Breastfeeding Sucks

Self-deception is always a problem.  With me, it usually rears its ugly head in the thought that I don’t really need to count just this one little piece of chocolate.

So I can't claim to be shocked when I observe it in others.  I think it's a normal human trait.

But it has been a consistent and disturbing fact over my career that mothers are given information which is simply and obviously wrong.  I don't know it for a fact, but I suspect the problem is well-intentioned propaganda.

I admit that I can justly be accused, in an ad hominem argument against me, of being mammarily-challenged.  But that doesn't make it right.

My job, naturally enough, has brought me in contact with hundreds and hundreds of mothers and babies over the years.  Even mothers who have nursed many children say that at the beginning, it's quite painful.  Later on, when the baby is months old, they still say that almost always the initial latch causes a flash of pain.  (Once this latch pain is over, however, it's usually painless.)

It bothers me that the vocal, even militant, advocates for breastfeeding have so downplayed the discomfort associated with normal breastfeeding that they might be hurting their own cause.

I don't know for sure, but I suspect the authors of breastfeeding books and others resolutely claim that nursing is painless because they don't want mothers to be scared of trying it.  My guess is that they have wanted to give mothers, especially first time mothers, the idea that nursing is a blissful satori-like state in which your earth-mother womanhood will reach some sort of ultimate fulfillment. 

What I hear in my office, from every Gaia-aspirant, is very different.  The initiation of breastfeeding—even for mothers who have nursed many previous babies—is painful.  Let's face it:  nipples are a reasonably sensitive part of your body, and they are generally not conditioned to this use.  Many times a day.  Sure, babies generally aren't born with teeth.  But they can, as the expression goes, suck the chrome off a trailer hitch.  As if that's not enough, saliva is a digestive juice.  It might not be as irritating as stomach acid, but leave any skin wet with saliva and it will get irritated within hours.  (By the way, this is an important reason that toddlers using pacifiers often have a rash around their mouths.)

I have not seen a baby whose mother has not noted this pain.  Clearly, it's normal.  I don't think knowing about this pain would make a new mother avoid breastfeeding.  She just had a baby!  I think she can handle it.

Since I try to promote nursing, I've been frustrated by the mistaken expectation of new mothers that the process is supposed to be painless.  They often get the feeling that they must be doing something wrong, or there's something wrong with them, or there's something wrong with their baby.  Again and again, I have to tell them that the baby and their breasts are doing just fine, and what they are experiencing is normal.  I give them lots of suggestions for things they can try that might help.  And I am unhesitant to send them to a lactation consultant.

I suspect that some postpartum depression is worsened by this feeling of helplessness and inadequacy, that there's something fundamental wrong with themselves, or their bodies.  Their expectations for motherhood were so high, that this normal deviation from those expectations can't be anything but disappointing.  So I wonder if breastfeeding advocates have made it sound so effortless that many mothers switch to formula right away.  Some have told me that they think there's something wrong with them, and being good mothers, they want to be sure their baby is getting enough.  By formula feeding at the most painful time--often when the baby is 2-5 days old--they never produce enough to get the system working effectively.  They are afraid that they aren't able to produce enough, and sure enough, they can't.  This confirms their self-doubt.  But it's just something else for them to feel bad about.

I think it would be much more helpful to tell women openly what they should realistically expect.  At least they will be prepared and reassured that what they are going through is normal.

Hothouse, Postpartum—Part 1

I arrived at Amy’s house just a few minutes after hanging up the phone.  I brought my house-call bag with me out of the car, but I didn’t think I would need much to examine Henry, who was about a week old.  He had been full-term, and was doing everything right.

Before the baby, Amy was a working professional, very smart and with a good sense of humor.  This is often an important coping skill.  It can also be an important tool for parents who bring their children to me.  I often have to remind them that:  ‘Just because you are sick or in pain doesn’t mean I can’t make fun of you.’  It’s a coping mechanism for me too, of course.  I try to help parents see the humor or absurdity in themselves and what their kids do.  But, I suppose like all humor, it doesn’t play to every audience.  The families who appreciate my point of view know that when needed I can slip quickly into the role of a serious doctor.  Sometimes it’s hard for me to tell what’s needed.  Being happy is often infectious, so staying upbeat can bring somebody up.  But being unrealistically optimistic can make a depressed person doubt your sincerity and simply not trust that you understand how they are seeing the world.

The phone conversation with Amy started in a typical way.  She had some concerns about breastfeeding, especially wondering if the baby was getting enough.  This was the most common question that new mothers asked, and I explained that we can be reassured if the baby is gaining weight and having lots of wet diapers.  If he’s growing and peeing, and not sneaking out for snacks when she’s not watching, he must be getting it from her.  That was the ‘gold-standard’ for determining breastfeeding success.  She bought that reasoning. 

But when she asked the real question, which she tried to hide in the words of an innocent question, alarms developed over my years of experience started ringing.  She asked if I thought she’d still be breastfeeding in 6 months.  And added, quietly, “if he’s still…here.”

Though nobody wants to bring it up, every parent has dark fears.  I think we all do about people we love and depend upon.  The inconceivable loss looms, we all know, above us too distant to see clearly.  But we know it’s always there, hidden in tragic news stories that happen to other people.  We’d all be in trouble, however, if we fixated on this instead of going about our daily tasks.  A couple came to interview me to see if they wanted me as their doctor.  They had just moved from Florida with their baby, and I was making pleasant conversation.  I asked why they moved.  They said they had stayed through a couple of hurricanes last year.  That was enough, they said.  They had a child now, so they moved here to the Bay Area so they didn’t have to cope with the constant threat of a natural disaster. I told them I would be happy to have them in my practice.

The dark thoughts are there, lurking deep in the background.  We might know how fragile babies are, but good parents shove these concerns to a back burner while they focus on feeding the kid and making sure they don’t run out of diapers. 

It’s natural to wonder if the baby is getting enough.  It’s natural, even, to worry about it.  If the baby isn’t getting enough, he might not gain weight well.  He might even lose weight.  He might—heaven forfend—have to get formula.  Most parents who have these concerns are genuinely worried.  They might or might not realize that these concerns are sometimes out of proportion to the actual risk to the baby.

I tell parents that they should never tell a child who’s getting a shot that it won’t hurt.  Shots do hurt, at least a little.  A smart child will immediately reach the correct conclusion that either you didn’t know that shots hurt or that you knew and lied about it.  Either way, you’ve lost credibility.  Sadly, you’ve also lost the credibility to comfort the child afterward.  In this way, I do not try to hide or gloss-over my concern for a baby that doesn’t gain weight as expected.  I try to take a measured and reasonably algorithmic approach, however.  It doesn’t scare me, and I have a lot of experience and knowledge.  If one thing doesn’t work, we’ll try another.  I will not give up.  When I’m concerned, I tell the parents and then do something about it.  Having a plan, indeed a whole decision-tree of analytical approach to uncertain events, can be a crucial tool in the management of complex problems and the anxiety these provoke.

But I knew, and she knew, that Henry was gaining weight just as expected.  The nursing was going well.  As described in the last post, she had not expected the appearance of her breasts to change.  I felt bad that I hadn’t expected this either—at least not overnight.  I had not warned her of this possibility.  At first, I thought she was concerned if her baby was getting enough, so I reassured her about that.  Then it appeared her concern was that her breasts no longer seemed to appear full, and she was worried that this might be a sign of a problem with her milk supply.  I reassured her about this, too.  One by one, I asked her about her concerns, and one by one I dealt with them in the best way I could figure.  Seriously, thoughtfully, and, I hoped, kindly.  On the phone, I thought I was getting her past this buzzing cloud of anxiety.  I didn’t expect her to ask if the baby was going to survive.  For that, there was no answer on the phone.

