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.