Cribsheet

by Emily Oster

  On the flip side, I’m sorry to report that drinking does not improve your milk supply. If anything, it may lessen it a bit, so if you are struggling with supply early on, do not consider alcohol as a supply booster.31

  Along with alcohol, many women worry about the impact of taking medication while nursing. It’s beyond the scope of this book to go through the interactions of every medication, but generally, most are safe and your doctor is a good source for more information. You can also search for virtually any drug in the LactMed database online.32

  Two drug groups are common enough to deserve some discussion here: painkillers (i.e., those you’d use after birth) and antidepressants.

  Childbirth is uncomfortable, and afterward, you’ll likely be in significant pain for a few days or longer. The first line of defense is Tylenol or ibuprofen, typically (in the latter case) in quite high doses. These are well tolerated and fine for use while breastfeeding.

  However, ibuprofen isn’t always enough, especially for women who have had a C-section. Codeine used to be a common next step, but more recent data has suggested that exposure during breastfeeding has significant nervous system effects in babies; it makes them extremely sleepy, and in a few examples, there were thought to be severe consequences.33 As a result, newer recommendations generally advise against prescribing codeine or other opioids like oxycodone.34

  Having said this, the recovery from childbirth, especially a C-section, can be extremely challenging, so your doctor may prescribe opioids, with appropriate caution. If these drugs are prescribed, it is generally for a short time and at the lowest dose possible. The tension between pain relief and breastfeeding is one you’ll need to work through with your doctor.

  The news on antidepressants is considerably better. All antidepressants are secreted in breast milk, but there is little evidence of negative impacts on the baby. Postpartum depression is serious, and treatment is important. Although there are some differences in the extent to which different antidepressants pass into breast milk, it is generally accepted that women should be prescribed the drugs that work for them. If you have been on antidepressants before and know which one is effective for you, then that is what you should use.35 If not, the first-line SSRIs for nursing mothers are paroxetine and sertraline, which transfer to breast milk at the lowest levels.

  A final note is on caffeine. Most people find it’s fine to have caffeine while nursing, and there is certainly no literature suggesting risks to the baby. However, some babies are quite sensitive to caffeine and get very fussy and irritable. If you find this is the case, you may have to avoid it.

  Tap water, though? Go for it. Hydration is important for everyone, breastfeeding or not. Take the water anywhere you can get it.

  PUMPING

  A couple of years ago, MIT held a hack-a-thon to try to come up with better design ideas for a breast pump. Nothing marketable has yet come out of this, but we are all holding our breath, because breast pumps generally suck.

  Here are some problems women have articulated: painful, difficult to use, requires constant cleaning, loud, heavy, ineffective. And these are just problems with the pump! Never mind the problems with actually having to do the pumping at work or while traveling—there is work time lost, and the endless problems of pumping in random airport bathrooms. Not to mention the TSA, who will carefully put their explosive-detecting wand over each bottle of milk you have lovingly packed up for the trip home.

  I remember distinctly my joy at arriving in the Milwaukee airport and finding that they had a pumping pod—a little pod, with a lockable door, complete with an outlet and a seat. It is telling that this prompted a wildly excited call to Jesse and an ongoing fondness for Milwaukee (slogan: Milwaukee: Genuine American).

  There have been some pumping innovations in the past few years. There is now a product called the Freemie, which is a pumping system where the cups effectively fit inside your bra and also collect the milk. The key, I think, is that the pump motor itself is quite small so you can store it in a pocket or clip it to your clothing. This postdates my nursing, and I could not get my friend Heidi to try it for research purposes, but I did hear from women who swear by it. In principle it allows you to, say, walk around outside while pumping. Someone told me she knows doctors who do surgery hooked up to this, but I think this falls in the realm of anecdote.

  There are basically three reasons to use a breast pump. Let’s review.

  First, if you are struggling with low supply early on, your doctor may suggest you try pumping after some (or all) feedings to increase your supply. As noted earlier, the theory is good here, although there isn’t much empirical evidence. If this is your only use of the pump, it may be a good idea to rent one from the hospital—it will be a better-quality pump. And you probably aren’t going anywhere much at first.

  Second, many women pump early on so they can start to give their baby the occasional bottle. Of course, you will pump while the kid gets the bottle, but if you want to have one ready for the first time, you’ll have to pump beforehand. You may also want to do this to build up a supply of milk if you are planning to return to work.

  I recall the logistics of this being complicated, especially when I was nursing Penelope and my supply was underwhelming. Some of the books told you to pump two hours after a feeding, even if the baby wasn’t up, since then there would be some milk. But sometimes she wanted to eat right away when she woke up, and there wasn’t much milk! Thinking back, these were among the most stressful moments of the early days.

