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Monday, 27 August 2012

Baby Routines: Empowerment or Placebo?

Overwhelmingly, the advice given to me when I admitted struggling with the needs of my first baby was this: put her on a routine. This advice came from any and all angles; parents, friends, well-meaning strangers either with or without children of their own. 'Routine' is presented as the magic bullet – the holy grail – of 'fixing' parents suffering from the biological demands of their infants.

So what exactly is a baby routine, and what does it entail?

And why, when it is a concept so liberally prescribed and held in such high esteem, was I so determined that it was the wrong thing for my family?

The meaning of the word routine in itself is fairly simple:

n.  1. A prescribed, detailed course of action to be followed regularly; a standard procedure.
2. A set of customary and often mechanically performed procedures or activities.

Apply that to the care of a human infant, and you have a strategy to map out a predictable, day-to-day schedule: a standard operating procedure. In essence, applying a routine to daily parenthood allows parents to take the reins and control all aspects of the day: resulting in the reassurance of predictability, and relief from the confusion instilled by the all-hours needs of an infant.

In the vulnerable, sleep-deprived and hormonally driven early weeks of motherhood, the lusty cries and unpredictable, frequent suckling of our babies can seem overwhelming. We've rarely seen, at length, the normal behaviour of a human infant until we have our own. Pregnancy can be long and filled with medical fears. We might be suffering through recovery from a traumatic birth. Breastfeeding seems hard, but the pressure to get it 'right' is immense. What do we do?

Popular self-proclaimed baby 'experts' will tell parents:
"When following a routine, you will begin to distinguish between your baby’s hungry, tired or bored cries because when she starts to cry, you will be able to look at the routine and see what is due next. If your baby is due a feed, you will start to recognise that as the hungry cry. If your baby is due to have a sleep, you will learn that is the tired cry." – Tizzie Hall, 2010. Save Our Sleep Article: The Importance of A Routine.
Along with now being able to assign a 'type' to their infant's previously unrecognisable cries, suddenly, a parent is given the added bonus of a reliable set of times within which they can plan their daily activities. Previous fears about fitting naps or feeds around outings are shed, because the routine provides pre-ordained indicators of when these things should happen.

"The feedback I get from parents is that routines make their lives easier. For example, organising things such as doctor’s appointments becomes easier because you know what your baby will be doing at each stage of the day." – Tizzie Hall, 2010. Save Our Sleep Article: The Importance of A Routine.
The advocation of a routine is almost always synonymous with sleep training of some kind. Rather than allowing the human infant to have it's own daily biological metabolic rhythms, a routine instead allows parents full control. The insinuation here is that the hapless infant doesn't actually know what it needs, and the parent must enforce authority over that. Somehow, by controlling every moment of the baby's day, prolonged and self-directed sleep will result as a consequence.

Then, add a generalised, emotive, tantalising promise (based on no science whatsoever) and it suddenly feels like not only the answer we've been waiting for, but that it is of physical and emotional benefit to our child.

"My routines also help babies to feel safe and secure. Your baby will know that her needs are being met and she has no need to cry, resulting in a happy, contented baby." – Tizzie Hall, 2010. Save Our Sleep Article: The Importance of A Routine.
No wonder it sounds like the answer to an exhausted parent's prayers.

But my concern is this: when we enforce a routine on a baby, are we doing it for the benefit of the baby – or for the convenience of adult? And does the baby really need a dictated daily schedule? After all, if a monotonous schedule was so inherently needed by the baby, wouldn't they just naturally behave that way? Just as a healthy baby is driven instinctively to find the breast, to learn to roll, to learn to crawl and walk and speak: so too will a healthy baby be instinctively driven to eat, sleep, and explore the world when he or she needs to do so.

A common social catch cry states 'happy mother = happy baby'; and while indeed it's true that a baby responds to the positive mood of a parent, I would argue that a mother and her baby would be truly happier if they were freed to listen to their instincts, and enjoy the bliss of unconditional love, nurturance and oxytocin-producing contact, rather than following someone else's arbitrary guidelines because everyone else says so.

