Search for tag: "breastfeeding"

It's been an issue for several weeks now, parents scrambling to try and find baby formula amid the shortage. So what are you supposed to do? You have a hungry baby who needs to eat.

Like many women, I was unable to completely provide enough breast milk to feed my boys. Trust me. It wasn't for lack of trying to increase my supply with supplements, medications, pumping, working with my OB and five lactation consultants. And we learned, for me, I have a medical condition that just won't allow me to make as much as my kids needed, so I had to supplement. And I find this is often the case for many of my patients' mothers.

Often, some women just choose not to breastfeed, and they want to just give formula. And that's okay too. Most important is for the baby to be fed and loved.

So what exactly happened to cause this formula shortage? The manufacturer of Similac products, Abbott Nutrition, recalled powdered formula brands due to bacterial contamination in some of their batches. This, combined with supply chain issues, triggered a nationwide formula shortage.

For families that were affected, this has triggered a lot of questions about what to do. The easiest thing that parents can do is to just switch to a different infant formula. I know that sounds scary, but many store brands and other brands, like Enfamil and Gerber, have formulas that are equivalent to Similac.

Most babies do just fine on a cow's milk-based formula, and there are a ton of variations for whatever your babies might need — gentle formulas, formulas for soft bowel movements, formulas for breast milk supplementation, formulas with extra ingredients to help with digestion and brain development. There are so many options out there.

I often recommend generic or store brand formulas because they're cheaper, but they still have the same nutritional quality as the brand names. We used generic versions of gentle formulas for both of our boys and found they actually tolerated them better than the brand names.

What if your baby is on a special formula, like for milk protein allergy or prematurity? The good news is these formulas really aren't affected by the shortage as much. Your pediatrician can help figure out what is best for your baby in those situations. There are milk banks where women who have excess breast milk donate their milk, and that's a great source for babies who are preemies. Neonatal intensive care units often work with milk banks to get milk for preemies. The milk is strictly screened and totally safe.

What about mixing infant formula differently to make it last longer? This is a big fat no. Adding extra water to make diluted formula is bad. I've seen it happen more than once, where parents do this and it has actually landed their babies in the intensive care unit. What happens is that too much water upsets the balance of salts in their body because the babies' kidneys can't process that much water. That causes the babies' sodium levels to drop to the point that the babies have seizures, and it could be fatal.

Babies will not get the correct amount of nutrients if the formulas are diluted. That is why we have specific instructions on how to properly mix formulas.

What about all of those homemade baby formula mix recipes? Those aren't a good idea either. While, in the past, people made their own baby formula, that was before we had a really good handle on the specific nutritional needs of infants. And those homemade baby formulas don't provide the right concentration of nutrients that we now know babies need. Some babies have even been hospitalized after being given homemade formulas.

Finally, what if your baby is close to turning 1? Can you start milk early? Well, it depends on how early. Babies actually need the nutrition that is in formula until they're 12 months old. I would say that if they're within two weeks of turning 1, you can start transitioning to whole milk. Transitioning before that puts them at risk of iron deficiency anemia because milk has no iron in it. Also, once they start drinking milk, they need to limit their consumption to 16 to 24 ounces per day, or they could develop iron deficiency anemia as toddlers.

Parents often ask what milk kids can have if they don't want to give their kids cow's milk. Luckily, there are a lot of alternatives. Soy and pea milk are the most similar to whole milk in terms of nutrition. They can also have oat milk or nut milks, like almond or cashew milk. Plant-based milks are good for calcium and vitamin D, but they may not have the best nutrition when it comes to protein, fat, and calories, things toddlers need from ages 1 to 2, as their brains are still developing. And other milks, like goat's milk, can cause pernicious anemia due to vitamin deficiencies.

The good news is there are reports that the formula shortage should start to improve in a few months once the factories get the okay from the Food and Drug Administration to resume production. Until then, hopefully, parents are able to find alternatives.

If you are considering having breast implants, for whatever reason, how do the new FDA guidelines on breast implants affect you and your decision?

Breast augmentation is near the top of the most cosmetic surgical procedures. Although the number of women who had breast implants fell by one-third in 2020, probably related to COVID-19 pandemic, still 200,000 people had breast implants in the U.S. in 2020, down from the usual 300,000 implants per year. About 75% of the implants are for cosmetic reasons, and the rest are part of reconstruction after breast cancer surgery.

