How Does Milk Production Work in the Early Days Postpartum?

The first few days and weeks after your baby is born can be confusing. You have so much to learn and so many things to worry about. It's stressful and scary. You want to be sure you're doing the best you can for your baby, and that includes making sure he's getting enough to eat. When you're breastfeeding, it can be hard to tell how much your baby is taking in and whether it's as much as he needs or wants.

So let's talk about how milk production works in those early days, so that you can be more confident that your baby is satisfied.

You start producing the early milk, called colostrum, between 10 and 14 weeks of pregnancy. Colostrum is milk, but it's not the mature milk you'll see a few days after your baby is born. Rather, it's a highly concentrated, thick, golden liquid consisting mostly of protein, beta carotene, and antibodies. Colostrum is sometimes called "liquid gold" because it is so valuable to a newborn baby to help protect his tender new gut, support his undeveloped immune system, and prepare him for life outside the womb.

10mL (2 tsp) of colostrum pumped on my baby's second night of life.

The presence of the placenta and the progesterone it produces keeps your milk volume low, so you won't produce mature milk until after your baby is born and the placenta is expelled. Your levels of prolactin - the hormone that tells your breasts to produce milk - are very high at the birth of your baby, but it's just floating around in your blood stream with no way to send the message until you start actually nursing a baby. The action of the baby suckling at your breast (or of a breast pump or hand expression) creates "prolactin receptors," places for the prolactin to attach within the breast so that the message to produce milk can be sent. The takeaway from this is simple: The more you nurse your baby in the first 3 days of life, the better your milk supply will be even months down the line.

Now, once the baby is born and the placenta detaches, your levels of progesterone, the hormone produced by the placenta that supports the pregnancy, drop, and you've started establishing prolactin receptors. This paves the way for the prolactin to do its job, and your body will begin producing more milk - and that milk will be the mature, watery, white substance we think of when we think of "milk."

It takes about 48 to 72 hours for your milk volume to increase. In the first two to three days of your baby's life, he does not need to eat much. Remember that he was being constantly fed by the umbilical cord while inside you, and his intestines are full of meconium - a greenish-black, tarry substance that coats the intestines. There isn't room for much food until the meconium is cleared out. Colostrum, along with all of its other amazing properties, acts as a laxative to help clear out that meconium. Your baby's stomach is very tiny at first and cannot hold more than about a teaspoon (5mL) of milk anyway, so it doesn't take much for him to feel full. Remember, in the last few weeks of your pregnancy, he was packing on fat stores to help him survive these first few days of life where he suddenly isn't eating much.

Though your baby isn't super hungry at birth, he will have a high need to suck. This high need to suck serves a few purposes. First, when the baby suckles at the breast, it stimulates the release of oxytocin, which helps the mother's uterus shrink back down and slows her postpartum bleeding. Second, as mentioned before, it helps set up receptors for the milk-production hormone called prolactin. Third, the sucking stimulates the baby's intestines to start moving out the meconium to make room for the milk. Finally, newborns find sucking comforting. Babies even suck on their hands inside the womb!

Remember that breastfeeding takes practice. The best thing to do in these first few days postpartum is to bring the baby to breast absolutely as often as possible, at least 12 times in 24 hours, or as often as the baby asks. The quickest and easiest way to learn your baby's hunger signals is to start out by offering the breast every time your baby fusses. You'll begin to recognize certain movements of his head and mouth that indicate that he wants to nurse. You'll learn the different types of cries that mean he's hungry or tired or uncomfortable. By offering the breast every time your baby seems fussy, you'll give yourself and the baby every opportunity to practice nursing and to establish those prolactin receptors and build your milk supply!

By about 72 hours after the birth, you should notice that your breasts feel fuller and are now producing something that looks a great deal more like "milk" than the colostrum did. Some women find they become extremely engorged literally overnight, while others notice a more gradual increase in volume. If your milk hasn't increased in volume by about 72 hours after birth, you may need to speak with a lactation consultant and/or your baby's pediatrician about providing supplemental donor milk or formula until you have a greater volume of milk available. It is important that your baby start eating so that he can grow.

Once the milk supply does increase, you'll want to know that your baby is getting enough to eat. You can monitor how much the baby is getting by counting diapers - what goes in must come out! A 3-day-old baby should have three wet diapers and three poops per day. A 4-day-old should have 4 and 4. A 5-day-old should have 5 and 5, and after that, there should be at least 6 pees per day and anywhere from about 3 to 6 or more poops. In order to be sure that your baby is really producing at least that many wet diapers, you need to check your baby's diaper at least that many times per day. If you're not sure how to tell if the diaper is wet, or you are concerned that your baby isn't wetting as often as he should, you can place a piece of tissue in a clean diaper. When you check the diaper, if the tissue is wet, then your baby has peed.

