Friday, July 13, 2018

The milk transition/calcium requirements

The milk transition/calcium requirements

Calls about the transition from breast milk or formula over to whole milk rank up there in the "frequently asked questions" category.
If you are breastfeeding and it works for you to continue to nurse beyond the first birthday, good for you! Don't be in a rush to stop. The length of time that you choose to nurse is a very individual and personal decision. For those moms who continue to breastfeed beyond the first year, that magical breast milk feels like a godsend if your child doesn't feel well. Not only is nursing a comfort, but breast milk is great for tummy bugs, eye issues and all sorts of stuff. One parent was poking a bit of fun at me and said "if you call Nurse Judy, she will just tell you to put breast milk on it."

On the other end of the spectrum, many moms (myself included) end up weaning sooner for any number of reasons. In our practice, the first birthday is probably the average age that the milk transition occurs. Keep in mind that if your baby is on formula and tolerating it well, there is no hurry to get off (except for the expense and the hassle). If you have a case of formula left over, by all means use it up.

While it is fine to carefully introduce milk-based products such as cheese or yogurt to your children once they are over 6 months, plain cow's milk is not an appropriate substitute for formula or breast milk in the first year, as it lacks some important nutrients. 

The first birthday is also usually when we recommend a blood test that checks the iron level. Formula has more iron than cow's milk, so if your child is a fussy eater it is important to make sure the iron levels are adequate before we switch over to plain milk. At our office, we usually send the patients to a local lab to have both the iron and lead levels done with one poke. If there are obvious concerns about diet or lead exposure, your doctor may end up doing the labs sooner.

Once you move along to cow's milk, I prefer that you use whole (full fat) milk. If possible, and you can afford it, go ahead and buy organic. I know there are folks out there that tout the benefits of raw milk, but I have a strong opinion that milk should be pasteurized. I have had parents asking me about vat pasteurization, and that does seem adequate.

Most kids who were on a milk-based formula have no trouble moving on to cow's milk. It is fine to do it gradually so that they get used to the taste (add a few ounces to the formula and see how they do). Intolerance will likely show up as tummy aches, poop changes or rashes. My older daughter got a terrible flare up of eczema when we first got her on milk (Eczema post). I put her back on her formula for a couple of months and when we retried the milk she was just fine with it.

But if you thought that the main choices about cow's milk were organic or fat content, think again. Along comes the choice between A1 and A2. Huh??? It turns out that there are indeed two kinds of cows out there (don't worry there won't be a test on the following paragraph).

A1 and A2 beta-casein are genetic variants of the beta-casein milk protein that differ by one amino acid. The A1 beta-casein type is the most common type found in cow's milk in Europe (excluding France), the USA, Australia and New Zealand. This is what most of us have grown up drinking. African and Asian cows are predominantly A2 cows. Milk from goats and humans contains only the A2 beta-casein.

There was a lot of buzz about this when I first wrote this post several years ago. The claim is that folks who have trouble with our common (A1) milk may in fact be able to tolerate A2 milk without any issues.
I rolled my eye when it first came around, but I confess that I have had some patients with milk intolerance who seem to do better on the A2 milk. In the past year, A2 milk has become more widely available at many grocery stores and doesn’t seem to be all that more expensive. For those of you with milk issues, it is worth checking out.

Milk is a great source of calcium, protein, vitamin D and the fat that your child needs for brain development. Not all proteins are the same. For those who can tolerate it, dairy milk is a complete source. It contains essential amino acids – the “building blocks” of protein – that our bodies need. The protein in most nut or plant-based milk substitutes is incomplete, meaning it's lacking in these essential amino acids. Since your body can’t produce essential amino acids on its own, it has to come from the choices you make in your daily diet - like dairy milk.

If you have a hard time getting your child(ren) to drink milk, it is important to make sure they are meeting those nutritional needs through other sources. If you choose to use a milk alternative such as goat, soy, rice, almond, coconut (seriously, there is a wide array of choices) the labels and see how they compare. In general:

Cow's milk and soy milk are both going to be the more complete sources of protein and calcium. Goat's milk is also good for protein and calcium, but doesn't have as much vitamin B-12. Almond milk and coconut milk have significantly less protein but are good sources of calcium.
It is important to be looking at the entire diet to make sure your kids don’t have any nutritional gaps

We want our toddlers to be getting at least 700 mg of calcium per day.
With a little planning, getting enough calcium should be reasonably easy if they are eating cheese and yogurt.
Table 1 and Table 2 at the bottom of the post will give you the calcium requirements through the ages and a list of calcium amounts in a variety of foods.

