June 22, 2009

The Really Dark Places

Every parent knows what the really dark places are. Nobody goes there.

There are aspects of postpartum depression that each parent keeps unsaid. These thoughts become more prominent as their sleep deprivation becomes more profound. But irrational thoughts are vulnerable to the bright light of day. In my approach to postpartum depression, I want the parent to voice these secret fears, so that I can share the burden of them if necessary, and deal with them openly. After all, it worked with a 9-year-old in Dark Places.

The first time a mother told me that she was afraid of going to sleep, I didn't know how to react. She had just brought the baby home from the hospital and though the baby was healthy in every way, she was afraid that the baby would stop breathing. Her husband tried to convince her that the baby would most likely be fine, but she told me she didn't trust his judgement on this. While she was up in the middle of the night, she got on the internet and learned about apnea monitors that sound an alarm if the baby stop breathing for some length of time. She requested a prescription for one of these. Her husband called a day later and told me that now she didn't want to put the baby down. I went to their apartment.

Mom cried when I arrived because she felt safer. I asked how the baby was doing, and she burst into tears again as she said that the baby was doing very well. When I told her I was not going to prescribe the alarm she wanted, she cried about that, too.

This mother was suffering. In most families with a newborn, there's a mixture of bliss and exhaustion. She was not enjoying much from her child.

I knew that there wasn't much I could do to improve this healthy baby. But I could, one by one, hold each one of her fears up to the light and defuse its power by giving the mother a lot of information and a sense of control. Her darkest place was SIDS.

This is a difficult, nearly taboo, topic to write about and a difficult one for a parent to read about. But again and again I am impressed with the power of knowledge to drain the potency from irrational fears. So here goes.

A recent study looked at all SIDS cases in Germany over 3 years. (Their experience is very similar to the U.S.) There were a lot of statistics, but taking most things into account, the scientists calculated the risk added by different factors. In this type of analysis, the baseline risk is set at 1.00 (it'll be clearer in a moment). In Germany, there's 40 cases of SIDS in every 100,000 live births. In the U.S., there's 54 cases in every 100,000. So it's a little more common in the U.S., but not a lot more. It is very rare. This is the baseline risk. The 'odds ratio' for this is 1.00.

  • If there's a pillow in the infant's bed, the risk is higher: odds ratio 1.03.
  • If the baby is not breastfeeding, the risk is higher: odds ratio 1.71.
  • If the parents and baby are bed sharing: odds ratio 2.71.
  • If the mother smoked during pregnancy: odds ratio 3.43.
  • If the baby was put to sleep on its tummy: odds ratio 6.08.
  • If the mother was less than 20 years old at delivery: odds ratio 18.71.
  • If the baby slept in the bedroom at a friend's place: odds ratio 38.67.
  • If family used a pacifier for the baby: odds ratio 0.40.

This is how I interpret the odds ratios. If the mother smoked during pregnancy, there's about triple the risk of SIDS. If the baby was put to sleep on her tummy, there's about 6 times the risk. If the mother is a teen mom, there's almost 20 times the risk. And there's almost 40 times the risk when mom and baby spend the night at a friend's. And using a pacifier regularly seems to reduce the risk to less than half of the baseline risk.

Some of these make sense. Maternal smoking might have an impact on the baby's breathing or even their brain chemistry. I can only guess that teenage mothers, compared with more mature mothers, might not be as good at planning or making careful, well thought-out decisions.

I don't know why pacifier use seems to be a little protective. Several studies have confirmed this finding in the United States and elsewhere. Maybe the babies are calmer?

The one that I know will be controversial is co-sleeping. The babies like it and the parents like it. It's very conducive to easy nursing in the night. But make no mistake, many studies confirm that it nearly triples the risk to the baby.

The hard part for us all is digesting and processing very small risks. Everyone who lives in the San Francisco Bay area knows that there is some risk of a major earthquake. If it comes at the wrong moment, the consequences for each of us could be severe. We don't know exactly what those odds are, but they are pretty low. We manage the multitude of little risks every day. The risk of a serious accident, building collapse, asteroid impact. People with anxiety disorders have difficulty ignoring many of these very rare risks and are sometimes trapped by their fears.

I had a piece of paper and had this mother dictate to me a specific list. We went through the list item by item. It made her feel better.

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