A Good Night’s Sleep…

After having a baby, most parents long for a good night’s sleep. Many turn to sleep training in order to make that happen. Sleep training is a controversial subject, especially lately with the Cry It Out method making national headlines. However, the importance of sleep for the health and happiness of the entire family is universally accepted. Very few infants sleep through the night before six weeks of age and if you ever meet a parent who says that their infant does – ask them specifically how and when they are sleeping. You will find that “sleeping through the night” has a very different definition for every family.

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While babies will start sleeping longer stretches (4-6 hours) at night around 8-12 weeks, most don’t truly sleep through the night consistently until 12-18 months. Even if a baby has been sleeping through the night, sleep patterns often changes with growth spurts, teething, and illness. If you make a decision to go through with sleep training, you will have to find a method that everyone is comfortable with and makes sense for your infant and parenting style. You may find that you must modify your chosen sleep training method at different stages in their child’s development and what works for one child may not work for another. Recent studies have found no long term impact on children’s development or emotional health with behavioral sleep interventions.

The most widely accepted sleep training methods range from the Cry It Out (AKA extinction or gradual extinction) to the No Tears Methods.
  • The Cry It Out methods involves putting your infant in the crib while sleepy, but awake. Then letting them cry either until falling asleep or leaving them for incremental longer periods of time before gently soothing with patting or shushing – but not picking up, rocking, or feeding. The goal is to teach your infant self-soothing tactics. These methods generally take from 3-5 days to work. Authors who have written on this subject include Richard Ferber, MD and Marc Weissbluth, MD.
  • The No Tears Methods typically involve repeating the same bedtime routine every night, starting when your baby is showing signs of sleepiness. This may be a bath, massage, lullaby, then rocking or nursing to sleep. Remember that your infant will likely require this same routine with each nighttime wakening, which may continue until early toddlerhood (but hopefully not). Authors who have written on this subject include Elizabeth Pantley and William Sears, MD.
  • If you are a parent who started off by sleeping with your baby or older child, then a method of gradual extinction from the room may be your best bet. Start with a nighttime routine, then gradually eliminate yourself from the bed, then room. Many parents start by turning away from their child, then sleeping on the floor, by the door, outside the door, then in your room with the doors open. This may take weeks to accomplish, depending on the degree of separation anxiety displayed by your child.
Typically, I recommend a combination of these methods, modified for each family and baby. I have had good luck with starting a daytime feeding and sleeping routine around 6-8 weeks, with little stimulation at night (dark room, quiet feeding). After the baby starts following a predictable eating and sleeping schedule, make an evening routine leading to bedtime. With both of my boys, I have ended up with a modified Cry It Out method, increasing in increments no longer than 10 minutes. After MY anxiety dissipated, everyone was sleeping better and now they have healthy sleep habits.
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The key to success with any sleep training method is developing a solid plan, being consistent and following through. Anticipate loosing some sleep and having some difficulty the first couple of nights with Cry It Out, seek support from your partner or family. You may feel that letting your baby cry is not the right approach for you or your baby and a No Tears Method may take longer, but will leave you feeling more at ease with your decision. Whatever your take, I hope for a good night’s sleep for everyone your family.
                                                                            —
Heather Joyce, MD
Sources and Sites:
Price, All M.H., BA, PhD; Wake, Melissa, MB BS, FRACP, MD; Ukoumunne, Obioha, PhD; Hiscoch, Harriet, MB BS, FRACP, MD. ” Five-Year Follow-up of Harm and Benefits of Behavioral Infant Sleep Interventions: Randomized Trial.” Pediatrics. Vol 130 No. 4 October 1, 2012 pp 643-651. http://pediatrics.aappublications.org/content/130/4/643

Breastfeeding Part 3 – Pumping

Whether you plan on staying home with your infant or going back to work, most breastfeeding mothers end up pumping at some point during their breastfeeding journey. Pumps range from single, manual pumps to double electric ones. For mothers who are only going to pump a few times, a single, manual or electric pump will work. However, if you plan on working out of the home or pumping frequently, investing in a double electric pump will increase your success rate and decrease your frustration in the long run. You do not have to buy a pump, you can borrow one from a friend, buy a used one or rent one from your local hospital. Several medical insurance plans are now covering the cost of pumps – all you have to do is call the number on the back of your insurance card and ask about your breast pump benefits (you may need a prescription from your pediatrician or OB/GYN). Just make sure to get new tubing, nipple shields, and collection bottles when you start pumping, especially with a used pump.