Interestingly, breast milk doesn't have quite as much calcium per ounce as cows milk, but the calcium it does have has twice the bio-availability. 


I personally don't feel the need to be completely off of the bottle at 12 months. I am perfectly fine with a snuggle bottle when first waking up or going to sleep for an extra couple of months. NEVER leave a bottle of anything other than water in bed. If a child falls asleep and keeps the bottle in their mouth it will cause tooth decay.

Try to transition most of the fluid intake to a cup. Once you start moving away from the bottle and transitioning to a cup, many kids significantly decrease their milk intake. Kids just don't like to drink as much milk from a cup. I couldn't tell you why. Some parents feel a little better assuring at least some milk intake by giving it in the bottle.

If you are trying to encourage your child to drink the milk from a cup, try adding a few drops of vanilla or a dash of cinnamon. Some kids might like it better warm. You can also try frothing it. I am not in favor of adding unnecessary sugar into your kids lives, so I would not suggest adding chocolate or strawberry flavor to the milk on a regular basis. Consider making smoothies with milk as the base. Kids like adding things into and turning on the blender. You can get a special cup that they have helped pick out. If you are using any alternative milks, watch out to make sure you aren't getting a sweetened version that is adding all sorts of extra sugar.

As is the way of things, There are those kids where getting enough milk in is always a challenge. One the other hand, there are those kids who drink too much milk are often anemic because they fill up on milk and don't eat enough solids. Those are the 'milkaholics'.
Once your little one is over a year, 12-24 ounces a day is a fine range.  

Friday, July 6, 2018

Speech milestones/Local speech therapy resources 2018

My older daughter Lauren reached her verbal milestones at a young age. It turned out that she was stringing together sentences quite a while before we could actually understand what she was saying. The fact that she was actually using real words to communicate became apparent to me one day when she and I were wandering around the zoo. She may have been as young as 15 months at the time. Lauren started to tug on my arm saying “shoofaloff”

It sounded like typical babble; I tried to figure out what she was attempting to communicate as we walked. Was it an animal perhaps? Did she want a snack?

“SHOOFALOFF” She kept repeating. She was getting upset that I clearly wasn’t understanding what she was insistent on telling me. “SHOOFALOFF”

I paused for a moment, happened to look behind us and saw that her shoe had fallen off and was about 10 feet behind us. Shoofaloff was “shoe fell off!” Duh! At that moment I realized that her fairly incessant cute little gibberish was actually speaking. As the weeks passed, Lauren became more and more articulate and I completely took it for granted that we lived with a little talking wonder.

When Alana came along, I expected nothing less. Alana (no need to fret about her, she graduated top of her Master's program and is currently working as a therapist) didn’t care about reaching milestones (any of them!) She had no trouble at all with comprehension, but her speech was incredibly garbled. By the time she was two, we could still barely make out a dozen words. Fortunately we had Lauren, who translated for her without any problem.

GUGUGUGGODH might mean “I would like more popcorn please”. Lauren was puzzled as to why we couldn’t understand her sister. This just goes to show that often siblings have magic communication skills with each other at a very young age. Eventually Alana had plenty of words, but there were still a few letters that were hard for her to pronounce until she was quite a bit older.

There is a huge range of normal, so when do we need to have our antenna up? There are a few basics to keep an eye on. By 4 months your baby should be cooing and making sounds. If this is not happening, one of the first things we would want to make sure is that your child doesn’t have an issue with their hearing. Babies born in California are given a hearing screen at birth, but it is still something to check out if you have concerns. Does your baby react to your voice? Do they look in the direction of a loud noise? As they get older, can they follow simple commands? If you are looking at a picture book, can they point to the appropriate picture with your prompt?