  There isn’t really any scientific advice about this, so your best bet to limit stress may just be to have a concrete plan. Many women report that it works well to choose one feeding—likely in the morning, since that is when the milk is most plentiful—and just pump after that feeding. You’ll get a bit of milk each time, and if you start early, over a week or two you’ll get enough to give a bottle. Then while the kid has that bottle, you can pump another bottle during that feeding.

  Finally, the main thing women use the pump for is to replace breastfeeding sessions after they’re back at work. The idea is that you pump at approximately the same times the baby would eat, and they eat what you pump the next day. If you are a prolific pumper, you may pump enough extra to freeze.

  There is no getting around this: most women find it difficult and unpleasant. Your job is supposed to provide breaks for pumping, but they may not always follow the rules. If you have your own office, super, but if not, pumping is often relegated to less than ideal locations. One doctor I spoke to said she pumped in the coed locker room, in full view of everyone (she used a towel to cover). Companies over a certain size are required to provide lactation rooms, but this isn’t always followed, and there is no requirement that the rooms be nice.

  Even in a perfect situation, you’re supposed to wash the pump parts after every usage, and it just takes time. (Pumping wipes can help with this part.) If you pump for thirty minutes three times a day—not unusual at all—these are ninety minutes you could be doing something else.

  It is possible to work while pumping—in some cases—and I strongly suggest you get a hands-free pumping bra. At a minimum you want to be able to read something on your phone. Many people suggest you try to relax, look at pictures of your baby, and generally wind down while pumping. The idea is that this will increase supply. There is no direct evidence for this; one study of moms pumping for babies in the NICU showed that being near their babies increased milk production, but this is pretty distant evidence. 36

  Oh, and while you are spending all your time hooked up to this pump, we should probably say that it’s not as effective as your baby at milk removal. Even a really great pump doesn’t replicate the baby. This varies across women—some women can have no problem fully breastfeeding but literally never get any milk from a pump; others find producing enough milk is no problem.

  There is no perfect solution here. I had a good fr
iend who had what seemed like a dream setup: her job was flexible and her kid’s day care was next door, so she just popped over to nurse the baby a few times a day. It seemed amazing—until she tried to go away for a day and found her son wouldn’t take a bottle.

  We are all holding our breath for better pumping technology. MIT—get on this!

  As a final note: For some women who struggle in an ongoing way with latching, pumping is the only option for the duration. This approach—where you only pump and never nurse—is called exclusive pumping (EP). If you find yourself in this situation, there is not much evidence to guide you on how to do it, but there are a lot of moms online who will help.

  The Bottom Line

  Breastfeeding can be very hard!

  On early interventions:

  Skin-to-skin contact early on can improve likelihood of breastfeeding success.

  On latching:

  Nipple shields work for some women, although they can be hard to quit.

  There is very limited evidence that fixing a tongue tie or lip tie can improve nursing.

  On pain:

  Fixing a tongue tie can improve pain for Mom.

  There isn’t much evidence on how to fix nipple pain, but focusing on the latch may help.

  If you are still in pain a few minutes into a feeding, or a few weeks into nursing, get help; it could be an infection, which would be treatable, or some other problem with a solution.

  On nipple confusion:

  Not supported in the data.

  On milk supply:

  The majority of women will have their milk come in within three days after the baby’s birth, but for about a quarter, it will take longer.

  The biological feedback loop is compelling: nursing more should produce more supply.

  Evidence on the effectiveness of non-drug remedies (e.g., fenugreek) on supply is limited.

  On pumping:

  It sucks.

  6

  Sleep Position and Location

  My children have a very old board book, a hand-me-down or tag sale purchase, called Wynken, Blynken, and Nod. At the end of the book, there is an illustration of a baby in his crib. What strikes me every time I see this image is just how much stuff there is in the crib with him. Stuffed toys, a blanket, crib bumpers, a pillow. My children’s cribs—even when they were toddlers—contained nothing but a tiny security blanket and a water bottle. When we finally moved Penelope to a toddler bed at three years old, it took her months to figure out the concept of covers.

  Parenting recommendations change over time, but perhaps nothing has changed more from our childhood to the current era than recommendations for sleep. When we were children, it wasn’t uncommon for babies to be put to sleep on their stomachs, covered in a fuzzy blanket, in a crib surrounded by a bumper. You can see why this would make sense: babies are small, and cribs are not inherently cozy. There is something a little jarring about a tiny baby alone in a giant crib.

  The latest recommendations from the American Academy of Pediatrics are starkly opposed to the toy-and-blanket-filled crib. The AAP says infants should sleep alone in a crib (or bassinet) and should be placed in the crib on their back to sleep. There should be nothing in the crib with the baby. Bumpers—pads that wrap around crib slats to prevent little hands or feet from getting stuck—should not be used. Infants should sleep in their own crib or bassinet—not in the parents’ bed—although the crib or bassinet should be in the room with the parents.

