleeding a lot, and this way you don't have to worry about staining your own clothes. However, by day two, unless you have some complications, your bleeding should be more controlled and the smaller pads will suffice. At that point, getting into a pair of sweatpants or pajamas will feel great and make you feel less like you're convalescing. I do like to continue to use the disposable mesh underwear the hospital will give you, just to keep the staining potential to a minimum. Also, take an opportunity to brush your teeth, apply deodorant, and do anything else that makes you feel more human.

Baby Care
Do as much of the baby care yourself as you can. Take care of the diaper changes, feed the baby yourself (whether breast or bottle), and be present for any tests, checkups, and procedures the nurses and doctors perform. If possible, request that these procedures take place in your room. Keep the baby with you at night (unless you are not ambulatory or cannot care for the baby appropriately for any other reason) so you can feed and tend to her yourself. Hold the baby a lot.

As soon as you can walk farther than from your bed to the bathroom, get out of your room. Get out of your room. You'll probably be advised to take your baby out in the bassinet and walk the halls. Do that. It's not exciting, but it's nice to be reminded that there's a world outside your room. You might even get to meet other new moms or dads out there. Walking will also help to rebuild your strength.

Limit Visitors
Everyone's going to want to meet your new baby, but for your sake, limit visitors. Spend as much time as possible alone with your baby and your partner, or even just alone with your baby. If you constantly have people in and out of your room (and you'll have plenty of hospital staff barging in at all hours), it's hard to find an opportunity to simply rest. Also, you may find it awkward to breastfeed with visitors around. When you're first learning to breastfeed, it's difficult to do discreetly, and you may not be willing to expose your breasts to all manner of relatives and friends. Tell family and friends that you'll be happy to see them in the coming weeks, but that right now you just need to spend time with your baby and rest.

Doesn't matter what time it is, if you've got an hour to sleep, take it. It's very hard to get enough sleep when you're in the hospital, so when you can, do.

The hospital will likely provide some kind of big ol' cup for you to drink from. Drain it and have it refilled, then drain it again. Drink, drink, drink.

What other tips do you have for new moms in the hospital? What do you wish someone had told you? Was there anything your hospital did that you felt was particularly helpful or unhelpful?

Friday, November 15, 2013

Jessica on Babies Life Shots: New on YouTube

If you haven't subscribed to my YouTube channel, you should go check it out. The Ask-Me Monday feature is still going strong (Have a question? Go like the Facebook page and ask!), and I'm adding new videos regularly.

We've started a new features called "Life Shots," snippets of my life with four boys. The first went live today. What's breakfast like at your house?

Monday, November 11, 2013

Weird Newborn Stuff: The First Two Weeks

Baby Y is just three weeks old now, and I'm remembering all the weird stuff about newborns, especially very, very new newborns. Newborn babies aren't like older babies, and they definitely aren't like older children or adults. They sometimes seem quite alien!

So what weird stuff is actually normal for your newborn?

Alien and Animal Noises
Newborns make weird noises. They snort and snuffle. They mew and wail. They trumpet. Baby Y alternately reminds me of a kitten, an elephant, and a hippo. Sometimes it looks like they're in a badly-dubbed movie, where the sounds coming from their mouths don't seem to match the shape their lips are making. It's bizarre, but it's normal!

Remember, newborns are just figuring out how their mouths work. They're just learning how to make sounds. In the womb, they couldn't make noises, so while they could practice moving their limbs, sucking, and mimic a breathing pattern, they couldn't actually make noise because they didn't have air to breathe and pass across their vocal cords. They also don't have much fine control over what their lips and tongue are doing, so they can't intentionally make specific sounds. Enjoy the weird alien noises your baby makes. Soon enough, she'll be repeating syllables and mimicking you.

Strange Eyes
If your baby is destined to be blue-eyed, she will likely be born with her true eye color. But if your baby will have brown eyes, he will likely be born with a dark grayish-blue eye color that will change over the next few months as the brown pigment starts to show up. Newborns also can't focus beyond about 12 inches from their faces (interestingly, about the distance from his face to Mom's face when nursing or being held) and will often appear cross-eyed.

Umbilical Stump/Bellybutton
The umbilical cord stump takes approximately five days to two weeks to fall off. In the meantime, it basically dries out and rots away. It's...gross. It may smell bad. It may ooze blood. And yet, it does not hurt the baby. Everyone (nurses, doctors) who saw my baby told me "don't do anything to it." You don't need to wipe it with alcohol, you don't need to use any creams or ointments. Just keep it dry and wait. And sure enough, on day 5, off it fell. But boy was it stinky until it fell off and started to heal!