I know about the dark places.  But I can’t make them go away.  If they are prominent in the moment to moment thoughts we need to have to get through our daily tasks, they interfere with doing what we need to do.  They sometimes interfere with what our children need.  They always interfere with what we need.

I didn’t ask what she meant when she asked if I thought the baby would still be there in 6 months.  I just got her address and told her I’d be there in a few minutes.  I didn’t ask her permission.  I didn’t ask if it was a convenient time, or if there was somebody else she could call.  This was not a time to be afraid to step up to the plate.  I stopped briefly in the supermarket across the street.  I bought a small serving of macaroni and cheese (usually quite bland at the place near my office) and a small amount of freshly cut-up watermelon.  I went to her house.  That’s coming up in Part 2.

Boob Job 2—Breastfeeding in the Real World

In the last post, I mentioned getting a call from Amy, a first-time mother.  She’s nice, very intelligent, very well educated.  She has a good sense of humor and a nice husband.  When they took baby Henry home a few days ago, he looked great.  He was losing weight, as expected. 

Usually, babies are born with a store of extra fluid.  For the first day or so, it’s not unusual for them to sleep nearly all the time.  They aren’t hungry yet, and a lot of their energy is taken up just keeping their body temperature stable.  Sometimes a new mom is worried by this.


Some breastfeeding books—and advisors—convey the idea that a newborn baby is completely driven to nurse from the moment of the first breath.  It’s true that babies have rooting and sucking reflexes when they are born, and that they can nurse if it’s available.  It’s unfortunate that some new mothers get the expectation that their newborn will nurse immediately and often during that first day.  Though exhausted by giving birth, some first-time mothers just can’t put the baby down.  Having pestered Santa for 9 months about that big toy they’ve been wanting, they finally see it under the tree.  Now that it’s open, they don’t even want to go to sleep and miss precious playtime with it.  The baby has also usually had a pretty exhausting first day.  It’s not unusual for a baby to sleep 22 of the first 24 hours.  So I hear a lot of concern and disappointment when I’m told that every time the baby is put to breast, he falls asleep.    


The problem with unrealistic expectations about nursing, of course, isn’t that they will result in a less-healthy baby.  They will, however, cause the mother to question the viability of her plan to nurse, and question her body’s capability to make milk.  I put this squarely on the culture of breastfeeding, at least in the community I’m in.  The books make it sound easy, painless, and problem-free.  This, as I’ve said, is counterproductive. 

It’s been a revelation for me to see the peer pressure at work in my community.  That clique of mean ‘popular’ girls in high school has morphed, at least here in Berkeley, into the competitive breastfeeding league.  They are the women who see a mother in the park and through warm smiles tell about nursing their baby blissfully and without problems.  Until high-school.  They won’t fail to tell horror stories about the ground-glass and petrochemicals in baby formula, the hormone-like bisphenols in baby bottles that are so potent that you might as well start saving now for the kid’s gender-reassignment surgery.  Not that there’s anything wrong with that.


As if these pressures aren’t enough, new mothers have a lot to cope with.  Their lives have been turned upside-down, their careers are, at best, in limbo, their relationships have changed, they aren’t getting enough sleep, their breasts have changed, their privates have changed, and they have—did I mention this?—a baby.


I’m prepared for breastfeeding questions and problems.


Amy said that she had a couple of questions.  She said she was worried that something was going wrong with nursing.  Over the prior few days, as expected, her breasts gradually would become engorged, and she had been producing milk.  She knew it because she would leak milk.  When Henry nursed, she could hear him swallowing, and some milk would leak out of his mouth when he was done.  I told her that was great.  But this morning, when she awoke, her breasts seemed different.  They seemed both to be kind of deflated, flatter.  Not painful or red.  Henry seemed completely satisfied when he nursed, and was audibly swallowing as ever.  She was still leaking.  I found this all pretty reassuring, and told her so.  I asked if she had ever seen a nature-show on TV or a National Geographic article that showed women who nursed their babies but don’t have bras in their culture.  They just aren’t, I pointed out, perky.  There’s a reason, after all, that Frederick’s is ‘of Hollywood’ and not, for example, ‘of Manaus.’  Appearance and functionality are simply not linked.

It’s worth mentioning that for most of their lives, women get strong messages about their appearance.  Men do too, of course, and I speculate that the pervasive influence of visual media has tended to increase the appearance-pressure on boys and men.  Still, women are bombarded.  In deep and subtle ways, these appearance pressures are all about cultural beliefs concerning attractiveness and ability to find and retain a mate.  Sometimes, as I create a dialog with mothers, they are concerned about the ways in which their bodies change.  It’s natural enough to think about this.  I wondered if this was the basis of her concern.


She said she was concerned that the baby wasn’t getting enough.  This was the most common concern of new moms who breastfeed.  I’ll point out again that  though the words are about infant nutrition, the meaning is all about anxiety.


I asked her to relate the entire day up to the time of her call.  She didn’t understand where I was going with this, but went along with my questions.  Every thing she said she did—even getting out of bed—was coupled with a question from me.  “Did the baby have a wet diaper?  Did you change him?”  By the time she got to our phone call, about 4:30 in the afternoon, she had changed at least 8 wet diapers, most of which had a little bit of soft yellow poop.  It was a revelation to her that he went through that many diapers.  It’s a normal amount.  I asked what else she fed the baby.  She was confused by this question and a little shocked.  Nothing else, of course.  How about her husband?  Did he take the baby to a drive-through window for a bacon double-cheeseburger?  Of course not.  So if the baby is having about a dozen wet diapers a day, he must be getting plenty of fluid from someplace.  If it’s not the all-you-can-drink fountain dispenser at a fast-food restaurant, it must be from her.  She embraced this reassurance.


I also made the following offer.  She could bring the baby to the office every single day and use our baby scale to weigh the baby.  The scale doesn’t lie, doesn’t give exaggerated reassurance.  If the baby is gaining weight appropriately, she’ll see it for herself.  If not, I’ll be right there to make whatever changes are needed.  I will not let her baby, or her, fail.


As an aside, I strongly discourage anybody from getting a baby scale in their home.  It is not useful in feeding management for healthy babies.  It is both a material manifestation of psychopathological anxiety and a prop that enables and exacerbates that anxiety.  It doesn’t help the baby.  By the way, I have recently been hearing about new parents who are advised to take their baby’s temperature daily or several times a day.  Even if it weren’t ironic, I would really advise most of these parents, too, to chill.


Each of these reassurances seemed to help.  I felt like I was helping her.  She asked me,  “Do you think I’ll still be nursing in 6 months?  I mean, you know, if he’s still…here.”

I said, “Give me your street address.  I’ll be right over.”  I got in my car and was there in moments.  That’s the next post.

Boob Job—Breastfeeding in the Real World

When Amy called, she sounded fine.  She’s in her early 30’s and just had her first child, a great and healthy baby named Henry.  The baby was about a week old.

In pediatric training, I wasn’t taught much about the mechanics of breastfeeding.  Sure, I was taught that it was a good thing.  I was taught to encourage it.  But how the process happens, how the machinery in the breast works or doesn’t, and what some of the key practical issues might be was all unexplained.  Luckily, I used to work with a fabulous nurse-practitioner, who is also a lactation consultant.  She taught me a ton, and I have learned more since.  So I’m no longer afraid of dealing with nursing issues head-on.

Before she left the hospital with the baby, I had told Amy what to expect, in general terms.  I told her that most women who are mothers for the first time don’t usually make a lot of milk for the first few days, maybe more.  But in order to get the factory going, she needed to keep putting the baby to her breasts.  It’s nature’s way to have the baby get hungrier over those first few days.  The baby gets hungrier, sucks harder, sleeps less and wants to nurse more.  This results in more stimulation, causing more hormone release from the brain, causing milk production.  As the milk starts coming, the baby gets some positive feedback from nursing, leading to a completely Pavlovian conditioning system, which leads to the baby wanting to nurse more, leading to more stimulation, leading to more production, and the next thing you know, you’re getting a bill for college tuition. 