The process of electric pumping can be daunting at first, ask a lactation consultant or nurse in the hospital to show you how to set it up and get started. First, hand off your infant because it is very difficult to pump holding your baby! Next, connect the tubing, set up the nipple shield and collection bottles. Finally, place the nipple shields to your breasts and turn on the suction, slowly. If you are going to be double pumping frequently, several manufacturers make hands-free pumps and bras for easier use. Pumping takes an average time of 10-20 minutes per breast. Continue to pump until the milk flow stops if you have adequate supply, or longer (5-10 minutes) if you are trying to build up your supply.

Some breastfeeding mothers start pumping in the hospital, within a few days of birth. Breastmilk supply is based on demand – so the more stimulation to the breast, the faster milk “comes in”, with increased supply. Sometimes, mothers pump because they want their milk to come in faster, which works, but is not necessary for most mothers. The mothers who do need to pump are the ones with infants who are being supplemented formula because of jaundice or weight loss, or those who have infants in the NICU.

There are several different strategies for pumping and you will hear different advice from everyone you ask. I make my recommendations based on whether or not you are going back to work and when. For mothers who are going back to work within 6-8 weeks, I recommend starting to pump during the “engorgement phase” – usually between days 3-7 after birth. You will make plenty of milk during that time and it will help make you feel more comfortable. Pump only a couple of times per day, after your infant feeds. Remember that when you pump after your baby feeds, your body will make more milk at that time… so you can take advantage of that and pick times when you will be able to pump when you go back to work. Continue to pump daily after that to store milk for when you go back to work. For mothers who are not working outside the home or have an extended maternity leave, I recommend starting to pump and introducing a bottle a couple of weeks before you need it or just doing it “as needed” for a night out.

Expressed breastmilk can be stored in hard plastic bottles or breastmilk bags. I recommend storing or freezing in 2-4 oz allotments, so you do not waste any milk when you thaw it for your baby. As your infant gets older and eats more, 4-6 oz bags work well.  Click here for a chart on safe breastmilk storage:

http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm

While most breastfeeding mothers will admit that pumping is not the most exciting activity, it does give many mothers the opportunity to provide breastmilk for their infants whether they are working outside of the home or just out for a quiet dinner.

Heather Joyce, MD

Breastfeeding Part 1 – The Initiation

The best time to start breastfeeding is within the first hour after delivery. After an uncomplicated vaginal delivery, most infants are awake and alert for about an hour and will latch and start to suck right away. Not all infants are able to go to the breast immediately and it is OK to wait until you and your infant are ready. Some have problems with blood sugar after birth and need a small amount of formula or sugar water to keep them safe – this is common practice in most hospitals. These infants will not have the energy to breastfeed if they do not get their blood sugar into the normal range. If your infant requires supplementation in the hospital, I recommend pumping every time this occurs, even if you don’t produce any milk – this will let your body know that your infant needs more milk and will help your supply.

During the first days of breastfeeding, most mothers produce a small amount (5-10 ml) of colostrum with each feed. You will feel tugging and pulling, but should not feel severe pain. If you do, then your infant’s latch may need to be adjusted. Take advantage of the nurses, doctors and lactation consultants in the hospital – they will have lots of advice and can provide hands-on help. You will also feel uterine cramping with each feed, this the due to hormonal contraction of the uterus – it hurts, but is good for your body. The more often your baby breastfeeds, the more milk you will produce, the more contacted your uterus will become, and the more experienced you and your infant will be prior to going home.