Recently, the FDA took some new steps to improve and strengthen the information guidelines about implants and short- and long-term consequences.

It's hard to know how women want to receive information about the risks of breast implants. They believe that they know the benefits, at least for the persons they believe themselves to be right now. They can't really assess the benefits to the woman they will be at, let's say, 60. However, the assessment of benefits is a completely personal process and will be different from woman to woman. And this includes trans women making the decision to have breast implants.

The risks are harder to communicate. Language is often very medical, numbers are hard to process, and some people don't even want to know the risks.

There are data from a randomized trial of information giving that women who received more information were happier with their decision, were less likely to experience preoperative anxiety, and were less likely to experience postoperative regret. So in the information era, I think more is better.

So what are the new components of these new FDA guidelines? First of all, they aren't exactly new. They've been worked on for several years now, and they went out for public comment and were published back in 2020. However, they became more official in the fall of 2021.

Firstly, the boxed warning, the ominous black box that comes on some package inserts of medications and devices that actually nobody really reads unless you stick it on their nose.

I'm going to quote here the example from the FDA with my own asides put in. "Warning," and this is in a big black box, "breast implants are not considered lifetime devices. The longer people have them, the greater the chances are they will develop complications, some of which will require more surgery.

"Breast implants have been associated with the development of a cancer of the immune system called breast-implant-associated anaplastic large cell lymphoma. This cancer occurs more commonly in patients with textured breast implants than smooth implants. Although the rates are not well defined, some patients have died from this." Okay, that's number two.

Three, "Patients receiving breast implants have reported a variety of systemic symptoms, such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases, and others. Individual patients' risk for developing the symptoms has not been well-established. Some patients report complete resolution of the symptoms when the implants are removed without replacement." Okay, that's the black box.

Well, I would want to know more about the phrase that the implants are not considered lifetime devices. There are no recommendations that breast implants be removed after some certain years, not like IUDs that have a finite effectiveness with recommendations for removal at a certain time.

Eighty percent of women who've had an implant placed still have it at 10 years. Of course, the woman that you are at 25 will not be the woman that you are at 55, and neither are your breasts, as all of us know.

"The chance of complication increases over time." What does that mean? Your surgeon should explain those complications, what they are, how often they happen, and what can be done about them.

The common ones are hard fibrous walls around the implant that can be unnatural-looking and feeling, or rupture of the implant capsule.

The uncommon one is the cancer that's associated with the certain kind of implant with a textured, not a smooth, outer covering. That cancer, which is mentioned in the black box, is called breast-implant-associated anaplastic large cell lymphoma. This is a mouthful, but is lymph cancer that arises over time, rarely.

The incidence in women who have these textured implants is 1 in 3,000 to 1 in 30,000. So it's not common. We have a great interview with Dr. Jay Agarwal on this kind of cancer and breast implants. You can find this interview at The Scope if you want to know more.

"Breast implants have been associated with these systemic symptoms." What does that mean? Some women have experienced symptoms such as pain, autoimmune symptoms, chronic fatigue. In the past, this has been somewhat ignored. But there are some women who've had fewer symptoms after their breast implants are removed. This isn't very well understood, but here it is in the black box.

To help understand the black box warning about breast implants, the FDA has created a model patient decision checklist. I think this is really great if it's given to the woman well in advance so she has time to read it or have someone read it to her and explain it to her. This isn't something to be handed out in the pre-op visit just to sign, the way you sign your permissions to your software like Google or your phone. This should actually be read word for word.

The FDA created this checklist to add to that surgeon's counseling. It is meant to be a springboard for discussion, and the patient will read and check off that they've read it and understood it.

It is long, multiple pages, with places for the patients to sign at the bottom of each topic. It includes who shouldn't have implants, at least at the moment: women who have an infection, women who are pregnant or breastfeeding, women who are having chemotherapy or have a suppressed immune system. It includes more information about the rare lymph cancer and about long-term systemic symptoms.

Actually, the example in the FDA guidelines is a really, really good one. If you're an information junkie like me and you read at, at least, the 12th-grade level, it's great.

The long-term risks of complications are spelled out. The frequency at which these things happen are attached, such as painful scar tissue around the implant reported in 51% of patients, rupture or leaking of the implant 30%, need for reoperation 60%. But those are just the biggies.