By 15 months they should be able to speak at least a few recognizable words.These don’t even need to be valid words. Alana couldn’t pronounce Lauren, but she could say Yaya and it was clear that Yaya meant Lauren. To this day, it still does! Perhaps "da" means dog. As long as they are consistent and communicating, those sounds count as a word. If your child knows some signs, those are counted among their words. If you know for sure what they are saying, repeat after them and expand on their utterance. When they see the dog and say “da!” you should say “Yes. DOG!” (repeat) “look at the big dog” (expand.) If they are using a sign, say the word. For instance if they are signing “more” during a meal, say “more” (repeat) and then expand, “would you like more peas?
By repeating and expanding , not only are you reinforcing correct production of their words, but you are supporting their language development

Michelle Geffen, a speech therapist at Jennifer Katz, Inc., advises not to pressure your kids by always asking them to say the specific word. Instead, let them hear you use the word and wait for a response. Waiting can do wonders!

If your child reaches 18 months and there isn’t any understandable language, this is an appropriate time to get a baseline evaluation from a speech and language therapist. Sure, it is okay to wait a bit longer if you like, but early intervention is always a good thing. I like to be proactive. Often the evaluation is covered by insurance.
By the end of the 2nd year, children should be able to speak roughly 100 words, understand 300, and have some word combos. They should be understood by close family members 50% of the time.

The earliest sounds for kids are usually Pa Ba Ma Na Wa Ka Ga. By the age of 3, kids should have most speech sounds. Ruth White, a local speech therapist, counsels that if the majority of folks can’t understand most of what your three year old is saying, an evaluation is advised. On the other hand, it is not uncommon for many otherwise articulate kids to distort some of the more difficult sounds such as l, r, s, sh,ch, v, z, th. These sounds may actually not be fully mastered until age 7 or 8. Ruth reminds parents that there is a wide range of normal.

Even though we know that some sounds aren’t perfected until later, 4 or 5 is a reasonable age to check in about articulation issues.
Bailey Levis, owner of San Francisco Speech and Fluency Center, receives many calls from parents who are concerned that their pre-school child might be stuttering. Many children will have some amount of disfluencies, (e.g. “Um um um, I want...I want...I want some ice cream”) in their speech, but only some of them will show signs of stuttering.  Some red flags for early signs of stuttering include tension or frustration if/when words get stuck, more than 2 repetitions (e.g. “cuh-cuh-cuh-cookie”), or if there are other family members who stutter. Whether or not you observe any of these red flags in your child’s speech, if you have any concerns, Bailey recommends seeking out a speech therapist who is comfortable working with stuttering. With early intervention, the likelihood of complete recovery is very high.

Frequent ear infections or fluid in the ear can impact your child’s early language skills so it is important to work closely with the doctor if this is an issue. We may send you along to an audiologist or ENT to be part of the team.

Of course, keep in mind that there is a huge difference between hearing and listening. I can’t tell you how many young child failed to follow the directions with our in-office hearing test, but when I quietly whispered “ would you like a sticker?” they heard me just fine.

One of my favorite in-home hearing tests is an active listening game. Tell your child to whisper a word to you (perhaps the name of an animal.) Then you quietly whisper a word back to them. Make sure they can’t see your face so that there is no lip reading. If you have any concerns that the hearing isn’t as sharp as you think it should be, get them checked.

Jodi Vaynshtok from Sound Speech and Hearing Clinic shared her explanation of the different aspects of communication skills that a speech language pathologist addresses:

Listening: In order to use the correct speech sounds, and understand/use language, a child must build upon their listening skills. This includes detection, identification and comprehension of spoken words. Listening therapy helps children learn to detect and interpret sounds, allowing their learning system to develop speech and language skills appropriately. 

Speech: This is often what people think all speech therapy sessions consist of – the production of sounds that make up our words and sentences. Speech involves the coordination of articulators (i.e. jaw, lips, tongue, vocal folds, vocal tract and respiration), divided into three areas: articulation, voice and fluency.

Language: A child’s language can be split into two domains. The information they understand (receptive language) and the language they use (expressive). Language therapy can concentrate on spoken, written or non-verbal communication. Goals can target vocabulary, grammar, formulation of sentences, following directions, and reading comprehension, just to name a few! A child’s ability to correctly understand and use language can affect their behavior, academic and social success.

Jodi also shares some tips for enhancing communication and language. Your child learns from every interaction you have together. Let’s learn some ways to enhance those communication opportunities to help your child learn the power of social interactions. Let’s O.W.L:

Observe: Body language – action, gestures, facial expressions – learn what is motivating and interesting to your child.

Wait: Stop talking, lean forward, look at your child expectantly – your child will take the lead. By waiting you can respond to your child’s signals, play, imitate, interpret and comment.

Listen: Pay close attention to all words and sounds – no interruptions, even if you know what they are trying to say.