Random Arm and Leg Flailing
When a newborn gets really hungry, he'll start waving his arms around frantically, but once you get his face near the boob, he'll often turn away from it or push it away accidentally! Poor kid hasn't figured out how all these body parts work. When he's calmer, he might also move his arms very gracefully, as if conducting his own internal orchestra. As for the legs, their muscles are still quite tight when they're so little, from being curled up in the womb. They'll kick their legs, especially during diaper changes, in a most unpredictable fashion. I've learned to "work with the kicks" when putting pants or a footed sleeper on a tiny baby, and it's hard to keep their little feet out of their diapers when you're changing them. Not to mention how much my newborn hates having his diaper changed and cries hysterically and kicks like mad whenever I try.

Angry Face!
Their facial expressions are as random as their noises and arm movements. They're still learning what has meaning. My favorite expression is the angry face when he's about to cry. He's just so mad that he isn't drinking milk yet! And, of course, most two-week-old babies don't smile yet, but sometimes a passing gas bubble will elicit something that looks like a smile, and is at least a preview of that beautiful expression you'll be seeing very soon.

Pooping and Farting are Whole Body Experiences
A newborn trying to poop is just about as dramatic as his mother was a few days prior trying to push him out! The legs kick in and out, the back arches, incredible sounds emerge from the tiny throat, until finally...pffffft, out shoots whatever was building up inside. The best is when they look completely surprised at the feeling. Newborns let you and everyone within a 50-foot radius know when they're having intestinal difficulties. And just as a word of advice: Don't change a diaper right away when you catch them pooping. Give it a few minutes to make sure he's really done, and then another few minutes after that just in case. Sometimes the act of wiping will stimulate some additional...output.

Of course, the most important way your newborn will communicate with you is by rooting when she's hungry. When she gets really enthusiastic, she'll resemble a baby bird eagerly awaiting her mother's return with some delicious regurgitated earthworm. Only, hopefully your milk is more palatable than regurgitated earthworm. Sometimes the rooting is so enthusiastic that she won't realize you've presented your nipple for her nursing pleasure, and she'll root in the opposite direction. It takes a few weeks for everyone to figure out where everything is.

If your baby feels like he is falling backward, he will fling his arms out and startle. If he is lying calmly on his back, his arms will end up in the "archer pose." These are strange newborn reflexes that are outgrown fairly quickly. There are others, such as "stepping," where if you hold a baby upright and let his feet touch a surface, he will appear to try to walk.

Switched Days and Nights
Most newborns, especially in the first week, have no idea about the very important difference between day and night. For them, in the womb, it was always dark, and often they were more likely to be awake at night than during the day. Many new babies will sleep very nicely during the day and then much more fitfully at night - or even be wide awake! - for a few days or even a few weeks. Eventually, their biological rhythms will start to match yours, and they'll learn that sound sleep is for the night. Expose them to daylight and activity during the day, and make sure you keep things quiet and unstimulating during the night, and they'll get it figured out. I certainly won't tell you "sleep when the baby sleeps," because I hate that advice, but it probably wouldn't be a bad idea to share at least one of your new baby's daytime naps in those early days. Remember, you need your rest, and you might have to get it during the day for a little while.

Enlarged Genitalia and Other Unfortunate Hormonal Side Effects
Baby boys are often born with proportionately large genitalia and can even get erections (although not through sexual arousal, of course). Baby girls and boys(!) sometimes have breast buds, can get mastitis, and may even produce a small amount of breastmilk. Both boys and girls may develop facial acne. Baby girls sometimes even have period-like bleeding. All of these strange events are a result of the mother's hormones still circulating in their tiny bodies. Eventually all of these excess hormones will clear out, never fear.

What weird things happened in your baby's first couple of weeks that freaked you out but turned out to be totally normal?

Tuesday, November 5, 2013

Jaundice, Part II: What is Jaundice and How is it Treated?

This is the second in a two-part series on jaundice, a relatively common and usually mild condition that occurs in newborn babies. In Part I, I described my own experience with jaundice in my fourth baby. Here in Part II, we'll look at jaundice from a clinical perspective.

What is newborn jaundice?