It's a really great document. It's what your surgeon should have been telling you anyway, but in the heat of the moment in the office, they might not take the 30 minutes to talk to you about this. And you might not remember. This is a great chance to take it home and read it carefully and bring it back with your questions.

And with the FDA guidelines, there's an updated suggestion about management of breast implant rupture or leakage, that 30% of the time it happens.

And last but not least, there's a card for the patient to keep forever in her wallet or personal records about what kind of implant she has, what it's made from, and when it was placed.

Now, you think you'll remember all this stuff, but you won't. And maybe you'll have them still at 80 and your memory is fading. Your surgeon may have retired or gone on to surgeon heaven. Your medical records may be lost. But at least you have a document about what is existing in your body.

If I had implants, I would laminate mine and put it next to my driver's license or my organ donation card.

I think these are really good steps in the right direction in patient information and decision-making. I know you just want what you want and you wanted it yesterday, but it's a long-term decision with long-term consequences, some good, some not so good. You should take your time and try to get it as right as you can.

Thanks for joining us on the "7 Domains of Women's Health" at The Scope.

You are an ICU nurse, Intensive Care Unit, working all the time, working nights. Your husband has a great job as a heavy equipment operator working days. You have three kids, and the two of you are just juggling to get all the bases covered and then you're called for jury duty.

Seven domains -- physical, emotional, social, intellectual, financial, environmental, and spiritual. So what does jury duty have to do with the seven domains? Well, it involves the social, it could the financial, maybe emotional, and possibly spiritual domains. So let's just get to it.

Women were often thought back in the 1800s and into the 2000s that their lack of intelligence, emotional stability, and need to tend to a home life would have them inadequate for the job of being a juror. When women got the right to vote and that was in the early 2000s, it was assumed that they would be allowed to serve on jury duties.

Well, that's sort of worked out. In fact, along with the right to vote, the West, states in the West led with having women on jury duty with Wyoming Territory first. Women were the first to be given the right to vote in Wyoming in 1869 and the right to jury duty in 1870. Then came Utah -- yay Utah -- in 1898. But they could use the excuse that they were women, and most women actually in Utah didn't serve on juries until about the 1930s. Washington State, Kansas, Oregon, and California followed right on those heels, and women were first allowed to be on juries in the West. Mississippi was last with women being allowed by statute to be on juries in 1968.

So women were allowed to be in juries, but they had to opt in originally. They had to actively put their names on a list to allow them to be called. It wasn't assumed that all women who were registered to vote or who had a license to drive a car would be actually called to jury duty. They had to actively opt in. And then that was declared unconstitutional, and then many states had opt out, meaning, women would be called, but they could say just because they were women, they could opt out of serving. And in 1979, a case before the Supreme Court, argued by Ruth Bader Ginsburg, stated that juries must be made to reflect the general population and the opt-out rule was unconstitutional.

Okay. So 34 years ago, I was called for jury duty. I was too busy. Number one, I was a busy doctor working 70 hours a week. Number two, my husband was a resident, and he couldn't pick up the pieces. Number three, I was a breastfeeding mother of a new baby. The judge said no to all of these. I showed up. It actually sort of felt like a vacation except for the breast pumping part. Today in Utah, there's only one statutory exemption for jury duty, and that is breastfeeding. An exemption written into the law and was passed in 2015 that breastfeeding mothers could be excused from jury duty, and it's the only exemption in the law.

There's no age exemption the way there is in some other states. People over 70 in some states are not called for jury duty. There are no legal exemptions. However, you can appeal in writing with the claim of extreme hardship due to physical, emotional, or financial reasons. But it's not likely to be granted. They may postpone your service for a month or so if you request it in writing and explain the conflict.

A jury should represent the population at large, and it's everyone's job unless they are unfit. It's a way we provide service to our communities is to serve on juries. We need women like The Seven Domain listeners on our juries as thoughtful people. But if you're breastfeeding and you have a newborn baby and you're in Utah, you can be excused. And thanks for joining us on The Scope.

Dr. Jones: Getting let down. Getting let-down. The first is a psychological consequence and the second is about breastfeeding. How are they connected? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health. This is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: There's a world of data that suggest for newborns "Breast is Best." That puts a lot of pressure on new moms to be successful breastfeeders. In the days before formula, a newborn's life depended on a mom's ability to provide breast milk, and a mom's health might already be precarious after what might have been a dangerous delivery. For this reason, many cultures have a time after delivery, several weeks or a month, to allow moms to heal and breastfeed.