Nearly always, I’d give new parents this speech or something close.  I started doing this because again and again I have had to reassure new parents that it was completely normal to have a 2-day-old baby who wants to eat but mom has nothing to give.  Colostrum, the early secretion of a breast, is very healthy for the baby but not very filling.  Though I haven’t found this written about much, it’s just this anxiety which seems to have coincided with abandonment of breastfeeding in patients I saw years ago.  The parents would care so much about the baby that they would draw a premature conclusion that their ability to lactate successfully had failed in some way, and start giving the baby formula.  Formula isn’t poison, no matter what you’ve heard.  Sometimes, it’s necessary and I recommend it.  But once a baby starts eating from a bottle, they learn that this is the way to eat.  It’s much more work for a baby to extract milk from a breast, and takes much more coordination of breathing, and sucking pressure.  So even after there’s a decent milk supply, the baby will nurse briefly and then complain, preferring the bottle.  They are saying that even though they like home-cooking, they’d rather go to the drive-through window and get fast food.

Honestly, I think that taking the time to explain what to expect has resulted in very few breastfeeding failures.  I’m very grateful, as well, for being in a community in which lactation consultants are available and can be enormously helpful.  Though I have a lot of the same knowledge, and am completely comfortable around nursing babies, I’m still a little awkward when it comes to judgmental assessments (‘wow, now that’s an inverted nipple’) and manual intervention (‘OK, push your breast this way, squeeze here, and massage your nipple like this’). 

It may be counterintuitive, but I think one of the smartest things that I do with breastfeeding promotion is give the parents some formula.  Hospitals used to give formula samples, provided by the manufacturers, to all the parents of new babies.  I’m against this.  It sends the wrong message, and some hospitals have stopped doing it.

It’s different when I do it.  I give the parents a small amount.  Sometimes I have premixed little bottles in packages of 4.  I like giving those.  Sometimes I have cans, and that’s OK if it’s all I have available.  I get these from the same manufacturers as the hospitals.  This isn’t formula to feed the baby, though the manufacturers would certainly like me to promote it as such.  It’s an anxiety-relief apparatus, which works at many levels. 

First, by coming from  me, I am implicitly granting permission for the mother to use it if needed.  If she decided she needed it, it would be OK.  I’d tell her that she should just keep it in the kitchen cabinet, just to have it on hand.  I tell parents that I don’t expect it will be necessary.

I’m not much of a back-country camper.  The whole idea of a bivouac is unappealing to me.  But I know plenty of people who love the outdoors and the idea of following a Road Not Taken.  Oddly enough, they still take along a cell phone.  Just in case.  Just because you don't anticipate a problem doesn't mean that you shouldn't have a contingency plan.  Maybe it's the cell phone, maybe that wacky silver emergency blanket.  Just having it along can give you the sense of security you need to go someplace that otherwise would be too scary to go.

Second, it’s a message that I won’t let their baby fail, and neither will they.  When a new baby comes home with a first-time parent, our insular society has precious little support to offer.  Other cultures, and our own of 150 years ago, provided a multi-generational household.  Several generations of women would be there waiting with a deep repository of knowledge and experience in nursing and babies.  If your milk didn’t come in easily, there was other milk available that would get the baby through those first few days.  My experience was that many or most of the women who turned to formula could, in fact, nurse successfully.  What they could not do was wait.  At some point, their anxiety about feeding the baby crossed the high threshold of their desire to breastfeed.  They wanted to make it work, but they couldn’t stand another moment of knowing the baby wasn’t going to get anything to eat.  This wasn’t bad parenting, it was good and loving instinct. 

I wrote a blog post about The Telephone Paradox.  The more I gave my home phone number to patients, the fewer calls I got.  None of my physician colleagues believe it.  I found that when patients knew and really believed that they could contact me at any time, they were empowered.  If the kid had a fever, they wouldn’t call immediately.  They’d try some fever medicine, knowing that if it didn’t work, they could call later.  Usually, it did work, so no call.  The parent was made to feel that they had the power to try what their common sense suggested, and that I was there if it didn’t work out as hoped.

So that formula in the kitchen cabinet usually sits unused until it’s past the expiration date.  The new mom is empowered by it.  Maybe she can get through just one more night with a hungry baby, maybe just a few more hours even.  If she needs it, it’s there.  But for now, she’ll keep putting the baby on the breast, doing what she needs to do to get that machine started.

I asked Amy if the baby was all right.  She said that the baby was fine, but she had a couple of questions.  They didn’t go where I thought they would, but that’s the next post.

Solids

Of the approximately 100 members of my class at Yale School of Medicine, every single graduate—100%—were eating solid food.

With that admittedly anecdotal experience, I have reassured many parents that at some unpredictable point between 4 months of age and medical school, their baby will—I virtually guarantee it—eat solid food.

Jamie, barely 4 months, used to sleep 6 or even 8 hours at night last month.  But as the weeks went by, he was awakening more often.  His parents said that he’d get a good nursing at about 10pm and then he’d be out for about 3-4 hours.  Then when he awoke, he’d nurse again, out for 2 hours.  Then 1 hour intervals through the rest of the night.  The nursing was sometimes 15 minutes, sometimes 30.  What was happening?

Unlike The Human Pacifier, this 4-month old appeared to want to eat.  He wasn’t looking for reassurance or comfort during the night, he was really nursing.  There’s a behavioral aspect to frequent awakenings, that can become a problem as babies get older.  (I hasten to add that there’s no crying baby who doesn’t need attention and care.  Maybe there’s a sleep problem or a behavioral issue, but the approach to this should never include ignoring the baby, even if it does include a measured response.)

There’s no way to untangle the comfort provided by nursing with mommy in the middle of the night from the baby’s hunger.  Or is there?  In the 3-part Human Pacifier series [part 1, part 2, part 3], the baby was waking up to nurse for a minute or two, sometimes less.  He’d go to sleep right away after just a moment or two of snuggling with mom.  But Jamie’s mom didn’t have it any easier.  She, too, was getting up nearly through the night.  This baby was nursing pretty much to the capacity of the mother’s production.

Here’s what’s going on.  The baby is full when he’s going to sleep.  That’s why he has his longest sleep immediately after that last big feeding.  He was about 2 pounds less a month ago—that’s a big proportion of his body weight.  At the time, it was enough to keep him nearly through the night.  Now, it’s enough for 3 hours, maybe 4.  Then he wakes up hungry.  Nursing for 15 to 30 minutes is enough to take the edge off his hunger, and get him back to sleep.  It’s not enough to fill him.  The less-than-enough feeding may take the edge off, but it’s not enough to last long.  So this second feeding doesn’t last as long as the first.  He wakes up and mom does her best.  But 2 hours later, he doesn’t get the same amount he got after giving mom a 4-hour break.  Her manufacturing apparatus just isn’t set up for just-in-time inventory management.  He’ll get just enough to take the edge off again, but this time wakes up in an hour.  This is much less time than the factory needs to meet demand.  So from this feeding until morning, both baby and mother are locked in lactational Reaganomics—a trickle-down model of infant feeding.

So there’s a couple of logical approaches, with both possibly rooted in an econometric, perhaps even game theory perspective on infant rearing.  Isn’t this the approach most parenting authorities take?

First, we can decrease demand to match supply.  It’s hard to see Superman taking valuable time from his busy schedule and presumably many other commitments to fly really fast around the planet backwards and so turn back time to when the baby would stay full through the night.  There’s some ambiguity about how Superman ages, since he progressed from baby to newspaperman quickly but hasn’t changed much since the 1950’s.  I mention this because he’s going to have to accomplish this same task every month forever if we’re really intent about restraining the baby’s growing demand.