Another way to reassure yourself that your baby is getting enough to eat is to watch his growth. Your pediatrician will want to see your baby several times in the first two months of life. Your baby should be gaining at least half an ounce a day, if not more, and should be back up to his birth weight by the time he's 10 to 14 days old. Even if you don't get to weigh your baby often, you'll notice as he starts outgrowing his clothing and diapers, becomes heavier for you to hold, and starts to fill out.

If you're concerned that he's not taking in milk, you can do what's called a "weighted feed," where you weigh the baby hungry, then feed him, then weigh him again on the same scale with the same amount of clothing. This requires a sensitive baby scale that can measure in small increments. Many baby boutiques and lactation consultants will have scales like this available to do weighted feeds and to check your baby's growth. Typically, a newborn baby will take in about 2oz. of milk in a feeding, which you can see because he'll be 2 oz. heavier after feeding!

Finally, you can tell if a baby is getting enough by making sure he's not dehydrated. His eyes and mouth should be moist, skin should be smooth and not have dry patches, and the fontanel (the soft spot on top of the head) should not be sunken. He should not be lethargic or floppy, should have periods where he's awake and alert, and should wake on his own to eat. If you see orange urine crystals in his diaper or he has fewer than six pees in 24 hours after day 5 of life, call your pediatrician immediately. Dehydration in a baby can be very serious but is also very treatable.

If you have any reason to be concerned about your baby, don't hesitate to call your pediatrician. Trust your gut. If your baby is not himself, it doesn't hurt to have him looked at. Often the nurse can listen to your concerns on the phone and help you determine if the doctor needs to see the baby.

Remember that a newborn typically eats 12 or more times in a 24-hour period, but that doesn't necessarily mean he's eating exactly every two hours. He might eat three times in three hours, then sleep for three hours, then eat twice more in the next four hours, then sleep for two hours, etc. Watch the baby, not the clock, for when you should feed him next, and follow his cues.

The best way to ensure that your milk supply is healthy and your baby is well-fed is to simply nurse, nurse, nurse. Avoid artificial nipples such as pacifiers and bottles until at least three to four weeks of age, when breastfeeding should be well established. Have your baby's latch evaluated if you have any pain while nursing. Sometimes it may look like your baby is nursing well but he's actually not transferring milk efficiently. Listen for the sounds of swallowing and for a suck-swallow-breathe pattern. If your baby is sucking but not pausing to swallow or breathe, he may not actually be getting any milk, or not enough to trigger the swallow reflex.

Check out my videos on newborn nursing to see what it looks like (and sounds like!) when a tiny baby nurses!

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!

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?

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.

Rooting
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.

Reflexes
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?

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.

New Edition of Kindle Book is Available!

Check out the new, updated Jessica on Babies Breastfeeding FAQ, available for Kindle from Amazon.com. Makes a great new-mom gift or a quick purchase just before (or just after) you have your own baby. At $1.99, you get Jessica's basic breastfeeding advice in the palm of your hand, accessible any time and anywhere you need it.

Some sample questions and answers from the book:

What is the most important piece of advice you would give a new mother about breastfeeding?

The first thing I would say to any new mother is, “Keep nursing!” The more you nurse, the easier it gets, and the more you nurse, the more milk you make. You’ll often hear “breastfeeding is normal” or “breastfeeding is natural,” which is true, but it’s important to remember that breastfeeding is a skill that must be learned and practiced, by both mother and baby. Just like with any skill, the more you do it, the better at it you get. When my first son was born, I was so convinced that breastfeeding was natural and instinctive that I was very discouraged by how complicated it all seemed. I felt like I needed three or four hands. When my second son was born, despite all the reading I had done, it still took several weeks for me to find comfortable positions and the easiest way to get him latched on and sucking as quickly as possible. As awkward as you may feel in the first few weeks, you’ll find it getting easier by the day if you just keep at it. The third time around, I knew things would get better, but the first three days or so were very hard; he would scream every time I unlatched him from my breast. I had to keep reminding myself that the more he nursed, the better things would get. Sure enough, by the end of the third day, he became a much more content baby, and I was able to settle into a more comfortable nursing routine.