Okay. That's all good. But after that in the US of A many moms have to go to work. That means if moms are still going to provide breast milk, that breast pumping pump at work becomes a reality. Now, to provide breast milk, a mom has to be at least moderately well-nourished and well-hydrated. But almost all American moms can accomplish that in the workplace. Then, there's the problem of let-down.

To make milk, moms need to be in reasonable health. They have to be breastfeeding, meaning they have to suckle. When the infant suckles, their nerves on the chest wall and the nipple feed information back to the brain to release the hormone prolactin from the pituitary gland. This hormone helps the breast make milk. But the milk just doesn't come out in a continuous dribble. It's made in the far parts of the breast called the alveoli and collected in tubes or ducts in the breast waiting for, you got it, let-down.

When the infant suckles, nerve fibers in the nipple cause the posterior pituitary to release oxytocin, which stimulates myoepithelial cells. These are little muscular cells to squeeze milk from the milk producing part of the breast called the alveoli so it can drain into the lactiferous ducts and then squeezes the milk down the pipeline to the nipple. It takes less than a minute from the time when the infant begin suckling -- the latent period -- until the milk is secreted -- the let-down. But what happens if the baby isn't there?

You're in your office or you're in the ladies restroom with your breast pump or if you're lucky you have a private room with a lock and an electric outlet and an electric breast pump and a rocking chair. Nice, but you still have to get let-down. Many experienced breastfeeding moms know that just the sound of their baby giving a hungry cry can begin let-down and that could be embarrassing if the baby isn't close and you start to leak through your clothes. However, for new moms, pumping at work let-down can be difficult to get started.

If let-down is a neuroendocrine reflex from the brain, many things can get in the way of timely let-down. Anxiety, pain, embarrassment, stress, stimulants like caffeine and nicotine, too much alcohol gets in a way but a little bit of alcohol might be relaxing, but not in the workplace. Acute fear or anxiety can suppress let-down. The fight or flight mechanism inhibits let-down, as it should if you're running away from tigers or something else.

Many years ago, when I was a young obstetrician back at work shortly after the birth of our son and pumping when I could find the time, my residents gave me as a joke, I think, a pager duct taped to a breast pump. Now, there isn't anything less conducive to let-down in my world than my beeper going off and a disaster happening to some poor laboring woman on labor and delivery. What a let-down.

So what's a new mom at work to do? Some suggestions include bringing a picture of your baby to look at when you're pumping. Bring something like a little t-shirt that smells like your baby with you. Try to get your head in a calm space before you put the breast pump to work. Deep breathing, focused visualization of having your baby at your breast and instead of that pump can be useful. Turning up the vacuum on the breast pump or just pumping harder with the hand pump won't do. The problem is let-down, not suction.

In an effort to increase the success at milk production and future breastfeeding for moms of very premature infants, some research has been illuminating. You can imagine that having a very sick newborn that you've never been able to nurse because they're too little and you're sitting in a pumping room next to the intensive care nursery might not be conducive to let-down.

A paper published in advances in neonatal care took 162 mothers of premature babies who were trying to provide breast milk for their babies and divided them into four groups. One group had standard instructions in a breast pumping room. The other group was taught guided imagery, imagining their babies and imagining themselves in a safe, warm, quite place with their newborns. Another group was given soothing music. And the fourth was given imagery and soothing music.

Women who were taught guided imagery or given soothing music had more output of milk. And the women who had music and guided imagery together has the most milk of all. Now, this wasn't just a little difference. Moms who had the interventions had two to three times more milk than moms who didn't. Mothers who had interventions to decrease stress also had more milk fat, had richer milk in the first days of the study.

So what else is out there? Last year the annual Make the Breast Pump, Not Suck Hackathon -- isn't that a great meeting -- awarded the Technology Frontiers Award to group that were testing out virtual let-down by transforming pumping rooms at work and in public places into a nursery decorated with pictures and videos and sounds of their babies by using a virtual reality headset.