So, like true Reaganomics devotees, we need to focus on the supply side.  Here, there is a fork in the road.   There are many ways to try to increase milk supply.  This is a reasonable way to go, for a while.  Babies, however, can be relentless in their ever-increasing demands.  Will they never learn?  The other fork bypasses this captive supply chain and outsources the inventory management.  This baby was ready for solid food.

Human milk is really easy to digest.  There isn’t much else that goes through a baby’s stomach faster.  Solids get digested much slower, so they keep the baby full a lot longer.  For the record, the calorie content of solids is typically much less than breast milk or formula—so I don’t rush to start solids in babies who are having problems gaining weight.  Not every baby takes to solids right away, but the level of stress this induces occasionally confounds me.  I think of my fellow graduates and can’t think of a single one, not one, who wasn’t eating solid food.  I can’t authoritatively say that this was true at other medical schools, of course.

The Human Pacifier, Part 3

It would be great to have a definitive diagnosis, and know for sure why 5-month-old Andy was waking up every hour. Whatever the reason, it was torturing his mother. And that's not going be a sustainable, optimal environment for Andy.

In this case, it would be a luxury to examine every tree, but I had to see the whole forest, and it was on fire. Sure, the care that most families would get probably wouldn't include trying to fix these problems, and probably wouldn't include even looking for these problems. It just takes too much time. But that's not who I am and not how I practice. And it's not the best thing for the patient.

So I decided not to try the many possible interventions in series, one after another, in a way that would eventually yield a diagnosis and medical approach to the problem. This family needed my help right away, and they couldn't wait around, trying one thing or another just so I could claim a diagnosis. I explained this to them, and they seemed relieved. I suggested doing everything at once. Hopefully, something will work. Once the problem is fixed, we could, if desired, peel back the interventions layer by layer as if an onion. Perhaps in this way, we could arise at some diagnostic insight but not wake up the sleeping baby.

First, let's establish a transition object. The transition is a fairly nonspecific one—perhaps between wake and sleep, or from being held by mommy to not being held by mommy, or maybe between a sense of security and insecurity. Sometimes it's called a security blanket. The most well known, perhaps, is that of Linus, created by Charles Schultz. I suggested that the parents get a baby blanket like those used in the hospital nursery: soft flannel, but nothing fancy, hand-knit, family-heirloom, or large. A hand-towel or even a washcloth will do. Every time the mother nurses the baby, she needs to hold this between the baby's body and her own. It will pick up her scent, breast milk, sweat, and the baby's drool, spit-up, and scent. This too, has been studied. Even babies just a few weeks old can recognize the scent of their own mothers. Whenever the baby is being put to sleep, even if in a parent's arms, the cloth has to be there. Maybe, at those shallow levels of sleep, the sensory feedback gently provided by this transition object will be just the reassurance necessary to send him back to a deeper level of sleep.

I told them to bite the bullet and put the baby in the other room. Yes, get rid of the co-sleeper. Every time the baby is getting to a shallow sleep level, he smells fresh muffins and needs his mother to provide them. I want her to be available to comfort him if needed (this is NOT about crying-it-out), but I want him to work a little harder for it. If you are just barely awake and smell the fresh muffins baking, vs. just barely awake but have to get dressed and drive to the muffin shop. Either way, you get your muffins. But I bet you sleep a little longer if you have to go to the store. I expect that changing his pattern of sleep/wake will not be easy at first. I didn't suggest letting him go cold turkey on this. That's what the transition object is for. How much worse can it get?

The removal of the infant into the other room, I hope, will enable mother to miss some of those subtle vocal cues that she has been conditioned to hear and cause her awakening. Maybe if she's not hearing the baby talk in his sleep, she won't have to wake up unless he really wakes up. And both she and the baby know that he's not really eating all through the night. The nursing for 1-2 minutes is not long enough for a nutritive meal. It's for brief comfort.

The baby's eczema must be treated. I prescribed some lotion with a very weak steroid in it to use on the dry patches and on the dry patch on his scalp. Hopefully, this will relieve the baby's itch and let him sleep better and longer.

If the baby has heartburn, which seems consistent with some observations of the parents, he's not going to like being put down flat, and he'll be harder to comfort and may not sleep as well. We know he seems to sleep better in the swing than in his crib. Why not let him sleep in the swing? I also suggested they let him sleep in the car seat. This will keep him in a much more upright posture (adults with heartburn often sleep with a lot of pillows or with the head of their bed propped up) and keeps him securely snug. I cautioned them not to put the car seat on a table, bed, or any other surface. If they put him to sleep in one, it needs to be on the floor. Even gentle movement of the baby can cause most car seats to move across a surface and fall to the floor.

And if this is reflux, why not treat it? I prescribed some first-line antacid medication. I don't like putting babies or anyone else on medication, but sometimes you have to keep your eyes on the prize, which is helping the baby feel comfortable enough to sleep through the night. My job is not to minimize medication. My job is to make the baby's life better.

I had an assignment for dad, too. I told him that life is tough all over, and he was going to have to pitch in. I wanted him to take the middle-of-the-night feeding if there was one. If not, he would have to take the first feeding of the morning. The baby might indeed get hungry in the wee hours with the new regimen of comforting the baby without nursing every hour. Mom has plenty of pumped milk and the baby will take a bottle. So dad is going to get the big feeding while mom is going to get what I hoped would be at least 4 hours of uninterrupted sleep.

Lastly, they needed to establish a rock-solid bedtime routine. Doctors who treat insomnia note that the overwhelming majority of their adult patients have poor sleep hygiene. That means that they have the TV on, that sometimes they go to bet at 10, sometimes at 2. Maybe they sometimes eat before bed, sometimes not. People of every age respond to the ritualization of sleep, and the establishment of sleep cues. I suggested that every night at their chosen baby bedtime, they have the exact same routine. It might start with turning off most of the lights, then giving the baby a bath. Then they put on a fresh diaper, mother sings him a song while nursing, then more lights go off, then he is put in the crib in the other room (or the swing/car seat as above). With his transition object.

They're coming back in a few weeks. I don't know what has been working or not. When I do, I will post Part 4.

The Human Pacifier, Part 1

When Andy was 4 months old, his parents brought him to me and asked why he wasn't sleeping through the night. It was our first visit, and they had heard of me and chosen me carefully. They had not been satisfied with their original doctor, and drove about 90 minutes to see me.

They said that he was constantly hungry, and demanded to be fed every hour through the night. Mom was anchored to the co-sleeper, which enabled her to get what little rest she could. At least with this arrangement, when the baby awoke, she could give him a quick feed without getting out of bed, and then both could get back to sleep. Dad was now sleeping in the other room, because he couldn't function at work after being awakened every hour.

Insatiable hunger can be a sign of a serious medical problem. As you can imagine, however, the desire to eat nonstop usually appears in those who look one of two ways. The obvious one is very fat, since if you're eating much more calories than you expend, your body stores it up (welcome to my world). If, on the other hand, there's some innate—presumably pathological—drive within you to eat and eat, but it's because your body isn't absorbing the nutrients it needs and therefore isn't sending your brain the signal that you're full, it's possible to be insatiably hungry and yet be starving. There are many malabsorption syndromes and diseases like this. Perhaps the most common is Cystic Fibrosis, which causes the pancreas to fail in the production of key enzymes and factors that help us absorb and digest different nutrients and fats. If you don't absorb fats, you miss out on a lot of calories. All of this is simply to say that I take seriously the observation that a child is insatiably hungry.

Note that if your child were insatiably thirsty, get your kid to a doctor right away.

