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.
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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 2 – The First Days Home

Congratulations…you gave birth, decided to breastfeed, and made it through your hospital stay!  With the support of doctors, nurses, and lactation consultants, by the time you are discharged, hopefully, you are feeling pretty comfortable with the breastfeeding process.

This is exactly how I felt with my first son…so, when I got home and started having difficulty and pain, I felt frustrated and started doubting my ability to breastfeed. He was fussy and frantic at the breast, which lead to painful feeding sessions. I knew some pain was normal, so at the time I didn’t even know I needed help. Most parents would agree that the first couple of nights home with your first infant are the longest, most exhausting nights of your life. Add in difficulty with breastfeeding, and a time that should be filled with joy, becomes one that is filled with frustration. The good news is that this time passes quickly and with some patience and support, breastfeeding can get easier every day!

In my opinion, the biggest reason that new mothers are in this situation, is the fault of our current medical system. We send mothers and their infants home within 48 hours of delivery – well before most mother’s milk “comes in.”  So, many infants start to get very hungry within 24 hours of going home. This is a time when they start to gain back the weight that they lost after birth. If your milk is not “in” yet, then you are dealing with either a sleepy baby who does not have the energy to feed or a frantic, fussy baby.

The second problem that many mother’s run into is engorgement. Once the milk “comes in,” the breasts become hard, swollen and painful. A baby who was latching on perfectly before engorgement, can develop difficulty finding a comfortable latch – especially at the beginning of a breastfeeding session, when your nipple can lay flat against your areola.

Here are my tips to help you get through the fist days of breastfeeding, with as little difficulty as possible:

  1. Find support – a friend, relative, or lactation consultant
  2. Put your infant to the breast as often as they want (every 1-3 hours) – you can work on a feeding schedule later. In the first couple of weeks, the more your infant feeds, the faster your milk will “come in” and the more milk you will produce
  3. If your infant is too sleepy to feed or falls asleep at the breast, attempt to breastfeed for 10 minutes on each side, then pump to let your body know that you need more milk. If your infant is not gaining weight or having problems with jaundice, feed the baby this pumped milk (either with a supplementing tube/syringe or a bottle) after attempting to breastfeed. As a side note, this is exhausting – so utilize your partner or a relative to hold or feed the baby in between breastfeeding/pumping sessions. 
  4. If you are having pain or difficulty latching your infant due to engorgement, express breastmilk either with your hand or with a pump for about 1 minute prior to attempting to breastfeed. Be advised not to pump too much during this time (like after every feed) because you will overproduce milk and this can lead to lots of discomfort.

You will know that your infant is getting enough milk by the number of wet and dirty diapers they are having. They should increase every day until day 5 or 6. They will also start gaining weight around this time. So follow-up with your pediatrician is important.

It is normal to feel nipple discomfort for the fist 1-2 weeks of breastfeeding, though if the pain is making breastfeeding a dreaded task or you develop red sores, cracks or blisters – then find a lactation consultant to help work on your infant’s latch. You will also feel pain and fullness during engorgement – starting days 3-4 and resolving slowly over about a week. This pain should be tolerable with a supportive bra and cold packs.

Within 10-14 days, breastfeeding should become comfortable for both you and your infant. If it is not, or your infant is not gaining weight – seek help, because there are fixes for most breastfeeding problems. However, you need to know that some infants are not great breastfeeders and some moms don’t make enough milk – which makes me very thankful that formula was invented!

Heather Joyce, MD

Breastfeeding – Is it Safe to Exercise?

So … you’ve decided to breastfeed.  You also want to get back in shape following your baby.  While breastfeeding is a huge topic of conversation, there’s not as much talk about breastfeeding and exercise.   Here’s a few questions you may be asking …

Will baby refuse the breast after exercise?  You may have heard that babies don’t accept breast milk as readily after mom has exercised because of a buildup of lactic acid.  However, most studies have found no difference in acceptance of the breast, even after maximum intensity exercise.  Research has also not shown a noticeable increase in lactic acid buildup after moderate exercise.  Even with maximum intensity exercise where there is a minimal increase in lactic acid in breast milk, there are no harmful effects for the baby.  While there may be a change in taste of breast milk from lactic acid, babies will not subsequently refuse to breastfeed because of it.  More plausible reasons for why your baby may refuse to breastfeed after you exercise are issues such as the salty taste of sweat on your breast post-workout.

Is the composition of antibodies of breast milk affected by exercise?  Exhaustive exercise does cause IgA levels (a type of antibody) to decrease for a short amount of time.  However, these levels return to normal within an hour – a decrease in IgA levels in one feeding per day is not likely to be significant.  Moreover, moderate exercise does not affect antibody levels.

Is your milk supply affected?  In short, no.  In fact, some studies have shown that women who exercise regularly had a slight increase in milk supply.  However, if you exercise to the point of exhaustion, or train for an event such as an Ironman, your body may be depleted to the point where producing milk is its last priority.  Bottom line – moderate, regular exercise should not affect your milk supply.

What types of exercise are best?  There really is no “best” type of exercise for breastfeeding moms.  It’s really more about what you enjoy and what makes you feel good.  Because breastfeeding moms are a bit more top heavy, things like running may be more uncomfortable, but it can still be done with the right type of support/attire.

What attire provides the most support for breastfeeding moms?  The key to being comfortable while exercising is finding a good supportive bra that fits you.  I would suggest getting measured at a sports specialty store for women (e.g. Athleta, Title Nine, etc) so that you know exactly what you need.  It really does make a huge difference.  You can avoid the two sports bra routine if you find the right bra that fits you 🙂

Other tips …  Definitely try to breastfeed right before a session of exercise.  Clearly, this is more comfortable, especially for weight bearing activity like running.  You may develop plugged ducts if you  lift weights involving repetitive upper arm strengthening (if that happens, start with lower weight/reps).  And make sure you drink and stay well hydrated!!

Rachel Brewer, MD