Jaundice in newborns is caused by rising bilirubin levels in the blood. Bilirubin is a byproduct of the breakdown of red blood cells, which all babies have an excess of at birth. Normally, bilirubin is processed by the liver and excreted through bowel movements. While many babies will effectively and efficiently process this excess bilirubin, some babies have too much bilirubin, or their liver can't handle all of the bilirubin they're producing, which causes it to build up in the blood. When this happens, some of the bilirubin is passed to the skin, which will give the whites of the eyes and the skin a yellow-ish tint. If the bilirubin levels in the blood reach high levels, treatment may be recommended.

There are three basic types of jaundice found in newborns:
  • Physiological Jaundice is the normal course of elevated bilirubin caused by the breakdown of red blood cells in the newborn baby. This type of jaundice is normal and not dangerous unless bilirubin levels reach a certain threshold. Most babies will require no special treatment.
  • Breastfeeding Jaundice occurs when a breastfed baby isn't getting enough to eat in the first several days of life. Because he is not feeding well, he is not having enough bowel movements to clear out the bilirubin from his system. If bilirubin levels reach a certain threshold, various treatment scenarios may be proposed. Otherwise, assistance with improving breastfeeding is typically all that is needed.
  • Breastmilk Jaundice occurs in a very small percentage of babies and is when an exclusively breastfed baby has elevated bilirubin levels but no other symptoms of jaundice and is feeding well and growing as expected. This is not a dangerous condition and will typically resolve within 6 to 10 weeks without intervention.
Notice that all three types of newborn jaundice usually resolve without treatment. Once good feeding is established and the baby's digestive system is kicked into gear, he will clear out the bilirubin on his own. 

Jaundice occurs more commonly in premature babies or babies whose liver may otherwise be compromised. It also may be caused or complicated by blood type incompatibility between the baby and the mother, birth injury, medications, or infection.

My oldest son N with jaundice. You can see how yellow his forehead looks. He was being treated in the hospital and was taken off the lights for a feeding in this picture.

When does jaundice need to be treated?

The trouble with elevated bilirubin is that it is known, at high levels, to cause a totally preventable, irreversible, severe brain damage called kernicterus. Kernicterus occurs when bilirubin literally stains the brain cells. Babies with kernicterus will suffer lifelong mental retardation, which may include both physical and cognitive delays. Kernicterus happens when the bilirubin levels in the blood are so high that bilirubin is conducted into the brain. It is not known what these levels need to be to cause kernicterus, and it is not clear if simple physiological jaundice, breastfeeding jaundice, or breastmilk jaundice alone can cause this terrible outcome or if other complications are involved. It is clear, however, that by reducing bilirubin levels before they reach a high concentration will prevent kernicterus.

To determine if your baby is at risk for needing additional treatment for jaundice, your pediatrician will order a blood test to measure your baby's bilirubin level. This will be plotted on a chart along with the baby's age (see below). There are four identified curves on this chart: Low Risk, Low Intermediate Risk, High Intermediate Risk, and High Risk. If your baby's bilirubin levels fall into the High Intermediate or High Risk zone, treatment will likely be recommended.

Find your baby's age along the bottom and plot the Serum Bilirubin level on the vertical axis 
to see which zone your baby's jaundice risk falls in.

Aside from kernicterus, jaundice may cause other difficulties in the early days of your baby's life, which may prompt your doctor to recommend treatment or management. High levels of bilirubin may cause your baby to become sleepy and uninterested in eating. This will make it more difficult for your baby to clear out bilirubin, and it will mean fewer feedings at the breast, which may cause a delay in your breastmilk increasing in volume, or it may cause a low supply due to lack of stimulation. This, in turn, will mean your baby is not getting enough to eat even when he does wake to eat, which will make him more dehydrated and lethargic, which will make him less likely to wake to feed, which will further reduce the amount of calories and fluids he takes in, which will worsen the jaundice and continue the cycle. This is a very dangerous cycle because you end up with a starving baby and a delay in milk production or a reduced supply. In this case, treating both the feeding issues and the jaundice are priorities.

Most pediatricians will recommend treating any kind of jaundice before bilirubin levels reach 20mg/dL in the blood. Most babies will not reach this critical point, but some may approach it, and it is important to know what the treatment options are so that you can make an informed decision about whether, when, and how to treat your baby for jaundice.

How do we treat jaundice?