You will not “know” how much milk your infant is getting, but if they are waking to feed every 1-3 hours, having wet diapers and clearing their meconium, they are getting enough. All infants loose weight after delivery, but should start gaining it back after 5-7 days. Your infant should see the pediatrician for a jaundice and weight check within 3 days after discharge from the hospital.

Breastfeeding for the first time will be uncomforable and sometimes stressful for the fist couple of weeks, but it gets easier. If if continues to hurt or your infant is not getting enough milk to gain weight, then find support. Most hospitals, doctors offices, and specialty baby stores have lactation consultants available. You can also talk with an experienced breastfeeding mother, who may have some great tips for you. Just remember, for every person who tells you that breastfeeding was the easiest, most natural part of motherhood…there are 10 others who will give you a different story.

Next up…the first days home and pumping (aka The Milk Machine).

Heather Joyce, MD

Infant Reflux

This post was inspired by a friend who is having a tough time with a fussy newborn, but dedicated to all the parents out there who have ever cared for a baby with reflux, my husband included.

Reflux, colic, gas, milk intolerance, or general demeanor…there are many reasons for an overly fussy baby. Many babies who cry excessively swallow lots of air and always appear to have belly pain or gas, so figuring out the reason for a baby’s fussiness can be challenging. I will focus on infant gastro-esophageal reflux in this post, though many of these suggestions can help a baby with colic. Some babies with reflux are not fussy at all (they just make huge messes with spit-up), while others can have discomfort, poor weight gain and feeding problems. The symptoms of reflux are caused by milk that makes its way back up through a weak muscle at the top of the stomach, into the esophagus, and to the back of the throat or mouth. Infants do not all have the same symptoms, but can have spitting up, frequent hiccups, swallowing or grunting, arching of the back or neck, coughing, wheezing, difficulty feeding or excessive crying. Most infants with reflux act like they are always hungry, this is because they cry and root as a reaction to discomfort – often 1-2 hours after a previous feeding. If your child has been diagnosed with reflux or exhibits these behaviors, there are many techniques you can use to decrease symptoms.

1) Feed sitting upright – with bottle feeding, this is easy; but with breastfeeding you will have to find the most comfortable position for both you and your baby.

2) Burp frequently – with bottle feeding, this means every 1/2-1 oz; with breastfeeding it is still best to burp in between breasts or after 10-15 minutes.

3) If you are bottle feeding, find the right nipple and bottle. Babies who drink too quickly or swallow too much air spit up more. There are many choices and you may have to try several, but I say go with the one that works best for you and your baby.

4) Feed small amounts, frequently. For small infants, this means 1-2 oz every 1-2 hours; bigger infants need 2-4 oz every 2-3 hours and increase gradually. Do not over-feed your baby, this will lead to more discomfort!

5) Keep your baby sitting upright 20-30 minutes after each feed. Easy to say, not so easy to do (especially in the middle of the night or when you are chasing around another child). You do not have to hold your baby, you can use any contraption that works for you – bouncy/vibrator seat, upright swing, head elevating positioner, wedge with a sling, baby carrier/sling, just to name a few.

6) Position your baby to sleep elevated (30-45 degrees). The easiest way to do this is to put a couple of books under the legs at the head of the crib or bassinet. If you are using a co-sleeper or pack and play, a couple of rolled up towels or receiving blankets under the thin mattress works well. They also make special foam wedges for this purpose.

7) Do not lie your baby down flat on their back, especially after feeding. If possible, try to change your baby’s diaper prior to feeding.

After utilizing these techniques, your baby may still spit-up. If they are happy and gaining weight, your next step is to stockpile burp cloths, bibs, and wet wipes. If your baby has extreme fussiness, coughing, wheezing, difficulty feeding or poor weight gain, you need to take them to the pediatrician. They may recommend an elimination diet (for breastfeeding mothers), a formula switch, or medication for your infant. This can be a very stressful time as a parent, so keep in mind that whatever is causing fussiness in your baby will pass with time.