We human animals are creatures of habit. We do like ritual and routine. Comfort is drawn from doing certain things certain ways, at certain times of the day. We all have our own metabolical and behavioural idiosyncrasies: that is one of the amazingly wonderful things that make us human. We have different needs for food and sleep, and pleasure and work and play and rest. We manage our days around these needs and the simplicity of a daily rhythm is soothing to our chaos.

However, the importance of feeding according to a baby's need, or 'demand feeding' in the early months at least, cannot be overstated. A baby is born hard-wired to cue it's mother to feed, and will need to go to the breast frequently, and at his or her own pace, in order to stimulate mother's milk supply. I am yet to find a leading source of evidence-based breastfeeding information that advocates delaying or restricting or controlling breastfeeding duration or interval.

A newborn can be confusing; wakeful, sleepy, crying insatiably, and sucking insatiably. We fear that if we don't instill order now, our life may forever be dictated by this tiny little... well, dictator.

But what can be reassuring to remember is that a newborn has come from the womb. A mother's womb is an environment of constant nutrition, constant rocking and holding, and no circadian (day/night) pattern whatsoever. A newborn is dependent entirely on her mother for survival, and that survival includes the almost instant meeting of all of her bodily needs; at least until she grows old enough to move away, to learn to wait, and to follow the natural day/night rhythms of all other humans.

Just like any other human being – creatures of habit – all babies grow and eventually develop the cognitive ability to enjoy a more rhythmical, more structured day similar to that of the parents. Just as millions of babies have, for thousands of years. All over the world. We just have to have the confidence, and the patience, to wait for that to happen. That is one of the many challenges of parenting.

So whilst the idea of following a routine, following a minute-by-minute plan, can bring safety and appeal: is it really giving parents what they need? And of equal importance – is it giving the baby what he or she needs? Many parents following a routine report a more content, more settled baby – but is that baby truly more content, or is it simply explained that way by a more confident parent – a type of placebo effect? Or of more concern, is the baby truly content – or has learned not to cue its needs as they mostly go unheard?

I would argue that empowering a parent, a mother, a woman, to nurture her young according to the biology that drives her; that same biology that conceived, and nurtured within her womb, and birthed her baby, is fostering the highest level of confidence and empowerment. Because it is dependent on no one else.

When mothering instinctively, when being supported to listen to your baby until you feel confident, there are no 'what ifs' – it simply is. And parenting by instinct allows the full expression of beautiful, human uniqueness. To the rapidly-developing mind of a human baby, this demonstrates acceptance – unconditional acceptance – and tolerance, and empathy, and compassion, and love, and trust, and respect. All of these truly wonderful things are demonstrated to the infant before they even have the cognition to form the words to describe them.

With every timely response, the mother tells her infant: I love you for who you are. You can trust me, and you are worth it.

Babies, and their mothers and fathers, don't need arbitrary schedules and routines dictated by a book to guide them. They simply need reassurance and support; reminders that they know in their heart what to do, and that loving their baby can only lead to the greatest kind of security within them all.

Peace and love to you. xo

Monday, 20 August 2012

A breast abscess: the physical manifestation of postnatal depression

A small, silver scar at the top of my left breast, just down from my armpit, is all that remains of a story that could curl the toes of many.

If you're squeamish, read on with caution. There's no overly graphic photographs: but I'll spare no detail in the prose. So perhaps don't read this and eat.

I've never shared much of this story because it always seems so secondary to the bigger problems I was suffering at the time: the debilitating mindset of postnatal depression. (You can read more about that here and here.) I'm sharing this story now because I think it is an important illustration that even the most severe of breastfeeding complications needn't always equate to weaning; and that often, breastfeeding complications are intricately tied with what's going on in our mind.