But there's a reason we do growth charts. The happy baby smiling and laughing with me was at the 50^th percentile for weight, height, and head circumference. He wasn't thin or fat. He was exclusively breast fed. Though it's possible to overfeed a baby who's breastfed, it's a lot more common in bottle-fed babies whose parents, for whatever reason, use the bottle to soothe the baby. Since a baby sucks for comfort (they are often seen on ultrasound sucking on their own hands or fingers in the womb) and sucks instinctively (they will suck on a stick or anything placed in or near their mouths), these parents get the mistaken impression that if the baby is sucking on the bottle, the baby must have been hungry. Andy had not been overfed.

Though many people wait until 6 months to start solids, and I generally recommend that too, this was an exception. I thought that if we started solids right away, at 4 months, it might help. Solids of all kinds generally move through the digestive tract much slower than liquids. And much, much slower than breast milk, which is very easy for the baby to digest. My thinking was that if the solid feeding were at night, the baby might stay full a lot longer, and thus not awaken hungry so often. Great idea, I was assured by the parents, and they would try it.

It didn't work. A month later, they had driven all the way to my office for follow up. Not from the drive alone, they both looked exhausted. The baby was 5 months old and awakening every hour. He did great with the solids, still rice cereal, once a day. He continued to be at the 50^th percentile for growth. I had to take a better history.

Mom said that he nursed like a champ during the day. He spit up a little but not too much. He liked the cereal they had tried. He didn't mind being put down into the swing or the car seat, but hated being put down flat. Andy had taken to shaking his head vigorously against the crib mattress when he was put down, and now he had a little red area there that they think was caused by this.

I asked about the specifics of this 'insatiable hunger' that mother described. She said that almost like clockwork, he would wake up every hour during the night and make some noises—not crying exactly, but she said that she knew that if she didn't nurse him right then, he would escalate this into a vigorous cry and it would be much more difficult to get him back to sleep. So she now hears these little noises, and wakes herself up, picks up the baby, nurses him, and he goes right back to sleep. This process repeats every hour through the night.

Each feeding lasts, she said in response to my asking, about 1-3 minutes. She doesn't change him, because that, too, would wake him up more and make it tougher to get him back to sleep. How much, I asked her, did she think he was really getting during those feedings. “Not much,” she admitted. “I feel like a human pacifier.”

The situation in brief:

1. Baby won't sleep solid 2-6 hours at 5 months;
2. Mother not getting a sustainable amount of sleep;
3. Father sleeping in another room.

Are the following facts related:

1. The baby is insatiably hungry, but is growing normally;
2. The baby hates being horizontal, but is OK in the swing or carseat;
3. The baby shakes his head on the crib mattress;
4. The baby nurses a lot during the day.

And lastly, what exactly is my job and how do I perceive my role in this family's life? Here are some choices:

• The baby is growing and developing normally, so I can reassure the parents that they will all get through this difficult time and that they should return in 2 months for the next scheduled well-baby visit. (This, by the way, is the 'standard of care.')
• I should try to diagnose the reason for the baby's frequent awakenings, and treat this or at least help the parents understand this.
• I should avoid 'medicalizing' this normal variant of infant behavior and development. I shouldn't agree with the parents that the baby has a problem. It's their problem having difficulty living in their otherwise-normal baby's life. Why does every minor inconvenience need medical intervention? Does this require a diagnosis?
• Is the baby suffering? After all, he's my patient. If the baby—laughing and smiling with me in the office—is none the worse for wear, everything else is incidental to me as his physician.
• Do I try and fix this? In the early 19^th century, a popular medicine for babies was Godfrey's Cordial, a liquid mixture of molasses, sassafras, and opium (sometimes brandy). The good news is that it worked great. The bad news.... If I decide to try and fix this, what exactly do I fix? What's broken? What, when all is said and done, is my job?

Next post: My analysis and decision process at the end of the visit.

The Slobbering Grandmother

I don’t like taking off my shoes when I go to someone’s house. Hey, haven’t they heard of vacuum cleaners? But I’m the visitor, and it’s their house, after all. So even though I don’t like to do it, and they don’t have to do it at my house, I take my shoes off. It’s polite, as a guest, to respect my hosts.

Even with 9 months to think about it, even if you read all the available books about how to prepare, you’re never prepared when the baby arrives. Suddenly, you’re a parent.
As I said in An Aunt Who Shares, our modern style of family unit often leaves new parents, and new mothers in particular, very isolated. There is a natural tendency with bright independent young adults not to ask for help. I think this is a mistake, and tell them so. I encourage getting those grandmothers and other close relatives to watch the baby for short periods that allow the new mother to get some precious sleep. An absolutely essential part of being a good parent is being available to your child. With a newborn, you need to look out for your own healthy nutrition and exercise, and more than anything, you need sleep. The baby needs the most alert, healthiest mother possible.

So part of the journey into the ‘parent’ part of your life is taking care of yourself so that you’re there to take care of the baby. It’s one of the key stepping stones of adulthood.
In this spirit, I had been seeing one of my new babies nearly every day. The mother, Melissa, was struggling. She was indeed isolated, by the circumstance of having moved here from far away. Her husband was as supportive as he could be, but I suspected that he had an extensive list of pre-birth expectations that needed immediate reappraisal. When they were in the office, for example, he seemed to be impatient with any cry from the baby. I got the feeling that he thought that if the baby was crying, the mother was doing something wrong. Still, he let her do 99% of the baby care. Newborn care looks easier from the outside. Melissa was, of course, sleep deprived and emotionally fragile. I knew she was getting depressed.

But the reason for her call late at night, when the baby was about a week old, was a surprise. “I need you to answer a medical question. Is it safe for the baby if someone who’s had herpes like a hundred times is kissing him on the mouth and slobbering on him?" But I heard something else in her voice. I asked why she’s worried about this.

Her husband’s mother had come to visit. She insisted on holding the baby and kissing the baby on the mouth, kissing his eyelids. She did, in fact, have a long history of eruptions on her lips. Melissa told me that she had politely asked her mother-in-law not to do that, since it made her uncomfortable. The activity didn’t stop. The next day she asked again, and this triggered a cascade of discussion which included Melissa asking the baby’s father to ask his mother to stop doing this. The mother-in-law, in a spirit of helpfulness no doubt, explained that she raised 3 children of her own and knows much more about babies than Melissa. Her son said that he didn’t want to get in the middle of anything. Melissa called me and asked ‘a medical question.’

In general, I don’t like getting in the middle of anything either. But I told Melissa that my answer had 2 parts. First, the recurring cold sores that her mother-in-law gets on her lip are certainly herpes. It’s from a virus she caught years ago, that doesn’t go away but remains dormant in the nerve cells of her spinal cord and reappears from time to time with illness or sometimes stress. It’s definitely contagious when there’s an eruption, but it is probably somewhat contagious just before or just after an eruption. So since her mother-in-law isn’t having an outbreak right now, chances are very good that the baby will be fine. I pointed out for future reference that during an outbreak, I’d be reluctant even to let the person hold the baby, since if they touch the annoying sore, the virus can be spread on the hands. I apologized for not being able to tell her categorically that this woman shouldn’t be handling the baby. Melissa sounded disappointed.

I reminded her that there was a second part to my answer. This was her baby, I reminded her. This lady had her 3 kids, just as she said, but she was not this baby’s mother, and has no say in how to raise it, feed it, hold it, or choose who gets to do what with it. It was hers. I told her that I, too, cringed when she described this woman kissing the baby’s mouth and eyes. I was glad the grandmother felt affection for the baby, but when asked to stop, there could only be one acceptable response, and that was to respect Melissa’s wishes.