The second basic piece of advice I always offer is, “Give it six weeks.” The first few days and weeks can be challenging, and even painful, as you adjust to having a new baby and all the new demands placed on you by this change in your life. If you persevere through the first six weeks, nursing on demand, getting used to the baby’s cues and needs, it only gets easier. I’ve seen new mothers go from “Why is this so hard? I don’t want to do this anymore!” to “Oh yeah, I think I’ll nurse for at least a year,” in the space of just those few weeks. There’s something about that six-week point after which everything starts to seem easier. Also, as the baby grows, breastfeeding gets easier just because the baby’s mouth gets bigger, his neck is stronger, and he is more able to support himself. If you stick it out for those first six weeks and put in the work at the beginning, you’ll be able to continue your breastfeeding relationship for as long as you and your child desire.

I heard that giving a bottle of formula before bed, or adding rice cereal to the bottle, will help my baby sleep better and longer. Should I try this?

It is not a good idea to offer anything but breastmilk to your baby before six months of age. Remember that your milk supply is governed by the baby’s demand. If you give a bottle or other food instead of nursing the baby from the breast, you are telling your body that your baby doesn’t need milk at that time. This can cause your milk supply to drop, requiring that you continue to give your baby a bottle, which can cause your milk supply to drop further. It’s a vicious cycle that is difficult to get out of. 

There is no evidence that giving a bottle of formula at bedtime will help your baby sleep better at night. There is mounting evidence that doing so may be harmful to your milk supply as well as possibly contributing to postpartum depression or other maternal health issues. Recent studies show that mothers who breastfeed exclusively in the early months feel happier and better rested than those who attempt to supplement with formula in order to get more sleep. My sons woke frequently to nurse, and it was much easier just to pull the baby to my breast and go back to sleep than it would have been to get up and prepare a bottle for him. My husband and I were both much more sleep-deprived with our first son, who was formula-fed, than we were with our breastfed babies.

As for adding rice cereal to a bottle, or giving any other kind of solid (non-breastmilk) food to a young baby, this is highly discouraged by the American Academy of Pediatrics, the World Health Organization, and many other groups. It is recommended that you do not feed any foods or liquids except breastmilk to an infant under six months of age, unless under a doctor’s direction for a medical reason. Putting rice cereal in a bottle is also a choking risk. 

Also, giving a bottle in the early weeks of life may have a negative effect on the baby’s desire to latch properly on your breast (see “Should I give my baby a bottle?” below for more on bottles).

My nipples are bleeding. What do I do?

For short-term care, squeeze a little milk from your breast after a feeding and apply it to the bleeding nipple. Breastmilk has healing properties that will help the nipple heal faster and prevent infection. You may also purchase pure lanolin (usually found under the brand name Lansinoh) to apply to your nipples after a feeding. Lanolin is safe to leave on when your baby is ready to eat again and will soothe your nipples and help them heal. However, bleeding nipples are typically a sign of a bad latch or other feeding problem, and you shouldn't hesitate to contact a lactation consultant if the problem doesn’t resolve within a few days. 

Adjusting to a Second (or Third, or Fourth) Baby

While there is always plenty to worry about when you're pregnant, you'll have different concerns when you're pregnant with your second (or third, or fourth...) than you did with your first. When you've already had a baby, your life has already adjusted to the presence of a child. But now you need to adjust your older child(ren) to the presence of a sibling, and you have to figure out how you are going to care for yet another child. Here are some of the common concerns parents have when adding a new baby to the family.

What if I don't love my new baby as much as I love my son/daughter? 
This is one of the most common questions I hear from second-time moms who are expressing their worries about the impending birth of their next child. The overwhelming love we experience when our first baby is born is indescribable, and we worry that it can never be matched. Fortunately, love is not finite, nor is it parceled out. Bonding with your first baby left physical changes in your brain that mean bonding with your next will happen in just as breathtaking a fashion. Love expands into a bubble that encompasses every child together and each child individually. You may not love your second in the same way that you love your first, but the quantity and quality will not be in any way diminished. Finding that each of your children is an individual with different needs for attention, affection, and interaction brings a whole new dimension to the overall love you will feel for your family as a whole and for each child. And the love between siblings gives your heart a whole new reason to swell.

What if I love my new baby more than I love my older child?
This is a different sort of worry. You know you love your child, but maybe you had trouble forming a bond the first time. Maybe the birth was traumatic, maybe you were separated for a hours or days, or maybe you were so befuddled and overwhelmed by the addition of a new baby to your little family that you took a few days or weeks to feel the kind of love you were looking for. What if, this time, you bond faster, your love is stronger? It is, in fact, likely that you will bond faster with subsequent children than you did with your first. While some parents had no trouble bonding the first time, it is very common, too, for it to take a little time to understand how this new little person fits into your world. Rest assured, your capacity for loving your children is not limited or finite, and you will find that as you experience a new bond with your baby, your bond with your older child will increase as well.