Heather Joyce, MD

A Potty Training Strategy

Potty training can be a very exciting or a very frustrating time for both parents and children. Making potty training stress-free is an exercise of patience for a parent, but does make the process easier in the long run. There are many options for potty training your child, but the real secret is consistency and perseverance. That being said, I do have a favorite method that stresses positive reinforcement with relatively quick results.

Step #1: Introduce the potty early (12-14 months). Let your curious toddler explore the bathroom, watch you or other siblings use the potty and get them a small potty to experiment with. Every time your toddler shows interest in the potty, give positive feedback with smiling, clapping, hugs/kisses (whatever makes you look silly and gets your child excited)!

Step #2: Start encouraging your toddler to sit on the potty without a diaper on. I do this before or after bath time, when they are already comfortable being naked. If they are resistant, then wait longer and try again. When they do sit on the potty or actually pee, increase the positive reaction to a full on party! Continue this step until they make the connection between the potty and peeing/pooping. Your child is physically ready to move on to Step #3 when they can go 2-3 hours with a dry diaper and they know (and can tell you) when their diaper is soiled.

Step #3: When you and your child are ready – meaning you have a few days at home, your child has made the pee/poop/potty connection, and is physically ready – you can start the real potty training process. Prepare to stay at home for 2-3 days and take away the diapers. You can keep your child naked or in “big boy/girl underwear” during the day. I suggest staying in a room with floors that are easy to clean during this time and only giving drinks with meals and snacks. Put your child on the potty every 1-2 hours and 10-20 minutes after eating or drinking. If they do go pee or poop on the potty, do the same as before and have a huge party or reward them with something they like, IMMEDIATELY. The first day, they will most likely have several “accidents”. When they do, calmly clean it up and take them to the potty. You will notice less “accidents” as the days go on and on the 3rd-4th day, most people can attempt outings without diapers. They do make plastic covers for carseats, which I suggest investing in!

Most children are not ready for naptime/nighttime potty training when they start daytime potty training. It is normal for some children to have nighttime accidents until late childhood. Make sure to explain to your child that diapers and/or pull ups are only for sleeping and underwear is for the daytime. I do suggest putting a waterproof mattress cover on their bed at this time, because some are ready and willing to try nighttime training out. You will know they are ready when they wake up dry most mornings. Make sure not to sabotage their efforts by giving drinks before bed!

If potty training is not going well and either you or your child is frustrated, buy another box of diapers and try again in 1-2 months. Do not pressure your child during this time and go back to positive reinforcement for exploring the potty. Make sure to save the real parties for the fantastic moments that they do go pee or poop on the potty!

Heather Joyce, MD

Confessions of a Modern “Crunchy” Mom – Cloth Diapers

Though I work as a pediatrician full time, vaccinate on schedule, and sometimes hit the closest drive-though for a quick meal, I am often called “crunchy” by my co-workers and friends. There are many aspects of “natural ” parenting that feel right to me, including, cloth diapering, breastfeeding (or pumping) for as long as possible, homemade organic baby foods, and baby wearing. As a working parent, my life is an act of compromise, so I am flexible with my “crunchy” side.

The decision to use cloth diapers with our second child was not easy, but after reading many blogs and talking to parents who have used them, we decided it was worth a try. There are many pros to cloth diapering, including reduced cost, diaper rash, disposable diapers sitting in landfills (for who knows how long), plus they are so cute! We make it work by realizing that we don’t have to use them all the time to reap the benefits. We have used several different brands, all with inserts and covers. We use a diaper sprayer on the toilet and we wash them ourselves. However, we don’t take them on vacation or use them during diarrhea illnesses and when my son started daycare, we brought disposables to use there. As he gets closer to potty training, we have less diapers to wash and truthfully, I enjoy using them more!