So what do you do? For a new mom committed to breastfeeding and is returning to the workplace or needs to travel away from their baby, what do you do? Practice using your pump at home in your baby's room before you take it to a strange place. Get your head in the right place. This can take time and practice before you're rushing into a pumping place or a bathroom in the airport or your workplace. Get some soothing music and, yes, there are YouTube videos with music and guided imagery and meditation that you can use. You can just power it up on your phone, put in your headphones.

But use these first with your baby so the association can be stronger. Stay well-hydrated. And if you're struggling, get a coach through your hospital nurse lactation specialist or a La Leche League. This is hard, but you can do it. Don't get let down.

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Dr. Stoesser: Hi, my name is Kirsten Stoesser, and I am a family medicine physician. A question that a lot of new parents have is whether or not they need to supplement breastfeeding with formula. In most cases, this is not necessary but in some cases it can be helpful.

One of the times where we recommend that somebody supplement with formula is if the baby is not gaining weight appropriately, especially in those first few days to the first week. If we see that a baby has lost more than 10% of its birth weight and is not able to gain that back adequately enough and quickly enough with breastfeeding, then we will recommend to do supplementation with formula.

This doesn't mean, though, that you have to do a bottle feeding. There are actually some ingenious ways to be able to administer formula. One of my favorite ways is what's called the "Supplemental Nursing System," or the SNS system, and this involves sort of a drip line. There's a line that's taped over the mother's shoulder and then this line comes down and is taped across the breast and the nipple.

So a baby can still breastfeed and even if they're not getting much while breastfeeding, they are getting the formula that drips in and baby is still getting practice with breastfeeding so they're not losing that skill and mothers are still getting the stimulation at the breast, which helps to promote further breast milk production. Usually, when babies do the SNS system, they just need to do this for a few days and then they're able to catch up the growth and the weight that they need and are able to go back to breastfeeding.

There are different ways to supplement. Sometimes it can be because the baby's not getting enough nutrition, and sometimes it's because the mother's not producing enough milk. And so if the mother's not producing enough milk, having ongoing stimulation at the breast is important. So in addition to having the baby feed, one thing that I'll recommend to moms to do is to get a breast pump and after baby feeds to actually pump for five to ten minutes on both sides so that the breasts are getting adequate stimulation.

Another thing that's really important is for the mom to get plenty of sleep, which I know is hard, to make sure that she's eating regular meals, to drink plenty of fluids and to try to relax as much as possible. Another thing I'll recommend is that sometimes if just even one feed in the middle of the night, if somebody else can do that feeding, they can do a bottle feeding with either formula or with pumped breast milk, then that can allow mom to get a few hours more of uninterrupted sleep and sometimes that can help with breast milk production during the day because mom's not as exhausted.

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Dr. Jones: Breastfeeding, it should be easy. Mice do it, deer do it, cats do it. But if you have questions or problems as a new mom, who should you talk to? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and today we're talking to an expert on The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: I was born in Germany and my mother, who was a good Boston girl, was told by the nuns at the hospital where she delivered, that she should drink beer, dark beer, to bring her milk in. Well, it worked and then on the trip back to the United States on a boat, supposedly I got sick and wouldn't nurse and she didn't have the nuns to help her to turn her milk off.

Well, when my son was born and I was worried about my milk supply, by the way, obstetricians are not very smart about breastfeeding, I actually brought my sister in to help me, cause she'd done it twice, and she brought me a beer. And 30 minutes later, it was a done deal. so a superstition and a tradition, were born in my family about breastfeeding and beer.

Around the world, there are customs and old wives' tales about breastfeeding do's and don'ts but there are actually some people and some science about it. New moms, here at the university hospital who have questions, can get help from a breastfeeding specialist. Today in Scope Studio, we're talking with Mary Erickson, a lactation specialist, on our postpartum floor.

Welcome, Mary. So you're a lactation consultant?

Mary: That's correct.

Dr. Jones: Did I say that correctly?

Mary: Mm-hmm.

Dr. Jones: And we have a couple of them here at the U?

Mary: Absolutely, we do.

Dr. Jones: Is there somebody during the weekday that's always available? Is there somebody always on-call?

Mary: There is always, seven days a week, there is always going to be a lactation consultant. Also, a lot of the nurses that don't actively work as the consultant but they have gone through the process, so there's typically someone who knows how to help.

Dr. Jones: Okay and they have a certificate and . . . so it's not your mother who is going to feed you a beer?

Mary: Right, that's right.