It’s OK with me if, in the car on the way home, the mother-in-law complains bitterly to whomever she’s with about the lousy job her son’s wife is doing with her baby. It’s OK if she calls her friends and tells them how her son married someone so unworthy of him. Where it crosses the line is telling her son or daughter-in-law these opinions, and it’s way over the line when she goes ahead and does what she thinks is best despite the wishes of the parent.

I have posted in An Aunt Who Shares about how much we might have lost when our society moved away from the multigenerational household. These have been the standard for generations. The expression It takes a village to raise a child is an African aphorism (Nigerian Igbo culture) that confirms the naturalness of having more than a single caregiver.

But again and again I am the unlucky witness to conflict between mother and grandmother when a new baby arrives. As hard as the transition from adult to mother might be, there is a transition from mother to grandmother that is clearly a difficult one for many. The bookstore doesn’t have a big section of parenting books for grandmothers. If I wrote one, it would be short, so I’ll outline it here.

• Share your love, your time, your money
• Babysit
• Offer advice when asked
• Indulge the child much more than the parents ever should or would; much more than you did with your children
• Keep visits short
• Mind your own business

You are not the parent. You had your chance, and for better or worse, it’s over. Move on.
Your daughters and sons still need you a lot. But it’s their life now, and their family. If you want to keep your family together, respect theirs. The reward will be the calls and invitations to visit that you really want.



Epilogue: Melissa appreciated my support. I asked her permission to do a blog post about it, and she said it was OK. Things are tense with all of the husband’s side of the family.

An Aunt Who Shares

When a baby is born at the local hospital, the clerk in Labor and Delivery calls the pediatrician identified by the parents. The call I received one night about 3:00 AM was a little hard to understand. Granted, I had been awakened. But I asked the clerk for the patient’s name. ‘Oran…,‘ she said, then ‘Oranolantu…,‘ then ‘…bat…. “Do you mean Oranolantubaataar?“ I asked. Relieved, she told me I had a healthy big baby girl to come in and take a look at. I knew the family, and took care of the 4-year old son. I told her I’d be in later that morning. She politely told me that everyone in Labor and Delivery would really like me to come in now. I got dressed and went to the hospital, fearing the worst.

The Charge Nurse for L&D, who is the supervisor of all the nurses and operations of the department except for the obstetricians, and always one of the most experienced veteran professionals there, met me at the elevator, before I entered the ward. She said she’d never seen anything like it and didn’t know if it was OK and wanted me to evaluate this and write a note about it in the chart. She was afraid the hospital might get sued, and maybe a little afraid of losing her job. When I walked into the room, I was not prepared for what I saw.

The mother I knew was smiling happily in bed. Her labor had been relatively short with this second child, born about 2 hours earlier. She greeted me warmly in her broken English. I looked around. “Where’s the baby?” I asked her. She pointed to the chair next to her bed on which was a young woman. ‘Sister’ was her one word introduction. This woman was bare-breasted and nursing the newborn child.

I had never seen anything like it. I met with a group of the nurses, the charge nurse, and others.

The transition from unencumbered adult to parent is always unforeseeably and indescribably enormous. It seems that in recent years, the pressure on new parents has continued to build. The parenting shelf in the bookstore has become a whole section with many aisles. Perhaps it’s a good thing that you now can choose to learn what one author thinks you should have been expecting while you were expecting and another author claims to help you raise a child who is an over-achieving, healthy, gifted, socially adept, high IQ athlete who knows both how to control her temper and who goes to sleep without problems. (My approach to advising parents is almost always to ask the child to provide the right guidance. They usually know.)

Why has this proliferation of parenting advice taken place? The simple answer is that there’s a market for it. Publishers are aware of the demand and are in the business of meeting it. What’s behind this demand?

The desire to produce a text on childrearing isn’t new. Especially with the industrial revolution, the idea gradually took hold that maybe there was a ‘right’ way to raise kids.

Especially for the new parent, and the new mother in particular, these books can seem like an essential reference. There is a tendency for new parents and new mothers in particular to feel that the ‘success’ of nursing the baby, soothing the baby, even bathing the baby is a great burden that falls on them and them alone. If things aren’t going exactly right in the first days and weeks, it’s hard for new mothers not to see that as a personal failure. This is a major contributor to postpartum depression. But what has caused this crushing pressure? Is this part of Eve’s curse (Genesis 3:16)?

I don’t think so. According to archeological evidence, and according to countless cave-people movies, humans most likely never went through a phase of living in completely isolated family units. The idea, maybe born out of the settling of the American West, that there would be settlers who lived a hardscrabble life by themselves on a ranch the size of some European countries, is not one that has typically existed elsewhere in the world. Sure there are subsistence farms and always have been, but they are small and the families live close to other families.

And, finally I’m getting to the point, all the households are multigenerational. With marriage as teenagers, there would usually be grandmothers and even great-grandmothers living with the new mother. There would be sisters and aunts with their babies, too. And despite the considerable work all the women were required to do, some of the work of childcare and an enormous amount of cumulative experience and wisdom would be easily available and given.

Though it’s a good guess that midwives, people with special expertise in childbirth, have been around for a long time, Lactation Consultants are likely a newer breed. Within a multigenerational household, there would be lots of sources of advice about sore nipples and babies who don’t latch well. I suspect that postpartum depression has always been with us, but some of its pervasive contributors--isolation, the feeling that every need of the baby must be met by the mother, the sense of failure if the mother’s milk hasn’t come in by day 3 or 4--would be so very much relieved by having a crew of experienced and trusted peers who know what the heck they are doing.

The baby’s mother was from one of the Mongolian families I take care of. Some speak no English at all. But they all live very near each other in one neighborhood of Oakland. Many bring their kids to me. Her sister had given birth a few months earlier, and was still nursing her own infant. In their culture, this wasn’t unusual--it was simply what was done.

About a hundred years ago, and for millennia before that, wet nurses were common. Women who couldn’t nurse or those who could but had the resources to avoid this task of the masses, would employ a woman whose lactation was maintained by her continued employment. There were few alternatives. (The picture above is from a booklet produced about 1900 by Nestle, for a product called Nestlé's Food, which was among the very first commercial baby formulas. It’s from my collection.) But before there were professional wet nurses, there were women who would share their supply with the less fortunate, or the babies who had survived childbirth when their mothers did not.

One of the nurses asked if it was hygienic. Honestly, I didn’t know. I suppose, in these days of Universal Precautions and doctors afraid to touch you without gloves on, I could see what the concerns might be. There are some diseases which can be transmitted through breast milk, along with many medications. As politely as I could, I tried to get a little medical history from this other woman. She spoke almost no English, and the postpartum mother was translating my questions—I think. She’s the one who told me ‘she OK’ and left it at that.

I told the L&D crew it was OK with me and I would write an order in the chart explicitly allowing it.

The woodcut from 1550 is by Hans Brosamer and is from my collection. It shows the creation of Eve, her temptation, and the expulsion from the Garden of Eden. The poster from the 1958 movie Teenage Caveman was part of the collection I sold in 1992. Produced by—who else?—Roger Corman, I think it was Robert Vaughn’s first starring role.

Too Many Clean Diapers

As devices go, babies are pretty basic. They eat. They sleep. They poop.

New parents give so much, so fully. Shouldn't they expect something in return? So maybe it's natural that some parents ascribe to the baby's material productivity some kind of assessment of their parenting prowess.

Ellen was about 4 weeks old when her parents brought her in. They were generous enough to let me hold her and play with her while they told me why they were in my office. She hadn’t pooped in 4 days. Last week, she went 3 days, then several times a day for a few days, and now nothing for 4 days in a row. I was kind of listening to them, but I was having a lot of fun making Ellen smile, which she did easily. I asked them if she was this happy at home. She was happy, ate well, didn’t throw up, slept well, and was nursing like a champ. Her weight gain was perfect.