Turn Taking: From body language, cooing, and words, use these tips for turn taking - match the length of your child’s turn. Try to match how much your child says or does by keeping your turns short and simple too. If your child uses one word, use no more than two! Match your child’s pace; let your child set the pace for the conversation. Slow down and wait longer if necessary. This allows your child time to explore, understand, and respond. Match your child’s interest; focus on what your child is interested in. When following their lead, they’ll interact longer.

Four S’s
  • Say less: Use short, simple, but grammatical sentences when you talk to your child.

  • Stress: Make important words stand out.

  • Go slow: Slow down your speech giving your child time to understand what you’re saying.

  • Show: Children learn best when they can see what you’re talking about – visuals help show what the words mean.

I am grateful to the speech therapists who took the time to share their wisdom with me about this post!

Below is a partial list of some excellent resources that we have in the SF area. For some folks finding someone in their insurance network is of primary importance. For others it is location and availability. You won’t go wrong with any of the folks on this list.

Sound Speech and Hearing 415-364-8774
Sound is one of the wonderful resources here in SF. They are the one stop shop that can combine the hearing and speech assessment in one visit. They also have the option of having Mavis, the animal therapy pup at the visits ( it doesn’t get better than that.)
Check out their blog. Below is a recent article about children's headphones

Bailey Levis 415-496-6757
Bailey does all sorts of general speech therapy for all ages but is top notch for stuttering issues. He offers a free 30 minute consultation.

Jennifer Katz Inc415-550-8255
This popular practice has several locations and has been taking care of my patients' speech therapy needs for many years. They have expanded to several locations. They also work with many insurance plans, which is a bonus. Their team includes feeding therapists.

In addition to their individual speech-language sessions they have a wonderful small group program called TheraPlay. TheraPlay is a language-based therapy group that is highly structured with an array of carefully planned activities targeting social skills, speech and language development, pre-academic, fine and gross motor skills. The groups are lead by a speech language pathologist and an aide with a maximum capacity of four children per group.   

Jennifer Katz, Inc. is happy to let you know that they will be doing their More than Words program . More Than Words® is a parent training program for children with social communication and language delays that provides parents with practical tools on how to support their child’s communication and social development during everyday routines.  More Than Words® was developed by expert speech-language pathologists and is grounded in extensive research and evidence-based practices. More Than Words® is an amazing program that will complement the services you are already providing to families. Some of the valuable things parents will learn when they attend the More Than Words® Program
•      What motivates your child to communicate
•      How to use your knowledge about your child to set appropriate and realistic goals
•      How to make interactions with your child last longer
•      Tips for using pictures and print to help your child’s understanding
•      Strategies for how to talk so that your child understands you
•      Strategies for developing your child’s play skills
•      Ways to help your child make friends
*Registration is due August 30th

Ruth White 415-225-6152
Ruth has a private practice but is also an instructor at SFSU in the communicative disorder clinic and currently run graduate clinics there.

SF Speech Therapy 415-404- 8343
SF Speech Therapy is a small, family centered private practice in Diamond Heights. It provides speech, language, and feeding therapy to people of all ages, with a particular emphasis on early intervention for the very youngest San Franciscans. Therapists at SF Speech Therapy have specialized training in a number of areas, including infant and toddler language, articulation, stuttering, voice disorders, and the Sequential Oral Sensory (S.O.S.) approach to feeding. There are both English and Russian speaking therapists on staff, and home visits are offered. To get a feel for the practice, check out the blog and website below. Appointments can be made by calling Teresa Newmark at 415-404- 8343 or by emailing,

Northern California Speech and Hearing 415 -921-7658

Shannon Kong and Sara Spencer 415-469-4988

Shannon Kong, MS, CCC has been renamed to Seven Bridges Therapy ( and they now have offices in SF, San Mateo, and Oakland. They specialize in working with children 5 and under as well as children with autism but see children of all ages!

Sara Spencer, continues to see children ages 6 and up under her company name, Sara Spencer and Associates. Same addresses in SF and San Mateo. They continue to work hand in hand as they always have (since 2000).