Dr. Jones: Oh good, oh good. So what are some of new moms' most common questions or concerns?

Mary: Probably the most common concerns are discomfort. There are some discomforts that are associated with the breastfeeding. And also her inability in her mind, that she cannot meet the demands of the baby and this might include baby's crying, won't sleep in his crib, baby's hungry, or wants to be held all the time, and all of those she usually internalizes and figures it's her own fault.

Dr. Jones: And it's her breast milk, rather than, who knows?

Mary: Right, yeah.

Dr. Jones: So that's some that the lactation specialist or consultant can help the mom interpret what's hunger and what's fussiness, and what's just, you know, "Wrap me up a little tighter," or, "I'd rather be with you, Mom, than by myself over there in the corner."

Mary: Right, so a lot of my job is educating what is normal newborn feeding behavior and just normal newborn behavior? When is the crying normal?

Dr. Jones: Yeah, right. Well, so how do you help moms who seem to be worried about not enough milk? Remember now, our patients who have a normal vaginal delivery, go home in 48 hours, even before their breastmilk has even come in. So how do you help those moms about their fears that they won't have enough, or help a mom who really maybe, her baby got sick and she didn't breastfeed for a while and now she's not got enough? What can you do for those moms?

Mary: So first of all, I think it's important that they understand what is normal behavior, as far as . . . a lot of them want very concrete, this is what's going to happen but . . .

Dr. Jones: Get ready for parenting.

Mary: Exactly. So Just talking to them about, the first 24 hours, this is what your baby is going to act like. And then when babies' 48 hours is going to be totally different. And then 72 hours, when your milk comes in, different again. And just preparing them, that every single day is going to be a little bit different, and trying to help them recognize when it's okay and when it's not okay. And then what to do when it's not okay.

Dr. Jones: Okay, so for moms who don't seem to have enough milk, it's hard. Moms may be going back to work. Now once again, they're heading to the hospital so can they still call? If they have delivered here, can they call, cause their problems may arise because their breast milk didn't even come in 'til they went home?

Mary: Right, right, and we're very fortunate, we do have a breastfeeding clinic, so moms do need support past the hospital period, so they do need someone to call. And it's very nice to be able to bring them in, have them a doctor, a pediatrician will look at their baby, make sure baby's okay, and then have them work one-on-one with a breastfeeding person that can help to troubleshoot and figure out what's going on and also hopefully, to give her a lot of reassurance.

So if she felt like she did not have enough milk, for me, it depends on where she's at on that timeline. If she's day five, six, seven, I would expect that she should've had breast changes and that she should be a little more reassured that she does have enough milk and if not, I would definitely want her to be seen.

Dr. Jones: Well, I remember, after that beer which was probably just given at the right time. I don't think it was the beer but it did relax me. My milk came in like a milk truck and then I thought, "Oh my gosh, I have way too much." And then I remembered that we were setup to maybe even nurse twins, so at the beginning, we have a lot. We probably have more than we need, so I figured that was just a chance to put it in my bank in my freezer. But some women actually let-down very quickly or have a lot of milk, and that doesn't settle down to a pattern. What do you do for those women?

Mary: Well, first of all, not enough milk is a lot more difficult to deal with than too much milk. But too much milk can also be a problem, especially for the baby. It is like trying to drink from a fire hose sometimes and that can be pretty challenging. So if that's the case, there are different things that she can do.

One thing that I like is I tell moms after the breast is empty, to do ice. Ice will decrease the blood flow and that should help her get on top of the volume a little bit better. Other things that they can try is breastfeed the baby on one breast per feeding, so they get a good milk mix of the hindmilk and the foremilk.

Dr. Jones: So you do ever suggest that the mom, with the milk comes out like a fire hose, just express some milk just so the pressure is down a little bit? So then maybe the baby can latch on a little easier, and not get flooded the first mouthful, and then get disrupted, and get upset. How do you deal with that?

Mary: Very good strategy would be to go ahead and get that first let-down over. That first let-down is going to be the most forceful so after that first let-down, the milk flow will be a little more gentle. So some moms do have to do a little bit of pumping or just a little hand expression and get that first let-down passed. Dr. Jones: It's great to have some professionals here helping us out. It's good news because in fact, I really didn't like beer.

So thanks for joining us on The Scope.

Mary: You're welcome, thank you.