I told them what I knew at the time. Breastfed babies have unpredictable stooling patterns. Medically, I wouldn’t diagnose her as constipated unless she went at least 5 days. They were pretty amazed by this, and though they didn’t seem worried, I got the impression they weren’t fully satisfied, either.

There were many things that could be done to help the process along. An old remedy is to add sugar syrup (Karo syrup) to a baby’s bottle. Another is to sneak in a little pear juice. Taking advantage of the baby’s autonomic nervous system, a little direct anal stimulation will usually provide an effective reminder (that's why they usually go after getting their temperature taken).

They called me the following day, at 5 days. I tried to be reassuring.

They called me on the morning of day 6 to report that nothing productive had occurred. I called one of the very smart specialists in pediatric gastroenterology at Children’s Hospital Oakland. The specialist chuckled a little and said that he’s seen healthy breastfed babies go a long time.

I didn’t hear from them the next day, so I called to ask about the blessed event. I got a surprising response.

On the insistence of the baby’s grandmother, they reported being fortunate to get an urgent appointment with the grandmother’s chiropractor. He diagnosed the problem as a misalignment of the baby’s coccyx. In an additionally fortunate stroke, he was confident he could realign the baby’s lowermost spine to alleviate this problem. In order to reach the coccyx, which is deeply protected in the center of the pelvis, he put on a glove and pressed directly on the baby’s anal and perianal area.

Sure enough, said the parents, the baby went within an hour. They were told, however, that this alignment procedure was only temporary and the baby had a tendency to sacro-coccygeal subluxation. For this chronic problem, they would have to return once or twice a week for the foreseeable future. Each visit was $100.

They continued to see me for scheduled check-ups. Every few days, Ellen got a realignment. They never again had a problem with constipation.


The astute reader will notice that in the uppermost photograph of the felt-and-velcro skeleton which hangs in my office, a creative anatomist placed the pelvis and thorax upside-down. The sacrum and coccyx are oriented correctly, however. By giving medical experts of varying ages the opportunity to share their expertise, I have access to a valuable consulting resource. It could be argued that the implementation of a 21st-century perspective requires a voice born in the 21st-century. The occasional redesign of the human form is a small price to pay for this cutting-edge knowledge, especially from someone who has just learned to walk.


For the neuroanatomicially curious, the nerves controlling sphincter muscles and thus pooping emerge from the cauda equina tail of the spinal cord at the S3 and S4 segments of the sacrum, above the coccyx. For this reason, one could live life with a subluxed, broken, deformed, or absent coccyx and poop like a champion. There are champions for this, aren't there? I'm not much of a sports fan so I don't know for sure.

Please see my post on Swine Flu, UPDATED 5/5/09

Postpartum Depression: A father's comment -- strategy for relief

My job, as I see it, is to make a child’s life better if I can. The comment that this father emailed to me about a blog post gave me a glimpse into the first days of their lives as new parents. So I tried to break this situation down into problems that I could solve.

First, the wrist. This was my first target because it was the easiest. With sleep deprivation, small but persistent annoyances can appear as giant and impenetrable problems. They can be the spark that starts big fires. I brought the parents into my office and found the right kind of splint on my computer. I gave them the printout and told them to buy it that same day. Mom was to wear it all the time, except when showering or sleeping. The thick aluminum bar in the splint would prevent the wrist from flexing, allowing the tendons to heal on their own.

Then, the breastfeeding. The father said in his comment, “…we keep telling ourselves the benefits the baby will receive from breastfeeding will far out way [sic] a strictly formula diet.” Maybe it’s heresy, but breastfeeding may be best for the baby, but by how big a margin? Will one bottle of formula a day (maybe less than 10% of the baby's total nutrition) make a real difference? There's an interesting article on this from The Atlantic magazine, which poses this question. My priority is clear: what’s best for the baby? Breastfeeding dogma, which is powerful here in Berkeley, would have us believe that there is no other way. I saw an alternative path that I’ve used before.

• First, I need to relieve some of the relentless pressure on this first-time mother. By giving her permission to feed the baby pumped breastmilk or even a couple of ounces of formula once a day, I might be able to absolve her of some of her performance anxiety. She’d worry less about the baby not getting enough and worry less about her own inadequacy. And skipping a direct feeding might give her a needed relief for her soreness.
• Second, I needed to find a way for her to get help she could have confidence in. This would also take some pressure off.
• Third, dad needed to be involved. He needed the opportunity to shoulder some of the burden his wife had been under alone. He also deserved an opportunity to step into his baby’s life.

Every night, they were to give the baby one bottle feeding. Dad would do this feeding by himself, so mom could sleep. True, it would be in the middle of the night. But dad would have this precious time for just him and his baby, in which he was meeting all the baby’s needs and the needs of his wife, too.

I saw this family again about a week later in the office, though I had called and spoken to them on the phone several times in the intervening week. Everything was better. They were still tired, but mom’s mood had brightened a lot and dad was now king of the night-time feeding. When I asked how things were going, mom told me a lot but when she was done, dad had a lot to add about the baby’s expressions and actions and feeding behavior and sleep pattern. He really knew.

Postpartum depression, and perhaps depression in general, seems sometimes to blind us to paths leading out of the dark places in which we sometimes find ourselves.


Next Post: Do 8-year-olds get depressed?

Postpartum Depression: A father's comment--observed

A father’s Comment, observed.

In my last post was the comment of a new father. This story has many elements in common with a lot of the cases of postpartum depression that I have seen. The mother isn't overtly depressed, and wouldn't identify herself as depressed. Dad says that he is, but is quick to say how happy he is. But when I read this, I don't get a happy feeling. I think most readers will hear the tone of sadness throughout the comment. Professionally speaking, I don't think things are going all that great for these parents and I don't fully believe that either one of them are really happy with the situation.

Can I relieve some of this suffering? Does it have to be this way?

Her Mood:
When I received this comment, I called the family and asked them to come in to the office. The baby was doing fine, which enabled me to focus on the parents. Just as hinted at in the father's comment, mother was at the same time territorial about the baby's care and yet feeling overwhelmingly pressured to do everything herself. I started with the usual, ‘How are things going?’ She said everything was going fine, and she felt good. But every time I asked about something specific, it was a different story. Mom used a lot of tissues during the visit.

Breastfeeding:
For this mother, as she saw it, nothing was going the way it should. Breastfeeding was very painful, and she had been told it wouldn’t be. She was very afraid that the baby wasn’t getting enough, even though his weight gain was good. To her, he always seemed hungry after nursing because he continued to want to suck. She couldn’t stand his screams. The baby was telling the world that what she was producing, what she was doing, just wasn’t good enough.

Dad’s Mood:
She didn't think the father could do a lot of the tasks she did, but never asked him for help or showed him what she wanted. She never let him help, and was angry at him for not helping. He felt like an outsider looking in, saddened by his isolation and by his own helplessness.

The Wrist:
The mother felt bad enough without the excruciating pain in her wrists. Every time she went to pick up the baby, she felt that she was destined to wince in pain. She didn't know who to tell about this problem, but I'm glad the father told me. She had something called nursemaid's wrist. (Important note: this has nothing whatever to do with nursemaid's elbow.) It's an overuse injury that you get from picking up babies all the time. The fix is rest. What I told her to get was a wrist splint with a metal bar in it for stiffness. All the wraps and elastic things won't help. The wrist has to be immobilized for the inflamed tendons to heal.

It’s tough enough to keep your spirits up when you’re in pain. But she told me that her wrist pain made her feel bad. She explained that every time the baby cried, she dreaded having to pick him up, as if he were causing her pain. She felt terribly guilty about these feelings and knew it wasn’t the baby’s fault—it was her fault.