The baby will require so much attention. I don't want the older sibling(s) to be jealous.
Yes. The new baby will require a great deal of attention. This is true. And you will be tired and overwhelmed and discombobulated. And your other child(ren) will still need you for diaper changes, potty help, baths, reading books, helping with homework, meals, laundry, and everything else you already do for them. And it is entirely possible that they will get tired of hearing, "Mommy (or Daddy) will be with you in a few minutes, just as soon as I finish feeding/bathing/holding the baby." Remember, though, that a lot of the attention the new baby needs at first is fairly passive. Nursing (or giving a bottle), holding and rocking, carrying around, keeping an eye on, are all things you can do while you give attention to an older child. Your older child can cuddle with you while you nurse the baby. One great bit of advice that many new parents find helpful is to set up a "nursing basket." Put together a box or basket of special books, toys, and movies that you can engage in with your toddler or preschooler whenever you sit down to feed the new baby. Your older child will still get to spend quality quiet time with you, and may even begin to see nursing-the-baby time as a special Mommy time for him/her, too. In addition, make sure your older child(ren) get a chance to hear you say, "Hold on, Baby, your brother needs my help first." Let him know that he's not always going to be second to the needs of the baby. Also, if you can, arrange for regular one-on-one time with the older child with one parent or the other.

A second bit of advice that works well for toddlers is to have the "baby" give the older sibling a gift. When the baby is born, you'll likely receive gifts for yourself and for the baby. Store away something in advance that the baby can give to his big sister or brother. Also, if you can enlist a relative or two to give the big sibling a gift (even something small), she or he will feel less left out of the excitement.

Another part of this equation is giving your older child(ren) the chance to become helpers and caregivers for the new sibling. I have found that this facilitates the sibling bond and makes the older child feel needed and special, too. Give them a "job" (equal to their abilities, of course). "Can you help me out and be such a big girl? Can you run upstairs to the baby's room and get Mommy a diaper? I think the baby needs a change." It may sound corny, but if you make your child feel like she is the only one who can do this monumental task to help you and the baby out, she will be full of pride. And if she doesn't want to help you, no big deal. She'll still appreciate that you asked her. Another way a verbal toddler or preschooler can be of great help is by "watching" the baby for you. When the baby is in a safe place such as a swing or on a blanket on the floor, if you're trying to accomplish something like fold laundry or make dinner, ask your older child to watch the baby. Have him sit down beside the baby and talk to him, keep him company, try to make him laugh. Make sure you've already established boundaries like no touching the baby's face and no trying to pick up baby, of course, for safety. Make sure he knows what a great help he's being.

It takes me 10 minutes to get out the door with just one kid. How long will it take with two?!
You'll find that because you've already got experience with packing up a diaper bag and getting everyone dressed and ready to go, adding a baby to the mix likely won't end up doubling your "out-the-door" time. Certainly, at first, you will need to leave yourself extra time to get where you're going. In my experience, it's always just as you're about ready to leave for an appointment that the baby poops and needs to eat. But getting everything else ready shouldn't take too much more time than it already does. Snacks, diapers, wipes, change of clothes for the older one (as needed), diapers, wipes, change of clothes for the younger one (and bottles if applicable) all go in the bag, and off you go. Some people find it easier to keep two bags ready, one for the older child and one for the baby, although I find this just means more to carry and keep track of. If your older child still needs to be carried out the door and into the car, leave the baby in a safe place in the house (already buckled in the infant car seat, for example), run the toddler out to the car, buckle him in, then go back for baby. I find that if I start encouraging the older child to be able to walk out to the car and climb in before the baby's born, while I can help him figure it out, getting everybody in is much quicker once you're juggling more than one child. This, of course, depends on your older child's age and abilities. Of course, if you live in an apartment or have to park on the street or have another circumstance where something like this scenario isn't realistic, you'll find a way to make it all happen. You've already worked out how to get one kid out safely, after all!

How will I manage bedtimes, naps, and errands?
I like to plan ahead and understand how the bedtime routine might change, where I'll put everyone when I go grocery shopping, and when and how everybody will get the naps they need. The thing is, it's hard to really plan ahead for any of this, because you have to see how your older kid(s) will react to the new baby, you have to see what the baby's needs are, and you need to know how much help you'll have in terms of other adults around. If you can share the bedtime routine between both parents, then I'd start making any necessary transitions at least a few weeks, if not a few months, before the baby is born. If Mommy usually cuddles with the toddler until he falls asleep, can Daddy do it now instead? Or can you help the toddler learn to fall asleep on his own, or after just a few minutes of cuddles? If you are alone with your kids at bedtime and you're used to "doing it all," you may have to improvise. At first, you can likely just hold and/or feed the baby while you do any book reading, cuddling, and so forth. If your baby is fussy or needy right around your older child's bedtime (which is common!), this may be more difficult. I find that it's usually helpful to get the older child to bed and then deal with the baby, if that's possible.