The simplest treatment for jaundice is feeding. If your baby has not been feeding well, increasing the number and quality of feedings will help stimulate bowel movements and clear out the bilirubin. Make sure your baby is eating at least 12 times a day and that when he feeds, he is actually taking in colostrum or milk. Watch for signs of a deep suck and swallowing when your baby is feeding. Make sure he is actively sucking and swallowing for at least several minutes at a time. If he falls asleep at the breast after a very short time, try to stimulate additional sucking by massaging the breast while he is latched on. You can try to wake the baby by burping him or changing his diaper and then return him to the breast for further feeding. Also, be sure to monitor diaper output. 

If your breastmilk has not increased in volume by the end of the third day postpartum (72 hours), it is important to feed your baby from some other source, whether donor breastmilk or formula. The number one rule, here, is feed the baby. Ideally, this supplementation would occur at breast using a feeding tube or syringe so that the baby can continue to stimulate milk production while receiving the supplemental milk or formula. A three to four-day-old baby does need more than colostrum, though colostrum is enough for a baby in the first and second days of life.

If the baby is feeding well but bilirubin levels remain in the High or High Intermediate Risk zones on the above chart, phototherapy may be recommended. Phototherapy involves the use of a special blue light that shines on the baby, with a maximum amount of skin exposed to the light. The light breaks the bilirubin down into a water soluble form that the baby can excrete through his urine. This, in addition to regular bowel movements, will bring down his bilirubin levels much more quickly. Phototherapy can be done in the hospital nursery or at home using a portable phototherapy device. Your doctor will likely have a preference as to whether to keep your baby in the hospital (or readmit him) to use the hospital phototherapy bed or whether to have a home healthcare service bring you a home phototherapy machine to use. It typically takes 12 to 24 hours, or up to two days at the outside, of phototherapy to bring down bilirubin levels to an acceptable range. It is important for the baby to continue to feed regularly while under phototherapy. Continue breastfeeding about every two to three hours. Phototherapy is not invasive and not painful for the baby. The baby is kept warm and generally just sleeps while under the lights.

Baby N on home phototherapy. A pad that emits light is against his back, connected to a machine 
by the gray tube you can see emerging from his blankets.

Some pediatricians may recommend supplementing with formula for 12 to 24 hours, or even a course of "interrupted breastfeeding" for 12 to 24 hours, to clear out breastfeeding or breastmilk jaundice. This path only becomes necessary if breastfeeding is not going well and the baby is clearly in need of feeding beyond what he is getting from his mother alone. Supplementation with formula will help to treat the jaundice, as it will cause the baby to pee and poop much more than from colostrum and early milk alone. It will also help to rouse a baby who is lethargic from lack of feedings and/or high bilirubin levels and may be helpful in severe cases. However, be aware that introducing formula may have other long-term consequences to your baby and your breastfeeding relationship. It is important to weigh the risks and benefits of supplementation. If possible, discuss these risks with your pediatrician and a lactation consultant before making your final decision. If you do choose to supplement, be sure you do not reduce the amount of at-breast feeding your baby does. If you cannot be with your baby, you should pump your breasts every two to three hours, or in between feedings, to stimulate your own milk production. It may be possible to supplement your baby with your own pumped milk rather than formula, if you are able to produce for a pump.

How long does it take for jaundice to go away?

Bilirubin levels will generally peak between days four and six of your baby's life and then taper off into a normal range in about one to two weeks. Your doctor may want to monitor your baby's bilirubin levels until they begin to fall by ordering daily blood tests. Assuming your baby is otherwise healthy and feeding well, once it is clear that his bilirubin has begun to fall, no further treatment will be necessary. Typically, once bilirubin levels peak and begin to drop, they will continue this downward trend.

The exception to this is breastmilk jaundice. Babies with breastmilk jaundice may appear yellow and have elevated bilirubin for up to about 10 weeks of age. Breastmilk jaundice is not dangerous and will go away on its own. As long as the baby is otherwise healthy, alert, feeding and growing well, and meeting milestones, you can simply wait until the jaundice resolves. Some pediatricians may recommend interrupting breastfeeding (stop breastfeeding and give formula) for one to three days to clear out breastmilk jaundice. While this will effectively "treat" the jaundice, it may have a negative impact on your breastfeeding relationship as well as introducing other risks of formula feeding. Unless there is other cause for concern, this is probably not a necessary step in simple breastmilk jaundice.

In the first week of life, while bilirubin is still elevated, watch your baby for sleepiness, not waking to feed, floppiness, and dehydration (urine crystals in the diaper, dry mouth, sunken fontanel). Examine your baby in natural light to look for increased yellowing. Contact your pediatrician immediately if you have any cause for concern.