As an aside, this brings up once again a philosophical problem with medical care. I'm the baby's doctor and the baby was doing OK. Should I mind my own business about everything else? Hint: what do you think?

Next Post: A strategy

Postpartum Depression: A father's comment

Shortly after posting New Mother, Breastfeeding I received a comment online. The original comment had a lot of names in it, which I have removed. I am posting the comment with permission.

Hey Dr. Wolffe,

[Our son] was born Jan 18th, which makes him just eight weeks old today. You've been seeing his mother since his second week or or so. His mother will be in with him on Tuesday I believe. We were so thankful for gaining you as [his] pediatrician.

Now for the topic of discussion. my wife still struggles daily with breast feeding. We've had many a discussion, and for the most part I try to back off and let her handle it. Their her breasts, not mine. Her mothers made comments about her sister not having the same troubles. She's had problems with engorgement, so on and so forth. But, everything is getting better from day to day as well. He screams at the top of his lungs when he's hungry. My wife still gets up at all hours of the night. We hardly sleep together since she's up so much. We've had lots of help over the past few weeks from her mom and sister. During the first couple of weeks my mother was here helping out with what she could. Every now and then I see the PPD monster climb out, but after a little bit of rest and noticeable improvement with the baby, PPD settles down. I am the husband, and I feel a little depressed from time to time. I'm not to worried about it since overall, I am happier than I've been in years. Marriage and fatherhood have been great for me. Now if we can just keep ironing out all the wrinkles that come along with being new parents.
My wife's number one complaint is pain from him tugging on her breasts.
#2 is her sore wrists. He's getting heavy fast. Heck I'm twice her size and he strains my wrists too.

For her first complaint, I've asked her to continue to go to breast feeding class, so they can help her master the technique. I notice sometimes her posture and technique of latching don't go hand in hand with what I watched her being taught at Alta Bates [Hospital]. I tried to point these things out, but it mainly causes arguments.

I have sat with her and helped with the entire process. I do admit, she's getting better, and the baby's feeding better. In the evening I don't think she's producing so much milk, so a couple of times we have supplemented formula to give him a full belly. This takes care of the crying.
Her sore wrists don't seem to be getting any better yet. I have purchased her several different athletic supports (splints) to help out, but they aren't working too well. I've asked her to ice, but I've never seen her actually do it or heard her say she has. Being an wrestler in high school, college, and post college, I can attest to ice being the miracle drug for joint pain, bursitis, strains, sprains. Icing twenty minutes on and ten minute ice massage are uncomfortable at first, but they works.

Today we went out to REI in Berkeley, and ended up cutting our trip short as she was having too much pain in her wrist to breast feed him in the car. I realize this is uncomfortable, so I encouraged her to put a pillow or something in the car so she can feed him comfortable. We went home.

I was very pleased this afternoon to get him to take a pacifier for about twenty minutes. He did well. I can see smoother sailing ahead for all.

So for all concerned, we keep telling ourselves the benefits the baby will receive from breastfeeding will far out way a strictly formula diet.

Next Post: My response and follow up

Postpartum Depression: Andrea opens my eyes

I met Jabrea for the first time when she was about an hour old. Her mother, Andrea, was in the delivery bed, exhausted but smiling broadly. Her husband and sisters and parents were all huddled around me as I did my exam. "What does Jabrea mean?" I asked her.

"Nothing," she said, "I just liked the way it sounded."

"I have a suggestion for you. People will ask her and you about it her whole life. Tell them it means 'beautiful princess.'" She liked this idea. Now, 8 years later, sometimes her parents call her 'BP,' though it's usually when she doesn't clean up her room.

Andrea was a happy and healthy young woman, with a supportive family and husband. I wasn't worried about her or the baby. She was a middle child, and her younger sister was still in school. Her older sister already had 2 young children.

She brought the baby to me for follow-up shortly after leaving the hospital. The baby was adorable and everybody in the office fawned over her. We went into an exam room and I asked, "How are things going?" Immediately, she burst into tears. "Everything's going great," she said, crying. I asked all the usual questions--breastfeeding, sleep, poop, rashes, breathing, eye contact, and so on. She answered them all without any cause for concern. While crying loudly. Eventually, I did ask her why she was crying. She said, “I don’t know.” I told her in the most convincing manner I could that the baby looked great and that I thought she was doing a great job. The baby was 2 days old. The next usually-scheduled visit was at 2 weeks of age.

That visit was more difficult, though the baby continued to look great, was gaining weight well, and seemed developmentally normal in every way. No matter how confident I tried to appear, Andrea kept crying. The visit was scheduled for 15 minutes (some clinics schedule 10 minutes), but I couldn’t move to the next patient. There was something here that I had to understand. I had to try and make things better. A long time ago, I was taught to approach complex problems in physics by breaking the problem down into more comprehensible pieces. Not having any idea or training in any other method, I tried this. I asked her about every detail of her life with the baby. She told me, after a lot of very specific questions, that she had stopped breastfeeding. She did this because she wasn’t a good mother: her body couldn’t do it, her breasts hurt, she could never do the things that her older sister could do so effortlessly, she could never do what came so easily to every mother she heard about or read about in baby books. Worse than this, her completely innocent baby would suffer from her incompetence. She would lose the benefits of breastfeeding, she would lose the better immune system and better nutrition and now she has doomed her daughter to having serious illnesses and eating disorders. Worse still, she would never bond with her mother and always know that her mother didn’t care enough about her to live with the pain. Andrea knew this to be true because the baby no longer wanted her, and was rejecting her. The baby clearly knew that her mother didn’t have want she wanted and needed. The baby didn’t need her for anything, and neither did anybody else.

What was I actually observing? In the little exam room, there was a pervasive sadness and feeling of despair and failure. Andrea had no history of psychiatric problems, and it didn’t occur to her to seek professional help. Indeed, she didn’t think anything was wrong with her. She was simply a concerned and observant parent who wanted to be sure her baby was OK. She didn’t think of herself as depressed. She acknowledged that she cried an unusual amount, and she said that her husband was frustrated because he was unable to cheer her up. She didn’t think he understood the baby as well as she did and would only let him take care of her when she was there to supervise closely.

I bought a book. Beyond the Blues by Shoshanna Bennett and Pec Indman.

Every day in my practice, I was seeing mothers with newborns. I started asking a question I had never before asked. “How are you feeling?”

Postpartum depression had never been mentioned in the psychiatry section of medical school. It had never been mentioned in my pediatric residency. Maybe I had heard the term but now, looking back, I don’t think I ever thought about it. Apparently, it is at least mentioned in the training of Ob/Gyn doctors, I guess when they aren't doing surgery. They typically see the woman for follow-up 6 weeks after she leaves the hospital.

Maybe it’s obvious that if you don’t ask a question, you probably won’t find out an answer. There’s an unspoken secret in some areas of medicine, however. Sometimes there’s information a doctor doesn’t want to know, and questions the doctor doesn’t want to ask. Asking about how the patient feels is likely to evoke an answer that will take a lot more time to deal with in a competent way that if the patient is never asked. Some doctors and clinics go so far as to spell it out. They tell the patient that each visit deals with one problem. So it’s either the rash or the headache, not both. The questions they ask for each problem are extremely specific. This helps manage the limited visit time in an optimal way for the institution, not for the patient. The patient’s time, indeed the patient’s health, is not the most important factor in this model of care.

Because so much of postpartum depression isn’t noticed by anyone in the medical field and because many of those suffering with it don’t report it or seek treatment for it, we really don’t know how common it is. But it’s common. Maybe as high as 15% or 20% in some published sources.

Nobody I knew had a clue about this. I felt like I had discovered an underground epidemic, which was everywhere I looked, hidden in plain sight, right in front of me all the time. I decided to learn more.

Next Post: Andrea, getting help and getting sleep.