Naps are really the place where the younger sibling will suffer. I've been in the situation where the toddler's nap falls exactly between the baby's naps, and I feel like I can't ever leave the house because one or another of my kids is supposed to be sleeping. Unfortunately, it may happen that your baby becomes a slave to the routine and schedule you've already established. If that means baby naps in the car or during errands, at least he's getting some sleep, right? If you can baby-wear and/or arrange to take your longest car trips when baby needs to sleep, you'll at least be able to ensure that she's getting some nap time in, even if naps aren't always in bed!

As for errands, baby-wearing will be your friend, here, too. If you have a toddler who still needs to sit in the cart, for example, you can wear the baby and still put the toddler in the cart. Some of the larger stores have carts that can accommodate more than one child at a time, but in a regular grocery store, you may not have any other options. It is dangerous to prop the infant car seat on the child seat in the cart, so I don't recommend doing that, regardless of how many children you have. One thing I used to do when my third was born was take all three of my kids shopping. My oldest was capable of pushing the baby in his stroller while my middle sat in the cart, which I pushed. My oldest really liked having that important job to do. Better still is if one adult can run to the store while the other stays with the kids! Or take just one kid with you on errands and make that a special one-on-one time. Maybe you can get ice cream or buy him a special treat once in a while if he comes with you, so that he'll see that he still gets a fun time alone with Mommy or Daddy.


The best observation I can make is that, yes, the first several weeks will be a period of adjustment. You'll fumble with figuring out how to integrate the new baby into your routine. You'll have to figure out how to meet the baby's needs without depriving your other child(ren). You'll have to get used to dividing your time and attention. Your older child(ren) will likely act up or behave strangely because they will also be affected by the change in their routines and their lives. They'll notice that you are not as readily available to them. They'll be aware that things are different now. Be sure to acknowledge those feelings. Also, know that things will get easier. You will adjust. Your family will adjust. Give it some time and get a little creative, and, most of all, take what help you can get!

Enjoy your growing family!

What tips do you have for parents adjusting to the birth of a subsequent child? How did you help your older child(ren) get used to having a new baby in the house? How did you integrate the new baby into your established routine and busy day-to-day lives?

This, Too, Shall Pass, and Other Wisdom

I find myself, with about eight weeks left of this pregnancy, suddenly terrified of having a newborn again. This happens with each consecutive child. I cycle from excited, to thinking we must be crazy, to content, to excited, to terrified, to content, to excited, to OMG WHAT WERE WE THINKING?, then back to excited, then content, then terrified.

Part of it is our kids are spaced just-so, that we finally are at a point where sleep is basically working, routines are basically established, everybody's got some level of independence, and I feel like I'm in the groove, and then we throw another newborn into the mix and everything gets thrown out of whack again. And this being my fourth time through the ringer, well, I kind of do know what to expect.

In some ways, knowing what to expect is comforting. I know what to do with a newborn. I know phases start and phases end. I have almost seven years of watching kids grow up under my belt and have been through sleeplessness and teething and illness and firsts and potty training and nightmares and picky eating and tantrums and I know that "this, too, shall pass" is an absolute mantra of parenting. I know I can stick it out for a little longer until one problem ends as suddenly as another begins. I can pass along the sage wisdom of, "Just when you think you have it all figured out, they change it up on you again," and I can remember it for myself. I know that "do what works," "wait it out," and "give it another couple weeks" are absolute truths. I know that every kid is different, that every baby needs love, and that I have the strength and capacity to make it through this hour, this day, this week.

But in other ways, knowing what to expect is terrifying! I know about the sleepless nights, the crying for no reason (both me and the baby!), the stress of feeding issues and poo-splosions. I know about the pain of recovering from childbirth. I've experienced the complexities of balancing the needs of the older kids and the baby, and the sheer exhaustion of new parenthood. (And it's still new, even when it's for the fourth time.) I know about the disruption of routine, the randomness of life with a newborn, and the stress of evening fussiness. I know that sleepless nights and teething woes are once again on the horizon.

I find I do have a longer view than I used to. I'm already thinking about next fall, when my second will start kindergarten, my third will be three, and the new one, who is right know kicking and dancing within me, will be almost one. Because I can envision that, when it used to seem impossible that my kids would ever grow up, grow bigger, start school. It used to feel like toddlerhood was forever, that I'd be always wiping butts and noses (not simultaneously), cutting up food into tiny pieces, and washing sippy cups. Now I see that it is not. That life will change. That one day my days will be my own (except for school breaks and sickness), that my kids will be helpful in stores, that I won't have car seats to buckle or diapers to change, that I won't have to supervise trips to the bathroom, that as suddenly as life changes when you give birth, life gradually evolves again as that baby becomes a little person who walks and talks and has opinions all his own.