Also, be aware that jaundice tends to run in families. If you have one baby with jaundice, there is an increased chance that a future baby will have jaundice as well. Jaundice is more common in boys than girls, as well. Indeed, all four of my boys had jaundice! 

I hope this information* helps you to have an meaningful conversation with your pediatrician if your baby is diagnosed with jaundice.

*Please note that I am not a medical professional and cannot offer medical advice. This information is provided for your education only and should not be used in place of the advice of your pediatrician during an in-person examination.

Monday, November 4, 2013

Baby Y's Birth: Photos

I've told you Baby Y's birth story, but I wanted to share some of the photos my husband took of the labor and immediate post-delivery.

Arrival at the hospital, smiling during a (short) break in contractions. So happy this pregnancy is almost over!

Checking in on Facebook! Gotta keep my people informed!

Contraction face.

Oof, that hurts!

Breathe and blow!

At this point, labor had picked up, I had turned around to face the wall, and my husband was busy at my head helping me through the contractions and pushing phase. And then...

It's a baby!

Being warmed and stimulated. His color wasn't pink enough for the nurses.


While we're here, let's weigh him! Look at that big boy!

Whew, I did it!

Okay, time to breastfeed.

Come on, nurse!

Okay, some relaxing skin-to-skin.

More skin-to-skin.

Stick out your tongue!

Yay, latched on!

My awesome doctor and nurse.

Yay, he's nursing!

First breastfeeding.

Checking my notifications.

Updating Facebook again.

Aw, everybody's happy.

Switching sides.



Tuesday, October 29, 2013

Jaundice, Part I: Baby Boy Turns Yellow

This is the first in a two-part feature on jaundice. In this post, I'll tell you Baby Boy #4's jaundice story, and in the next post I'll address jaundice from a more clinical perspective. Now that Baby Boy has been named, we'll call him Y.

At 5:30 a.m. on Tuesday morning, when Y was about 27 hours old, the nursery did a heel stick to draw blood for his PKU test. This is a standard newborn screening done at approximately 24 hours of age. At the same time, they checked his bilirubin levels to see if he was at risk of needing treatment for jaundice. Most people know jaundice as a yellowing of the eyes and skin due to various problems associated with the liver. In newborns, it's a relatively common condition due to the breakdown of excess red blood cells in the baby's body after birth. Most babies will clear out the bilirubin on their own without needing special interventions, but some babies will have bilirubin levels high enough to elicit concern, as very high levels of bilirubin may cause irreversible brain damage called kernicterus.

But back to Baby Y. When the pediatrician came in to check him over and report on his test results, the first words out of her mouth were, "Did any of your other kids have jaundice?" When I told her all three had, and two had required home phototherapy, she nodded. She showed me his bilirubin level, which was 8.6. For his age, this was considered "high intermediate risk". If the number climbed into the "high risk" zone, he would require treatment. The chart below is the standard risk chart for newborn jaundice. You find the baby's age in hours along the bottom, then plot the bilirubin level on the left and see what curve you fall along. A level of 8.6 in a 28-hour old baby was near the high end of the high intermediate risk zone.

The question then was, do we take a wait-and-see approach, or do we take it on more aggressively, knowing that (a) all three of his brothers had relatively high bilirubin levels, and (b) he was already nearing the high risk zone? Levels usually peak between 4 and 6 days of age and then fall off gradually. To clear out bilirubin, the baby needs to poop, which means the baby needs to eat. Since breastmilk supply doesn't usually increase until day 3, and most babies under 3 or 4 days of age are still clearing out meconium, it takes a few days for the excess bilirubin to be excreted. I was still only producing a small volume of colostrum, and Baby Y wasn't pooping much, so we knew his levels would continue to rise for another day or two, at least. But we didn't know if they'd rise sharply or level off. There's really no way to know what will happen in any given baby.

I had been planning to go home on Tuesday, though I was technically entitled to another night in the hospital if I wanted to stay. The pediatrician suggested that I stay Tuesday night and let Baby Y have jaundice treatment through the night. In this way, we might be able to bring down his bilirubin levels to the low intermediate risk zone and then, even if the levels continued to rise a bit for another day or two, they would likely stay on that low intermediate risk curve. If we didn't treat Tuesday night, we would need to monitor him closely (by taking blood daily to measure his bilirubin levels), and if his numbers rose into the high risk zone, then we would need to treat, which might entail readmission to the hospital for him, meaning I'd have to find a place to stay because I would no longer be an inpatient there.