When my first baby was about a week old, I awoke feeling a bit achey and feverish, with some pain in my left breast. My milk was flooding in, so both breasts were a bit tender anyway. My mum took one look at me and said I had mastitis. Instantly, I was terrified. The idea of going to the doctor, of getting dressed and getting out of the house with this baby was more fearful than I could contemplate. I was annoyed; I didn't need this. I was struggling enough with this new baby – I didn't have time to think about what was wrong with me, too.

Only a few days out of hospital, I called the midwives on the maternity ward, unsure what else to do. The midwife pithily told me to use cold packs between feeds for the pain, to use warm packs before and during feeds to aid milk flow, and to aim the baby's chin toward the blockage during feeds. She said to go to the doctor for antibiotics if my temperature rose above 38.1 degrees.

So now I had a basic set of things to do; but I still didn't know what mastitis actually was, what caused it, what I should expect, or how quickly I should recover. But, conversely, I also didn't know that I needed to know these other things.

This went on and off for a few weeks. Some days I would feel feverish and achey, others not so much. If I was feeling feverish I'd start with the hot/cold packs; but that was about it. It began to just become another annoyance of mothering; another straw on the camel's back that was my overwhelming burden.

The day before my 6-week postnatal checkup with my GP, I suddenly felt annoyed with this persistent lump in my left breast. My entire life had been flipped upside down and I felt like nothing was going right. So, in the shower, I dug my fingertips into it; pressing and pushing and feeling intensely angry that it wasn't going away. I remember crying.

Bad move.

The next day, at my GP's appointment, he asked me if I was happy, and I shrugged and responded that I didn't know. We talked briefly about postnatal depression, and I pretty much brushed it off. He then asked me how breastfeeding was going, and I mentioned the mastitis. Once he took a look at the affected area, now a blue-purple lump that was exquisitely painful to touch, he calmly said it had abscessed, and he recommended draining it with a needle – much like a big pimple. Was I okay with that?

Was I okay with that? With, you know, sticking a needle into the painful, festering bruise on my breast?

So whilst my husband held our 6-week old baby, I removed my shirt and lay on the clinic table. A nurse instructed me to put my left arm back behind my head, and she placed a surgical sheet with a hole in it over the raised purple lesion on my breast. She carefully covered my skin with antiseptic, whilst I winced with pain at her touch.

I wondered how my life had come to this.

My doctor came in, he was friendly and reassuring but I was still petrified. The nurse murmured to him, "Are you going to use a local anaesthetic?"
"No, the local would hurt more than the aspiration," he answered.
Oh, shit. "Just give me a stick to bite on," I joked weakly.
They all tittered. (Pun intended).

As I took some deep breaths, the sting of the needle bit into tender flesh. But I must admit, after the initial twinge, the pain was bearable – almost a relief. He spent a minute or so drawing up fluid, and he commented that more pus had come out that he had anticipated.

"You'll feel much better with all that out," the nurse said.

I hoped so, but I knew there were more problems filling me at that moment than just pus.

Over the following weeks, as the fog around me thickened, the abscess never seemed to truly heal. Some days it was itchy, some days it was tender, but it never seemed to get better or worse. The area stayed a red or purple, and sometimes was scabbed over.

This isn't my breast, but is quite similar to how my abscess looked
Image source
My baby was often fussy feeding from that breast, particularly on the days when I was feeling achey or sore. But we managed, the other breast seemed to compensate beautifully.

And then suddenly, one day when my baby was about three months old and I was staying at my parents house, my breast began to swell again. The area around the wound became hot, pink and inflamed, and it the pain increased tenfold. But I ignored it. I didn't have the headspace for a physical problem, and besides, it would hopefully just go away again.

Later that night, in bed I lay on my right side, rolled a little forward breastfeeding the baby from my left breast. I could hear her beginning to snuffle, and I thought nothing of it at first, thinking she must just have a runny nose. But over the space of a few minutes her snuffling became more pronounced, and she began to fuss.