So, I'm terrified of the short term, of what I know is coming in the next few months and years. But I'm excited, too, about the long term, of watching another bright soul come into his own, of seeing our once-little family become huge and full of life and noise and warmth and love.

To those of you out there with one little one, or two little ones, who see life at knee-height, whose days are full of poop and whose nights are empty of sleep: give it a few weeks, months, a year. Life will expand. Your kids will grow. You will grow. You have the strength to make it through this hour, this day, this month. And while you may not look back fondly on every tantrum (yours or theirs), you'll look back and know that the weeks are shorter than they seem and that the months go by faster than you could ever have imagined.

Ask-Me Monday: Breastfeeding Positions

Sorry for the delay in posting this! It's been a hectic week. Here is last Monday's Ask-Me Monday video, all about breastfeeding positions! Enjoy!



To submit a question for Ask-Me Monday, like the Facebook page and comment to one of the Ask-Me Monday posts throughout the week!

Four Kinds of Breastfeeding Support: Emotional, Practical, Improper, and Unhelpful

I can't emphasize enough that when you have a new baby, you need support. Going it alone is unnatural and stressful. They say it takes a village, and while you may not have an entire village to help you, I hope you at least have your partner and a few trusted friends and relatives who are there for you.

When it comes to breastfeeding support, you need to make sure that (a) you have some, and (b) you have the right kind.

I've identified four types of support for new mothers. Each description below contains suggestions for the new mom herself and for the support people around her.

1.  Emotional Support

For Mom: Emotional support is crucial. You might also call this moral support. This kind of support could come from your partner, your mother, your sister, aunt, cousin, best friend, a random person you meet in the park, or even someone on the internet. When someone is offering emotional support, it's those encouraging words when you're at the end of your rope; it's the, "You're doing great!" when you feel like you're doing everything wrong. Emotional support helps you keep going, push through the rough spots, and lets you know that others have been where you are, and it does get better.

To Support Mom: Even if you don't have personal breastfeeding experience, you can be there for her. Let her vent, listen to her concerns, and offer an encouraging word, whatever comes naturally to you. Some of us are more comfortable with being cheerleaders, while others are better at simply listening and being a sympathetic ear. Avoid trying to give advice she isn't asking for, but offer to help in any way you can. For example, "Can I do something around the house for you so you can rest? I'm a great laundry folder! Do you need anything from the store? Diapers? Snacks? Juice? Can I get you a glass of water?" Make specific offers, not a general, "Is there anything I can do to help?" because she may not be able to think of something in particular, or she may feel uncomfortable making a request.

2.  Practical Support

For Mom: Practical support is also crucial. As much as you think you might know going in (and I say this as someone who's nursed a few babies!), it never hurts to have someone you can call upon when you have a practical question about your baby's latch, strange nursing behaviors, or other concerns. Every baby is different, and every nursing relationship is unique, and you'll want to know someone you can contact who has seen lots of  mom-baby pairs and helped solve many types of problems. It's important that whoever you lean on for practical support actually knows what to say or do to help. This may be a La Leche League leader, a breastfeeding peer counselor or other trained breastfeeding support person, an International Board Certified Lactation Consultant, or even just your mom who's nursed four kids. You need to know that the advice you're going to receive is correct advice. If you get advice you're not sure of, feel free to double check it on a reputable site like Kellymom.com, or contact a lactation consultant.

To Support Mom: Unless you're sure you know what you're talking about - i.e., you're a lactation consultant, peer counselor, CLC, La Leche League leader, or you've at least done your breastfeeding research, it's best to leave the advice to someone who is one of those people. If you do know how to help, make the offer. "Hey, I'm a lactation educator. If you want, I can come sit with you and check out your baby's latch." If I'm not absolutely certain what to say or do to help a new mother with her question, I will always recommend that she meet with a local lactation consultant. If you don't know of one, you could help her find one. If you do, give her the number!

3.  Improper Support

For Mom: Many friends and relatives will mean well, and they probably really do want to help you. However, sometimes you get tips and advice from people that is not what would be recommended by a lactation expert. For example, just because your best friend introduced a bottle of formula every night but continued to nurse for a year doesn't mean it's a good idea or that it will work for you. People improvise, get lucky, or make decisions based on unique situations that may or may not apply to you. Make sure you've done your own research and have consulted with someone trained in lactation before you supplement unnecessarily or make a decision that could harm your breastfeeding relationship.