This put us in a tricky position. On the one hand, I really didn't want to spend another night in the hospital. I wanted to get home to my other three kids, I wanted to come back to life and out of the sickly-feeling, "I'm in the hospital" mode. On the other hand, it seemed the easiest way to ensure that Baby Y's jaundice would be managed with the least amount of hassle. A secondary, but real, consideration was that if his jaundice became severe, his bris would have to be delayed. This had happened with our second baby, and we needed to know if that would be necessary for Baby Y. It seemed that treating him Tuesday night would stave off this potential complication as well.

The pediatrician suggested that we talk it over and that she order another blood test for the afternoon. If the number still placed him on that high intermediate risk curve, or, G-d forbid, was even higher, then that might help us decide for sure whether to stay the night or not. I agreed that this was a good suggestion. So, at 36 hours of age, his blood was taken again, and his bilirubin level was 10.7, still on the high end of the high intermediate range, and likely to continue to rise for at least another day or more. We decided to take the aggressive approach. The goal was to keep him under the "bili lights" for the night, in the hope of getting his bilirubin levels to level off or even drop. If the numbers fell into the low intermediate risk range by morning, then we could feel comfortable going home and not worry so much about having to be readmitted for treatment or taking blood daily to monitor him. A clinical approach, visually examining his color, looking at other symptoms, would be enough to monitor his health, and further testing or treatment would only be required if any other symptoms gave his doctor or me cause for concern. (I will discuss all of these symptoms and risks of jaundice in part II of this article.)

At about 7:00 p.m., Baby Y was whisked off to the NICU to be placed under the bili lights. Basically, bili lights are flourescent, blue lights that break down the bilirubin into a water-soluble form that the baby can then pee out, in addition to the bilirubin being excreted in his bowel movements. It's important to maximize the amount of skin exposed to the lights, so the baby is placed in his bassinet in only a diaper, on top of a pad that shines light up against his back. The bassinet is then placed under a second light that shines down from above him. He wears eye covers to protect his eyes from the bright lights, and he basically just sleeps there. The baby should eat about every three hours but should not be off the lights for more than 30 minutes at a time. The idea is to find a balance between maximizing his time under the lights while still getting milk into him so that he can pee and poop. It's a tricky thing, especially with a newborn who wants to nurse a lot but is still getting colostrum and not the mature milk that will encourage more wet and poopy diapers!

It was strange for me, to spend a night in the hospital without my baby by my side. It was also strange to visit him in the NICU, my otherwise big, healthy boy in there with the sicker babies who needed so much more care. We got off to a bit of a rocky start, too. He was there only about 45 minutes before he was brought back to my room, screaming. "He says he's starving!" my nurse said. I nursed him, then wheeled him back to the NICU to go back under the lights. The nurses there were trying to get him to take a pacifier, but he was protesting it.

I was advised that if he was going to need to eat so often, the lights wouldn't be very effective. The protocol was three hours on, 30 minutes off, but he wasn't willing to go three hours without nursing. And normally I would have been perfectly fine with that! A two-day-old baby shouldn't necessarily go three hours without nursing, both for his sake and for mine! His suckling encourages my milk production to increase, as well as nourishing him and stimulating his digestive system. I was happy to feed him every hour or two, but that would render our night in the hospital ineffective. I was frustrated, and so were they.

One of the nurses told me that giving him a little formula would probably help, since it would fill him up so he could wait longer to nurse again, and it would make him pee. Without peeing, he wouldn't clear out the bilirubin. "You have to decide what's your priority - breastfeeding or treating the jaundice," she said. I felt a bit threatened or judged, like maybe by clinging so hard to the "exclusively breastfeeding" mantra, I might be causing my baby harm or wasting my time (and hers?). I was taken aback. I had made it clear that he was not to receive formula, his case of jaundice wasn't severe (yet?), and I was educated enough to know that giving even one bottle of formula when supplementation wasn't medically necessary could cause long-term harm. But I'll tell you something, in all honesty: I almost gave in. I was desperate for him to stay longer under the lights. I was so nervous about "wasting" our extra night in the hospital. I really wanted this treatment to work. And if a couple ounces of formula was all he might need...I hesitated. I felt like I was already breaking so many "rules." Here I was, a trained Lactation Educator, on my fourth baby, a self-proclaimed breastfeeding advocate and expert, and my baby was spending a night in the nursery, being offered a pacifier, and now I was thinking about delaying feeds and supplementing with formula besides.