I flicked on the bedside lamp, and to my horror, saw her face was covered in pus. Thick yellowish liquid was all over her eyelashes, and all over her mouth and chin and nose. Pus was streaming from the wound in my breast. I shrieked. My mum came into the room, she helped me clean up and we put a dressing over the wound on my breast. I'm sure I spent some more time crying and feeling like an enormous failure; but I just don't remember it.

A few days later, I awoke again in the middle of the night. My shirt felt slick and damp, and as I sat up, I could feel it was heavy and wet all the way around to my back. In the bathroom, I removed a t-shirt covered with pus and blood. As I cleaned the wound, more pus would ooze out. Bending over the sink, I gently applied pressure either side of the swelling, and like a big pimple, it ruptured. I managed to massage out as much fluid as I could, put on a clean shirt, dressed the wound and went back to bed, mortified.

More weeks passed, and sometimes the abscess would leak, but I paid very little attention to it. And then, at 16 weeks postpartum, I finally approached my GP for help with my mental state. As well as prescribing a mild anti-depressant, he referred me to a surgeon to have the abscess incised and drained. He apologised for letting it get this far. I knew he was just being nice; it was I, after all, who had kept it all hidden.

The ultrasound I had before meeting the surgeon revealed a fluid-filled cavity in my left breast the size of a cricket ball. I distinctly remember the sonographer's eyes widening when he enquired how long this had been there, and I apathetically replied, "about three months."

The day before I saw the surgeon for the first time, the abscess ruptured again. It was another huge drain, and left me feeling queasy and revolted. However, my depression was starting to lift, so I was finally able to see the abscess for what it was: a wound, a transient condition that I just needed to pay a little attention to and kick. Just as my depression was not who I was, I wasn't this abscess, and this abscess wasn't me.

Of course, the next day the surgeon saw me, cheerful and without a swollen breast, and decided he wanted another ultrasound. "I'm reluctant to slice you open if I don't need to," he said. I appreciated his sentiments immensely.

This time, the ultrasound was done in a bigger clinic, equipped for more than just imaging. A doctor did the ultrasound, carefully assessed the cavity, and inserted another needle under the guidance of the ultrasound image. I watched him draw almost 20mls of fluid from my breast.

But when the doctor saw the fluid filling the syringe, he seemed happy. Now, the fluid was clear, slightly pink, not at all like the thick, sickly yellow pus I'd become accustomed to. "This is good," he pronounced, "this isn't infected. I'll just drain all this out and you'll be fine."

And I was. I returned to the surgeon, who shook my hand with a smile and said he hoped never to see me again. The feeling was very mutual.

The abscess was gone. I had a handle on my PND. In my mind, it is absolutely no coincidence that the timing of the two recoveries was so well matched. The pressure and pain building in my breast, festering under the surface away from obvious awareness, was a physical manifestation of what was going on in my mind.

I have read many stories from women suffering severe or repeated bouts of mastitis, or abscess, who have felt no choice but to wean. Obviously, people did ask me if I was "still" breastfeeding during my treatments for the abscess. But truth be told, stopping breastfeeding never entered my mind. I knew that weaning would only exacerbate the problem: my milk could take months to dry up completely, and in the meantime, I'd have breasts swollen with unmoving milk, I'd have a baby whose health would be compromised by weaning from my breastmilk, but most of all, I would have nothing left to give my baby. Weaning wasn't an option – I simply had to breastfeed.

And besides, in my mind, I never really made a conscious connection between the abscess and the act of breastfeeding my baby: the abscess was more about my inner turmoil and pain, than the simple act of lactogenesis.

Stories of breast abscess are quite rare; stories of women continuing breastfeeding through treatment even rarer. So I hope my story may help other mothers, who may be going through something similar, and are perhaps hoping to keep breastfeeding: even when everyone around them wonders why.

Further information on mastitis and breast abscess:–mum/mastitis