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Dr. Jones: Every year, tens of millions of Chinese women observe a practice of staying inside for a month after giving birth. This custom is called, "Sitting the Month." Is it a strange custom? What do we recommend? This is Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah Health and this is about the rituals we practice after having a baby on the Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: All over the world, for the hundreds of thousands of years that we have been humans, giving birth has been a very risky business. Until 100 years ago, 1 in 10 women died in childbirth. Of all the ways women met their death, giving birth was one of the most common. If they survived a difficult birth, they were often left weakened and anemic with trauma to their pelvic tissues. If their babies survived, they needed to successfully breastfeed, as there was no formula for babies. Mothers who found themselves barely alive had to also provide the milk for their babies to survive.

All over the world, there are cultural practices around this very delicate time after childbirth for the mom and the baby. In fact, we still use the word EDC, estimated date of confinement, as the term for the due date. But what is this confinement business? What do Chinese woman do? I trained in obstetrics and gynecology at the Boston Lying-In. Lying in was the term for the rest period for woman after giving birth, and many obstetrical hospitals have that phrase in their name.

The laying in period in the US was anywhere from two weeks to two months, even for healthy woman and it was their confinement. Of course, this was the luxury for woman of some financial means. Many women in the 1800s had no choice but to get up shortly after birth, and take care of the baby, all the other children, and help out on the farm. Although, most women were attended by other women in their family, or church community, and hopefully, a skilled birth attendant, they didn't have two weeks or two months to stay in bed.

Until World War I and World War II, women who gave birth in a hospital stayed in bed at the hospital for a week or so, recovering from the delivery. When hospital beds were needed for wounded soldiers, the time in the hospital was decreased from two weeks to one week, to four days, to our present 48 hours. The good news is that the frequency of a condition called Milk Leg, or blood clots in the leg from lying around that might have progressed to blood clots in the lungs, dramatically decreased when women got up out of bed after birth.

So what about those Chinese women in the practice of, quote, "sitting the month?" Women cannot go out. Family cannot come in. The guidelines are set to help women restore their energy balance to their bodies and protect their babies. Women are not allowed to bath or shower or go outside, drink cold fluid, or eat spicy foods. They cannot eat raw vegetables or fruits or drink coffee. No coffee.

All fluids have to go between room temperature or hot, and they have to bundle up and stay very warm. These practices have been noted in documents going back 2000 years. Today's affluent Chinese women can go to special confinement center, there's that word confinement again, and have all their ritual needs met for $500 a day. So we know that women are often exhausted and beat up after the birth of a child, especially the first one.

They're often exhausted, bruised, and battered down there. Their bladders don't work. And their hemorrhoids hurt. And breastfeeding every two hours doesn't help with the sleep problems. About 70 percent of women have the baby blues in the first couple weeks postpartum, and about five percent of women will develop postpartum depression. So what is good medical practice?

The first two weeks are rocky. That's the time that moms are establishing their milk production and their feeding schedule. They need to drink a lot of fluids, and eat a balanced diet of whole grains, lots of fiber for that beat up bum, fruits, vegetables, and protein. They may continue taking their prenatal vitamins several weeks for iron replacement if they had significant blood loss, iron rich foods or iron replacement can be recommended.

Ladies need a lot of rest. But as soon as they're comfortable, after the cesarean or difficult delivery, they need to get up and walk around. This is important by, in decreasing the risk of blood clots. Family can help by taking on the cooking and cleaning responsibilities in the home for the first two weeks or maybe the first two months or maybe two years. Well, two weeks at least.

In the US women are often given an appointment to see their OB six weeks after the birth of a child. That six-week idea was made up as the time by which women should have her pelvic organs back to normal. This is a totally ridiculous plan. By six weeks, new moms have either sunk or swum on their own. If they're suffering postpartum depression, they're already well into it. If they have a bladder problem, they've been suffering for over a month. If they're not breastfeeding, they may by already pregnant because they can ovulate at four weeks. And 50 percent of women resume intercourse before their, postpartum visit.

In Europe and Great Britain, it's common for home nurse visit by a midwife, or a nurse, at about a week after discharge from the hospital. This offers support and answers questions for the new mom. A randomized trial of a midwife home visit at 10 days and three weeks, instead of a physician's six weeks visit, found women were more likely to be using contraception, more likely to be breastfeeding successfully for longer, more likely to have their babies immunized, and less likely to be depressed, if they had a home midwife visit on that schedule.