To Support Mom: It's important not to give advice willy-nilly. Every mom will have different circumstances, and unless you are a trained lactation support person or have an educational background to go with your personal experience, you can end up doing more harm than good, even if you're trying to help. Simple suggestions like, "Maybe you want to get his latch checked," or, "My son had a tongue tie and I had the exact problems you're having" can be very helpful and give her a starting point for finding assistance. Thoughts based on your own experience that may make her life easier such as, "My daughter was really fussy, too, and babywearing really helped us on the bad evenings." It's best not to begin supplementation or take drastic measures without being seen by a lactation expert, however.

4.  Unhelpful Support

For Mom: The least helpful kind of support is from people who think they're being supportive but are actually making you feel worse. A great example of this would be, "I'm can see that you're trying really hard to nurse your baby, but if it's this stressful, I would totally understand if you wanted to switch to bottles. A happy mom makes for a happy baby!" This kind of advice, while usually well-meaning, does not help the mother who sincerely wants to exclusively breastfeed but is in the throes of the two-week growth spurt or is battling thrush or mastitis. It's hard, but as a new parent it's important to not allow unhelpful comments like these to affect your mindset.

To Support Mom: Rather than trying to deter her from a path you think may be causing her stress, it is more helpful and more supportive to try to understand what her own goals are. A better comment in the above situation might be, "I can tell you really want to make nursing work, and you're doing an amazing job. I heard of a great lactation consultant in the area. Do you want her number?" If the mom really wants to breastfeed, suggesting that she stop will not make her feel supported. Helping her attain her goals will improve her mood and situation.

Preparation and Education

As new parents, we need to be prepared to avoid the improper and unhelpful advice and to call upon our emotional and practical support people whenever we need to. Gather your support system around you before you give birth, and be ready to discard information and advice that isn't what you want to hear.

As supportive friends and family members of new parents, it's our job to say the right words and be prepared with the right information. It doesn't hurt for others besides the new mom to learn a little about breastfeeding so that we can help in a way that the new parents will appreciate. It's important to know what the parents want and how to help them achieve that. Parents are bombarded by advice, some of which is contradictory, and knowing they have people to lean on who will simply be there to say, "I know it's hard now, but you're doing great, and it gets easier" will be invaluable.

How have you supported friends or relatives as they begin their parenting journeys? How have you been best supported when you've had a new baby? When we came home from the hospital with my third son, it was an incredibly hot and humid day, he screamed whenever he wasn't on the breast, and I was completely emotionally drained. A friend texted me just to say I was doing great, and it felt so good to hear that, even though it was my third baby. What is your favorite thing to tell a new parent, and how do they usually respond?

So You've Just Had a Baby. Now What?

The initial postpartum period, the first six to 12 weeks after giving birth, is challenging. Whether it's your first baby or your fourth, you are adjusting to having a new member of your family, of meeting the demands of a helpless, dependent being, and of getting to know and love this new little person. Let's talk a little about what you can do to make this time of transition as healthy as possible for you and your newborn as well as the rest of your family.

Enlist someone to organize offers of help

You know you're going to need some kind of help after the baby is born. This can differ from person to person, but most new parents appreciate having others help them in some way, from caring for older siblings, to sending meals, to washing dishes, to folding laundry, to running errands. Figure out what you think you'll need the most help with before you give birth, and then ask someone to be in charge of organizing all the offers you'll (hopefully) receive. This can be a religious community leader, a good friend, a relative, a neighbor, or anyone else you trust and who you know can handle the responsibility. Often someone steps up to be the point person. Tell this person what you think you'll want the most help with and direct all offers of, "What can I do to help you?" or "Do you need meals?" to this person. There are also websites that can help everyone keep track of what needs doing and when.

A few things I can recommend, from experience, to put on the list:

• Help with your other kids: Entertain older siblings, assist with school pick-ups and drop-offs, take your toddler for a few hours (playdates, baby-sitting by grandparents/aunts/cousins)
• Food: Ask people to make meals that can be eaten cold or room temperature or that are easy to rewarm. Specify dietary restrictions, allergies, preferences to the point person.
• Laundry: Newborns generate a lot of laundry, and the rest of the family still needs clean clothes and sheets and towels. If someone can throw in a load of laundry or fold and put away clean stuff, this can be very helpful.
• Kitchen: You can use paper goods for a while, or you can take the offer from someone to wash dishes, load/unload the dishwasher, and put clean dishes away.
• Errands: If someone offers, send them to the store with a specific list of random things you haven't been able to get out of the house to pick up. Maybe you're low on certain staple foods, diapers, or receiving blankets and burp cloths. Be sure to establish how and when you'll be paying them back, or give them cash to take with them to the store.
• Company: Being home with a new baby can be lonely. Sometimes it's nice just to have someone come over with a cup of coffee and hang out. Keep the visits short and to close friends and family, and don't feel obligated to play hostess.
• Baby-Holding: The thing you'll probably both most and least want is for others to hold your baby. Make it clear that what you need help with is everything else, not holding the baby. However, sometimes you just want to take a long, hot shower in peace, and then it's nice to have someone around you can trust to hold the baby for 20 minutes while you take some time for yourself. Alternatively, if you know the baby is content and fed and should be fine for an hour, ask someone to keep an eye on him for you while you take a nap.