  These recommendations are broadly part of a safe sleep campaign designed to lower the risk of SIDS (which is now more accurately referred to as sudden unexpected infant death, or SUID, but given that most people are familiar with the acronym SIDS, I will stick with that here).

  The initial part of this campaign, “Back to Sleep,” focused on the importance of always putting infants to sleep on their backs. More recent additions have focused on co-sleeping and room sharing.

  The AAP sleep recommendations are simple to understand, but many people find them difficult to follow, especially in the exhausted haze of new parenting when many of us would empty our bank account for two hours of uninterrupted sleep. Many infants sleep better on their stomachs, and the temptation to try this when nothing else has worked is powerful. Similarly, it can be tempting to keep the baby in bed with you, especially when you are breastfeeding. When your baby falls asleep while nursing and you know they will stay asleep if you keep them next to you, it’s hard to move them.

  On the opposite end, the instruction to keep the baby’s bed in your room may be equally difficult. Jesse has never been able to sleep in the same room as the kids. When Finn was born, we had him in our room for a few weeks; Jesse slept on an air mattress in the unfinished attic. This did not feel like a long-term plan.

  All of this makes these decisions both important and very hard. Thinking about them requires thinking carefully about risks.

  SIDS, AND THINKING ABOUT RISK

  Excluding birth defects, SIDS is the most common cause of death for full-term infants in the first year of life in the US. By definition, SIDS is the unexplained death of a seemingly healthy infant under a year old, and 90 percent of these deaths occur in the first four months of life.

  The causes of SIDS are not well understood. It seems to occur when a baby spontaneously stops breathing and doesn’t start again. It is more common in vulnerable infants—premature babies, for example—and in boys.

  Among the most haunting aspects of parenting is the vulnerability that comes with having the thing you love most in the world be out of your control. There is no parent I know who doesn’t, at least at times, have the instinct to keep their child at home, to never let them out of their sight, to literally never let go.

  And yet we do take risks. We let our children learn to ride a bike—knowing that they’ll get some skinned knees. We let them play with other children, knowing that at least some of the time, they’ll return home with a nasty cold or the stomach flu. In these cases, it is not so hard to think about how to weigh the risks against the benefits. On one hand, stomach flu is yucky; on the other hand, playing with other kids is both fun and important for development. So we weigh them out, probably deciding it’s fine for our children to play with other kids, but maybe not when those kids are actively sick.

  It is much harder to think about risks when there is a possibility of a catastrophic outcome—serious illness or death.

  The first step is to put sleep risks in the context of the risks that we are implicitly accepting every day. We put our children in the car, which is not perfectly safe. This isn’t a danger we think about much, but it is there. On the scale of the underlying levels of risk we are implicitly accepting, some of the risks we talk about below—while real—are small.

  Second, we have to recognize that sleep choices have real quality-of-life impacts. If co-sleeping is the only way you can get any sleep, then you may choose to do it to preserve your mental health, ability to drive, and ability to function overall—all things that also benefit your child. And these crucial choices may outweigh a very tiny risk, even a tiny risk of a terrible thing. It’s easy to dismiss people who remind you to take care of yourself. But taking care of yourself is actually part of your responsibility.

  It is not easy to even think about parenting choices associated with risk, let alone make them. In at least some cases here, the risks are clear and not vanishingly small; in those cases, the choice is easy. In others, it seems clear the risks are really not there at all. But in some of these cases—co-sleeping, in particular—more complex considerations come into play, and we’ll need to confront them.

  When I was writing this book, I talked to my
friend Sophie, who co-slept with her youngest child for many months. Sophie is a highly trained doctor, and clearly not ignorant of the risks of co-sleeping. She told me she didn’t make this decision lightly, and she didn’t disagree with the AAP’s guidelines. But co-sleeping was the only way her baby would sleep, so she took all the steps that have been shown to minimize the associated risks: she and her partner didn’t smoke or drink, and they took all the covers and blankets off of the bed. Even with these precautions, she accepted the possibility of a small risk.

  Ultimately, this is a choice parents have to make, and it’s best to make it with full information. The medical recommendations to avoid SIDS have four components. Infants should be (1) on their back, (2) alone in the crib, (3) in their parents’ room, and (4) with nothing soft around.

  RECOMMENDATION 1: “ON THEIR BACK”

  Until the early 1990s, the most common sleeping position for infants—in the US and elsewhere—was on their stomach. The reason for this is likely that many infants sleep better this way—they don’t wake up as much.1 However, as early as the 1970s, there were some clues that stomach sleeping was associated with a higher risk of SIDS.2 Studies comparing populations with different sleeping patterns showed worse outcomes for the group that slept on their stomach.

  These early studies were largely ignored, and through the mid-1980s, most pediatricians recommended that infants be put to sleep on their stomachs. The edition of Dr. Spock’s Baby and Child Care that my parents used says, “I think it is preferable to accustom babies to sleep on the stomach from the start.”3