Tulips Speech 415-567-8133
tuLIPS Speech Therapy has exciting news. After 7 years on Union Street in Cow Hollow, they have opened a 2nd location on Castro Street in the heart of Noe Valley! tuLIPS Speech Therapy offers speech and language therapy, social skills groups and their very popular Talking tuLIPS program. They have an amazing neuropsychologist on staff who offers neuropsychological testing and they work closely with a wonderful occupational therapist. tuLIPS Speech Therapy is now accepting new patients. Call them today and ask about their complimentary speech and language screening!

Lauren Van Burkleo 415-633-6648

UCSF Audiology 415-353-2101
For our patients using any of the UCSF pediatric specialty clinics, including audiology, a referral is needed before they will make an appointment. If you are interested in meeting with them, let your doctor or nurse know. We can send a referral over and they will contact you to get something scheduled.

Friday, June 29, 2018

July 4th safety tips 2018/ You probably have NOT thought about of all of these

July 4th 2018

The phone calls that we get following the July 4th holiday are fairly predictable so here are some tips that can help you all have a safe & healthy holiday weekend.

Since some of the holiday festivities may involve large crowds, I have some recommendations for dealing with situations where you might find yourself in a throng of people. Dress your child in bright clothes that stand out from the pack. Take a photo of them before you set out, so if heaven forbid you get separated, you have a current picture to pass around that shows exactly what they are wearing. Another sensible and creative idea is to write your phone number on your child's wrist and cover it with liquid band-aid to make sure it doesn't wash off.

Make a solid plan with your older children. What should they do if they lose sight of you? Where should you meet up? This is a good time for the : What would you do if....activity

Will it be loud? Loud music and fireworks can be damaging to your child's sensitive ears. Consider getting some ear protection if you are going to be someplace that can put hearing at risk:

Please be very careful of fireworks. If you are skipping the organized shows and planning on setting them off yourself, make sure your kids don't have any access to the fireworks or matches ahead of time. Do an inventory and know exactly what you have on hand. Keep the kids at a safe distance during the actual fireworks. Have a bucket of water or a hose nearby.

Try to keep your pets indoors with windows closed in case the noise bothers them. I have not ever had a pet/child injury from fireworks, but Nurse Lainey points out that if your pet gets stressed from the fireworks, they need close observation if they are around your babies.

I have NEVER had a morning-after-July 4th without a call or two about fireworks injuries. Don't let this be you making that call. I will be kind, and I will help you out, but I may make you squirm!

If you are in San Francisco chances are you probably don't have to worry about the heat. When my kids were growing up, our July 4thfireworks watching usually included warm blankets, hot chocolate and lots of thick fog. I remember one year when Lauren was 3 or 4 and we were driving to a vantage point, she saw a traffic light through the fog. "Is that a firework? It's beautiful!" Ah, our San Francisco babies.

For those of you escaping the city make sure you stay well hydrated and protected from sun.

Get in the habit of doing a skin sun exposure check at least every 30 minutes (more frequently for fairer kids) to see if it is time to reapply the sunscreen. Be very wary about applying any of the aerosol sunscreens around a heat source (like a grill.) These are flammable and there are horror stories out there about terrible burns that have occurred.

Let's move our discussion over to grills. I was watching the news and a story came on about the hazards of metal bristles coming loose from utensils that are used to clean your grill. These metal strands may get lodged into pieces of food. People have been reporting mouth injuries and worse. Happily, that is one call that I have never gotten, but it seemed like a caution worth sharing. Check your utensil brushes to make sure there is nothing loose. While you are at it, check the grill surfaces to make sure there are no pieces of any foreign objects that can get stuck in the food.

Make sure your child can't get anywhere near any type of grill. The danger begins from the moment you light it and are waiting for it to be ready, until long after the cooking is done and you are certain it is completely cool.

If you are cooking meat, make sure that it is thoroughly and safely cooked. Food borne illnesses don't just love under-cooked meat; other foods can transfer the bacteria also. Pay attention to any picnic foods that will be out of refrigeration for several hours:

If your picnic/meal is outside and you will be spending time in grassy, wooded places, make sure you do a head to toe check for ticks once back inside:

Ticks are rampant right now. Finding them early before they have been attached for a couple of hours will vastly decrease any concern about disease transmission.

No, it is not okay to keep your child in bubble wrap; that isn't my intent. Go forth and have a festive, fun and safe holiday. Happy 4th of July!
Nurse Heidi just read this post and said, "This is why we always stay in!!! Go have fun; Really???"