Keep track of feeds, diapers, and sleep

It's very hard to rely on your short-term memory when you've just had a baby. This means that even if you're used to being able to remember things like the last time you ate, I guarantee, your brain will be too hazy and foggy to remember how many diapers you've changed, which side you last nursed on, and the last time the baby took a nap, all at once. Unfortunately, doctors and nurses LOVE to have this kind of information when assessing your baby's health, and it's important for you to have an idea of how often and for how long the baby is eating and sleeping and how many wet and dirty diapers he is producing in a given day. 

Some parents keep a detailed spreadsheet of every diaper, feeding, and nap. Others jot down the information in a notebook that they carry with them all the time. I tried to just rely on my memory with my three, but I can tell you, I usually had absolutely no idea how often my babies were eating. I usually only knew which side I had last nursed on because that side of my nursing bra was unhooked! Thankfully, in this era of smartphones and iPads, we can make technology do the work for us. There are a number of apps out there for both iOS and Android that can help keep track of all this information for you.

One app I can specifically recommend is smallnest. It's for iPhone, iPod, and iPad, and it has some really interesting features that make baby care a little bit easier to track. First of all, it has a very simple, clean interface that takes no time to learn to use. When you sit down to nurse, tap the "Food" button, select Left Breast or Right Breast, and it will instantly record that feeding. When you're done, stop the feeding. (You can also track bottle feeds and meals of solids.) It will then update the display to show how long since baby's last feeding and will add that information to a running list of the day's activities. You can also track pee and poo diapers and sleep. Secondly, the most exciting feature of this app is its ability to connect all of your baby's caregivers. By linking the app with your Facebook account, you can invite other caregivers, like Daddy or a nanny, to download the app to their device as well, and then they also can track feedings, diapers, and naps. This information is then shared to all devices that are connected to that particular baby, so everyone knows everything at the touch of a button. Plus, you can leave your phone downstairs and put the information into your iPad that you left by the bed, instead of worrying that you've left your device somewhere when it's time for a feeding. (Thanks to smallnest for signing up to be Jessica on Babies' first sponsor!* Click through and check out the app!)

Take care of YOURSELF

It's tempting to try to jump back in to all of your pre-pregnancy or pre-baby activities the minute you get home with your new baby. Often, we're still high on the hormone rush of birth and are raring to go. Take it from me: RELAX. The first six weeks postpartum are one of the only times we have in life to take license to simply rest. Your body needs rest. Your baby needs you to be rested. You have a lot of healing and recovering to do, whether you had a picture perfect, easy birth or a difficult c-section or something in between. The worst thing you can do is try to be up and training for a marathon two weeks after giving birth. Don't worry about weight loss. Don't worry about work. Don't worry about keeping up with your toddler. Take a few weeks to just RELAX.

One thing I won't say is to "sleep when baby sleeps." That was the one piece of advice I hated, because I know how impractical it can be. However, try to nap with baby at least once a day, or at least veg in front of the TV while he naps in your arms. You don't have to be running around all the time.

Surround yourself with SUPPORT

Help with meals and laundry is not enough. You also need to have a support system in place. Having people around who share your parenting philosophy and can offer support in the difficult early days is invaluable. They say it takes a village, and it really does. You need someone to commiserate with over the three-week growth spurt, the every-two-hours waking at night, the poo-splosions, and the boredom. You need someone who can answer your questions about feedings and give good advice (whether this is your mom, a trusted friend, or a professional IBCLC). You need people who will say the words you need to hear when you're feeling your most exhausted and worn out. You need people who will watch you for signs of postpartum depression, anxiety, or psychosis and ensure that you get the help you need. And you need people around who won't be driven away by your crazy hormone surges and moodiness.

Do you have other tips for new mothers that you'd like to share? We'd love to hear your comments!

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* If you are interested in discussing a possible partnership or sponsorship with Jessica on Babies, please email jessicaonbabies (at) gmail (dot) com. I would be very happy to talk about what options there are to increase your visibility among new parents.