I gathered myself. "Breastfeeding is my top priority," I told the nurse. "I don't want to mess up his gut with a bottle of formula if he doesn't really need it." If my head had been more in the game, I would have known what to do immediately, but since I was groggy from two nights without sleep, thrown by this change of plans, and caught off guard by this sudden suggestion of formula, I couldn't think of a solution. "Maybe he'll go longer this time," I said, and went back to my room.

The first thing I did back in my room was Google "formula supplementation for newborn jaundice" on my phone (thank G-d for smartphones!). I thought I remembered reading an article from the Academy of Breastfeeding Medicine on whether formula supplementation for normal newborn jaundice was necessary or standard protocol, and I wanted to refresh my memory. I found exactly what I was looking for (PDF). In short, formula supplementation is not recommended for treatment of newborn jaundice unless there are other complicating factors. Short-term formula supplementation can have long-term risks. While it will help to clear the jaundice, it may interfere with establishing a good milk supply, may cause nipple confusion in a baby who is still learning to latch and breastfeed, and will cause the gut flora to be affected by introducing cow's milk proteins and non-breastmilk compounds into the developing digestive system. My Lactation Educator classes came back to me in a rush, and I remembered what we had learned about jaundice and supplementation. There are indications for short-term "interruption of breastfeeding" under certain conditions, but my baby and my situation did not call for such a drastic measure at this point.

And like that, I knew what I needed to do. I marched myself (figuratively) back to the NICU and found a different set of nurses sitting near my sleeping baby.

"Is the reason you'd want to supplement because you could feed him while he's still under the lights?" I asked.

"Yes," one of the nurses said.

"So, if I were able to pump some colostrum, you could feed him that instead of formula?"

"Sure. We do that all the time. Ask your nurse to get you set up with a pump. You can bring us whatever you pump."

I tracked down my nurse and explained what I wanted to do. She said no problem, and within the hour, I was set up with a pump and had started harvesting that precious, precious liquid gold. I felt if I could get at least 10mL (about a third of an ounce) in any given sitting, that should be enough to tide him over between the every-three-hour breastfeedings. I had a mild concern that giving him bottles might affect his desire and ability to latch, but I felt it was worth the risk. At least by pumping between at-breast feedings, I was giving myself the breast stimulation I'd need to establish a good milk supply, as well as giving Baby Y the colostrum he needed to keep him full and happy and able to pee and poop.

On my first go, I got 10mL from both breasts. Thrilled with my success, I happily delivered my first of what would be five 10mL bottles of colostrum that night. In between 30-minute feedings and 15-minute pumping sessions, I'd conk out, sleep for an hour or 90 minutes, to be awakened from a weird dream or a deep sleep by my nurse wheeling in a crying baby ready to breastfeed again. Tired but pleased, morning came and we eagerly awaited his latest blood test, to find out the result of our night's effort.

Liquid Gold

After 12 hours on the bili lights, at 51 hours of age, his bilirubin levels were down to 9.9, lower than they had been at the previous test, and down into the low intermediate risk range for his age. Yes!

We came home later that morning with instructions to have him seen by his regular pediatrician on Thursday. His doctor checked him over and decided that doing another blood test was not necessary. He told me to keep an eye out for more yellowing, lethargy, or not waking to feed, but as long as he was producing diapers, was waking up when he was hungry, and was feeding well, he was not concerned.

Thankfully, Baby Y's breastfeeding was not negatively affected by the use of a pacifier or by giving bottles. My mature milk appeared, on cue, at about 2.5 days postpartum, and he began gaining weight at an incredible rate. At hospital discharge, he was 7lbs., 14oz., about 8 ounces below his birth weight of 8lbs., 6oz. On Thursday, he was up to 8 pounds even, and on Friday, he had gained an additional 3 ounces in 24 hours, to reach a weight of 8lbs., 3oz. Though he has not been weighed since, I'm certain that he has surpassed his birth weight already, at eight days old.

In the next article, I'll discuss jaundice from a clinical angle. I am grateful that I had the experience and educational background to be able to effectively advocate for myself and my baby. Don't be afraid to do your own research and ask questions. When it comes to your baby's health and your breastfeeding relationship, it's important to speak up!