Friday, June 22, 2018

My Father's Influence

I am actually writing parts of this post from the airplane on my way home from Pittsburgh. My siblings and I are in the process of clearing out the family house. This is an emotional, enormous and  daunting process that will take upward of a year, at least. (If anyone wants to buy a magical house in Squirrel Hill mid 2019, reach out to me.) This 100 year old house is palpably imprinted with the energies of everyone who ever lived there. It is the house of requirements, right out of a Harry Potter novel. The kids would find the exact thing they needed for a school project, the right dose of allergy medication, an eclectic book on a subject that they were interested in. This visit, my pants were too loose (hooray!),  I opened up a closet, and there was the perfect belt.

My dad would have turned 91 on June 21st. His birthday was always the week of Father's Day; some years they fell on the same day. We lost him 10 & 1/2 years ago. Time plays tricks and it feels impossible that it was so long ago. I have shared a good bit about my mother and it is time give a shout out to my father. I had planned to write a post about my dad this week, and since we had the week together the family recalled some classic stories like the time dad tried to calculate the width of a canyon based on how long it took for a sound to echo. In the same vein no one in the family can help but to think of dad during a thunderstorm.  We all find ourselves calculating how far the lightning strike is by counting the seconds between the boom and the flash.

The lock for my high school locker was Kr Cr Ar -- If anyone needs help figuring  out the code that would be 36 Krypton  24 Chromium 18 Argon. My dad had us remember combinations based on the periodic table. Yep, he was a nerdy scientist.

This had its pros and its cons. The first time my poor husband Sandy visited my house (at the vulnerable age of 18) my dad handed Sandy a Scientific American magazine and asked about alternative approaches for addressing the problem posed in the article. Deer in the headlights would probably be an accurate description of Sandy in that moment. My mom rescued him “Robert, leave him alone.”

Dad had so many varied interests.

He loved music and played his violin until his last days. Certain pieces of music bring him right to me. He loved animals. When he was older, he used to sit on the porch and all the neighborhood dogs and cats would stop by to hang with him. He was curious about everything and brilliant until Alzheimer’s dimmed his mind. If anyone had a question, before the days of google, the obvious choice was to “ask Grandpa.”

He loved to do things. When I was growing up he was a very involved dad. We were always on the go to fairs, concerts, bowling or sporting events (Go Steelers, Pirates and Penguins); I don’t remember him saying no. He was recycling and composting long before it was fashionable. My dad didn’t tell jokes, but he was the universal recipient and appreciated any humor that was directed his way with a broad grin and a big laugh.

One of the traits that  I got from him in spades and am most grateful for was his problem solving ability. If you come to me just to ketch and vent, I have learned to tell folks that they need to warn me in advance and I will try to simply listen. Without that caveat, I go right into problem solving mode.

  • Identify the issue  (sometimes this is the most challenging aspect)
  • Who owns the problem
  • What are some solutions.

Learning that not everyone wants to have someone “fix” them,  is something that I continue to work on. This would have been a foreign concept to my father. If he saw something that could use some correction or fine tuning, he would dive right in. A man limping? Let's evaluate the physics of his gait. An off key singer (his favorite)? He invented a method to teach anyone to sing. In some cases this might be total strangers.

His kids and grandchildren coined the verb “to Grandpa someone” which translated as constructive criticism, or instruction that was more than likely unasked for. He was pretty sure that anyone could learn anything, and he was ready and eager to teach.

My dad had a remarkably even temperament. It is possible that he never once raised his voice to me. I would like to think that this was mutual, but every time he tried to teach me the error of my bowling technique, I would lose control of my temper ( I should have listened, I am a terrible bowler.)

It was no fun being mad at him. He would simply get sad and say something along the lines of “I am going into the backyard to eat worms.”

He was a family man who loved his wife, children and grandchildren with all his heart and we knew it. He started with girls only, three daughters, followed by five granddaughters. The switch flipped. The next two grandchildren were boys, followed by two great grandsons, who he never got to meet but would have been so proud of. We are quite the force of nature when we all get together.
My daughter Lauren is getting married in August, and oh my goodness would my dad have been over the moon at the man she chose. Adam would have been the one to say “tell me more about how you can measure a canyon by the echo." They would have loved each other. Anyone who knows me will tell you that I truly believe that dad will be at that wedding, watching from somewhere and beaming.

Friday, June 15, 2018

The Partner's job

Father's Day seems to be the appropriate time for this post that I have been working on.