So what's the six-week postpartum visit for? We used to do a pap smear and start contraception at that visit. But now, pap smears are done every two to three years, and women should have started contraception or had a plan before they left the hospital.

Family practice docs, who do obstetrics and will also be taking care of the baby, see the mom and the baby at two weeks, a great idea. Combined group care with the pediatrician and an OB or midwife at two weeks would make a lot easier for new moms to, not only have to pile all that stuff in the cart once, but do it over and over again. So we're thinking about that here at the university and it's a great idea.

What are the cultural practices around the postpartum period in your cultural background? We certainly should celebrate the birth of a new citizen of the planet, and the woman who put her body and her life at risk to accomplish this miracle. As obstetrics practitioners, we should give up the arcane and useless rituals like the six weeks postpartum visit, and see women and their babies in a more evident space timing and do a more family friendly combination of services.

And if you can get your family to take over the cooking and cleaning for two years after the birth of a child, more power to you.

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updated: May 29, 2018
originally published: December 10, 2015

Dr. Jones: Your baby smiles and her whole little face lights up, but you can't smile back. What's wrong? Is it the baby blues or something more serious? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and we're talking about postpartum depression today on The Scope.

Announcer: Covering all aspects of women's health. This is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: The birth of a child rewires a woman's brain for maternal behavior. There are huge shifts in the hormonal environment from pregnancy to the postpartum state, breastfeeding turns on the bonding hormone, oxytocin, and adds some sleep deprivation in a world turned upside down and it's no wonder that women can experience a roller coaster of emotions. What are the baby blues and what is postpartum depression, and what can a woman do, and her family do to get help?

Well, let's start with the baby blues. Seventy-five to 80% of new moms experience some emotional upheavals in the first couple of weeks after the birth of a child. It's common. It's hard to do research on new moms. No prospective randomized trials, and we don't have any great animal models for the baby blues, rats. But we do know that a big change in pregnancy hormones and a drop in the levels of endorphins that got a woman through her labor and delivery might be part of the reason that women experience the following: weeping and bursting into tears, sudden mood swings, anxiousness and hypersensitivity to criticism . . . who would criticize a new mom, anyway? Low sprits and irritability, poor concentration, and indecisiveness, feeling unbonded with the baby.

I remember wondering when my new baby's mother was going to show up, myself. The baby blues happened in the first couple of weeks after delivery and don't last more than a couple of weeks, often just a few days. This is the time where family should be around helping the new mom get settled and get as much rest as possible with the new baby. Women without family or partner support may struggle and good news is that it happens to most women and it gets better in about a week or so.

When is the time that baby blues is possibly postpartum depression? If the anxiety and sadness continue the first couple of weeks and gets worse, this is more likely postpartum depression. Postpartum depression affects 8 to 15% of women, about one in eight. The symptoms are similar to depression, in general, overwhelming fatigue or loss of energy, severe mood swings, withdrawing from family and friends, reduced interest in activities you used to enjoy, feelings of worthlessness, shame, guilt or inadequacy. This list makes me sad just to say it out loud.

Where baby blues are common and short-lived, postpartum could go on for months and it should be recognized and treated for the sake of the mom and the baby. The women who experience postpartum depression may not even know what's happening. Families and partners need to be aware that the new mom's in trouble. Treatment is very helpful and can include talk therapy with a psychological therapist and medication can be important. Women who realize they don't feel well emotionally should call their doctors or midwives, or pediatricians and they can be referred appropriately.

There's one other postpartum psychological problem that is a medical emergency. Postpartum psychosis is very rare but serious disease that can develop within the early weeks after childbirth that's marked by a loss of contact with reality. Women may have hallucinations, hearing or seeing things that aren't real that say bad things about them or their baby, they may have delusions about themselves or their babies that are paranoid or irrational, they may show extreme agitation or anxiety, they may have thoughts of harming themselves or their babies.

This is a devastating condition for the new mom and the family and needs immediate medical care. New mom showing these problems should be brought to the medical care right away and often need to be hospitalized to protect themselves and their babies. The good news is that we're better at recognizing and treating women with postpartum mood disorders. We need to get the word out so that women and their families, that it's okay to ask for help, and they can feel better. So let's all go smile and talk to that little baby and thanks for joining us on The Scope.

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