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 2

Like every new mother, or maybe at least the good ones, Amy said she was worried if her baby was getting enough.  Henry was a week old, and I walked her through my iterative procedure to determine if he was getting what he needed.  He was gaining weight appropriately.  He was having lots of wet diapers.  He was satisfied after nursing, and could be heard swallowing voraciously at every feeding.  This was apparently an adequate response until she asked me if I thought he’d be alive in 6 months.


I wasn’t going even to try and finesse this over the phone.  I stopped at the supermarket, picked up a small portion of hot macaroni and cheese along with a little bit of cut-up watermelon, and drove directly to her house.  Intentionally, I did not ask if it was a convenient time for a visit.  I didn’t care if it was convenient—it was necessary.


Her mother was there to open the door.  Though it was just a few minutes ago when we were on the phone, her mother had arrived in the meantime.  I thought that was lucky and we introduced ourselves.  I asked where Amy was, and her mother directed me upstairs.  I was carrying the old-fashioned  housecall bag that I kept in the car, but I didn’t think I would need to examine the baby. 


Henry was a term baby, and healthy.  Amy had been doing a good job keeping up with the demands of initiating breastfeeding, and her general concerns were common, reasonable, and could be comfortably answered with rational reassurance.  


I walked up the stairs to the master bedroom, where Amy was in bed, holding the baby.  It’s was a nice big room, with big windows that looked out onto a garden.  The windows were closed.  I asked how she was and she said she was OK.  The baby was OK, too.  It was nice of me to come over, but it wasn’t really necessary.  I told her that I had brought over a little watermelon, which has a lot of water in it.  It was July, after all.  I also brought over some macaroni and cheese—though I had this before and the store where I bought it usually makes it quite bland.  It was a good way to raise your blood sugar if you haven’t been eating right.


She admitted that she hadn’t really been eating right.  She was in bed, I noted, and it was about 5:30 in the afternoon.  She said she hadn’t been out of bed much, either.  I didn’t mention it, but I didn’t really understand why her mother was downstairs and she and the baby were upstairs.  It’s hard to know what the right approach is to get a channel of communication open.  I’m usually very good and very intuitive at this with children, but I’m not as skilled with adults.  I decided that for the moment, I’d let my actions speak for themselves:  I was there.  I didn’t tell her to call if something happened, I actually showed up.  I believe that sometimes that is exactly what’s needed.


So I didn’t immediately confront her about what she said.  “Do you think it’s warm in here?” I asked.  It felt like a sauna to me, though I’m biased by my weight.  I was self-conscious about the beads of sweat I knew were appearing on my bald scalp.  In my little doctor bag, there was an infrared thermometer.  It read 95° [35°C].


Amy said, “Oh god yes.  I like it cool and so does my husband.  But it has to be warm for the baby, right?”  


“Is the baby cold?” I asked.  He looked comfortable enough in her arms, wrapped in a blanket and wearing a hat.  


“How can I tell?” she asked.  I asked if the baby’s hands or feet were cool or purple.  She had to unwrap him to look, and they weren’t.  But, she noticed, his back was sweaty.  I put down the doctor bag.  I asked if it had been this temperature in the room for the 4 days since the baby was brought home from the hospital.  It had been, she said, because they wanted it to be comfortable for the baby.


I walked to the windows and opened them.  “What are you doing?” she asked.  


“I’m making the room temperature compatible with life for non-reptiles.”  I explained that if having a newborn baby in the room was not enough of a cause of sleep deprivation, being uncomfortable would suffice as well.  

Her thought was reasonable, even right in a way.  Babies do have more difficulty maintaining their body temperature and need to be kept warm enough, especially if undressed.  But they are warm-blooded, at least in some general Linnaean sense.  They will maintain their body temperature with appropriate energy resources and insulation.  I coached her on this point as I undressed the baby and took off his hat.  I suggested a couple of thin layers, that were easy to add or remove as needed.  That kind of management is less practical for adults, so it was important to keep the environment comfortable for her and her husband.  The baby could be dressed as needed.  She liked this idea.


Maybe to my sophisticated readers this will seem simplistic, but I don’t think it is.  Again and again I find that housecalls can be profoundly helpful, often in unexpected ways.  In this case, Amy did indeed have some postpartum depression.  We are dealing with that, hopefully, in helpful ways.  But the housecall accomplished several important things.

She knows, in a convincing way, that I will actually come to her house if needed.  She’s not in this by herself.
I know what she’s got, I’m concerned about it but not frightened away.

She has my permission to be comfortable.  This is so important.  It’s crucial, of course, that the baby gets what he needs to thrive.  But those needs are pretty basic.  Once the baby’s needs are met, the next priority is finding a way to make the new world order work for the parents in some practical way.  Amy was doing a good job with the needs of the baby.  She was ignoring her own.  I wanted her to know that getting some relief in the misery of the mother is good for the baby, too.


After making the ambient temperature low enough to assuage my concern that the buttons on my shirt might melt and leave permanent scars seared into my chest, I had several other suggestions for her.  That’s next.

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.

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.

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