Cloth diapering tips:

1) Talk to other parents who have used them and people who work at local stores who sell them

2) Choose a style that works with your lifestyle

3) Make a washing schedule – we do ours every 2-3 days (buy enough to make it at least a couple of days)

4) Use newborn diapers until the umbilical cord falls off – I could not find a way to make the diaper fit without irritating the umbilical stump. Please comment below if you have the secret!

5) Buy a diaper sprayer for your toilet

6) Use extra inserts for overnight – we use hemp (they are thin, but absorbent)

7) Bleach, strip, and lay out in the sun to dry once in a while

8) Use essential oil in your dry bag to hide the smell

Once you figure out a routine and get used to washing poop, it really is doable for any parent who would like to give it a try.  Every cloth diaper that is used, means one less disposable diaper sitting in a landfill!

Heather Joyce, MD

Infant Reflux

This post was inspired by a friend who is having a tough time with a fussy newborn, but dedicated to all the parents out there who have ever cared for a baby with reflux, my husband included.

Reflux, colic, gas, milk intolerance, or general demeanor…there are many reasons for an overly fussy baby. Many babies who cry excessively swallow lots of air and always appear to have belly pain or gas, so figuring out the reason for a baby’s fussiness can be challenging. I will focus on infant gastro-esophageal reflux in this post, though many of these suggestions can help a baby with colic. Some babies with reflux are not fussy at all (they just make huge messes with spit-up), while others can have discomfort, poor weight gain and feeding problems. The symptoms of reflux are caused by milk that makes its way back up through a weak muscle at the top of the stomach, into the esophagus, and to the back of the throat or mouth. Infants do not all have the same symptoms, but can have spitting up, frequent hiccups, swallowing or grunting, arching of the back or neck, coughing, wheezing, difficulty feeding or excessive crying. Most infants with reflux act like they are always hungry, this is because they cry and root as a reaction to discomfort – often 1-2 hours after a previous feeding. If your child has been diagnosed with reflux or exhibits these behaviors, there are many techniques you can use to decrease symptoms.

1) Feed sitting upright – with bottle feeding, this is easy; but with breastfeeding you will have to find the most comfortable position for both you and your baby.

2) Burp frequently – with bottle feeding, this means every 1/2-1 oz; with breastfeeding it is still best to burp in between breasts or after 10-15 minutes.

3) If you are bottle feeding, find the right nipple and bottle. Babies who drink too quickly or swallow too much air spit up more. There are many choices and you may have to try several, but I say go with the one that works best for you and your baby.

4) Feed small amounts, frequently. For small infants, this means 1-2 oz every 1-2 hours; bigger infants need 2-4 oz every 2-3 hours and increase gradually. Do not over-feed your baby, this will lead to more discomfort!

5) Keep your baby sitting upright 20-30 minutes after each feed. Easy to say, not so easy to do (especially in the middle of the night or when you are chasing around another child). You do not have to hold your baby, you can use any contraption that works for you – bouncy/vibrator seat, upright swing, head elevating positioner, wedge with a sling, baby carrier/sling, just to name a few.

6) Position your baby to sleep elevated (30-45 degrees). The easiest way to do this is to put a couple of books under the legs at the head of the crib or bassinet. If you are using a co-sleeper or pack and play, a couple of rolled up towels or receiving blankets under the thin mattress works well. They also make special foam wedges for this purpose.

7) Do not lie your baby down flat on their back, especially after feeding. If possible, try to change your baby’s diaper prior to feeding.

After utilizing these techniques, your baby may still spit-up. If they are happy and gaining weight, your next step is to stockpile burp cloths, bibs, and wet wipes. If your baby has extreme fussiness, coughing, wheezing, difficulty feeding or poor weight gain, you need to take them to the pediatrician. They may recommend an elimination diet (for breastfeeding mothers), a formula switch, or medication for your infant. This can be a very stressful time as a parent, so keep in mind that whatever is causing fussiness in your baby will pass with time.

Heather Joyce, MD