While it is true that there is a certain intimacy between the birth mother and the baby that feels a little exclusive, don’t forget that you are an essential member of the team.

When I first found out I was pregnant, Sandy started reading all the resource books. He found a recipe for a protein shake that I was supposed to drink nightly. I remember it as pretty vile. I took one sip and then handed it to him, “Here, the baby will have a healthy father.” He did convince me to drink it nightly, but he also made a double portion and swigged his own portion down in support.

As the one who gave birth, I can only imagine what it feels like to be the partner. On one hand, the magical experience of growing a baby, feeling it move, feeling that bond is something that is unique to the person who carries the child. On the other side of the coin, that same little (or not so little) fetus, is bouncing on the bladder, causing heartburn and last but certainly not least...needs to come out!

Good partners go along to the birthing classes and learn to pant and blow along with the birth mom, but being an ideal support goes well beyond being a good labor coach.

Physical support
It is essential that you help your partner physically replenish.
For those first couple of days, make sure the birth mom needs to do nothing other than nurse the baby and rest. Someone else besides mom (are you lucky enough to have a grandparent around?) can do the changing and the burping.
Your job is to keep mom well hydrated. Every time the baby nurses, make sure that mom has something to drink. Plenty of fluid is lost during the birthing process and every time a woman nurses, she is losing even more. Good hydration is also really important for establishing a good milk supply.

If you are lucky enough to have a support system, consider having a friend organize some meals for your family for the first week or so.

Having a supportive community is so helpful but you may need to be the gatekeeper. Everyone has different social needs and mom probably needs rest more than she needs company. As you moderate your visitors, you also need to make sure they are healthy. If someone has a cold, they are not doing you a favor if they come over. If you are feeling shy, tell them that nurse Judy gave you your marching orders. Nurse Charity puts it very clearly:

Anyone in your home should be able to:

1. buy/prepare food and clean up the kitchen.
2. Watch you breastfeed
3. and scrub your toilet.

Anyone you would not feel comfortable asking to do those things, or who would be incapable of those things is not good postpartum company and should leave their casserole at the door with a friendly wave! This includes family. So if your mom is a busy body with no boundaries, she should wait a bit to come and "help" with the baby.

Emotional support
Prepare for hormones. At one of my baby boot camp sessions last year, one of the postpartum moms simply couldn’t stop weeping. Her baby was lovely and she was having a reasonably easy time, she just cried….all the time. Before long, every pregnant mom in the class was also crying, just because. Sometimes crying happens. Everyone got their own box of tissues and the class went on to talk about sleep, poop, spitting up and all those things that I cover. Crying is very normal, up to a point. Postpartum depression (PPD) is very real. It has nothing to do with prior mental health issues, or level of education. It can happen to anyone.

I think it is essential to talk ahead of time about PPD. If your partner sees any warning signs, agree that you will trust them enough to reach out for help.

More wisdom from Nurse Charity about postpartum depression

The post-partum time is a marathon of newly acquired skills. No one feels certain. Everyone is struggling to get it all done. So this is a time to think about needs vs wants. (I want the kitchen table to be clear of baby clutter, I need a shower). Prioritize needs over wants.The primary caregiver cannot do everything, by the same token - neither can you. Priorities are feed everyone, sleep round the clock (this means you too!), get a shower in, and then pick ONE thing you need to feel human. That one thing is different for everyone, but it should be doable in 20-40 minutes: examples are- read the paper, take a walk, call a friend, an extra grooming task, a project you love.

Don't compare your babymoon to anyone else's. Each family has their own strengths and skills and their own set of challenges. Be like an astronaut and work the problems you have with the skills and resources you have.

Post-partum depression for partners is a REAL thing. (1 out of 4 non pregnant partners experience depression during the pregnancy or within the year after birth). 

Click for a list of possible Postpartum Depression Symptoms:

Here are some resources just in case

This is a free counseling service available through the University of San Francisco.
1-844-415-BABY (2229).
It is NOT a crisis line.

415-441-KIDS (5437)
This is a 24/7 crisis and counseling line for parents who are under any kind of stress. This includes Postpartum Depression. They have resources available for emergency respite care, parent groups etc

(415) 781-0500
Crisis Line for SF bay Area. This is commonly referred to as the suicide prevention line but it is useful for any emotional crisis. You do NOT have to be suicidal to call.

Breastfeeding support
Talking to a breastfeeding mother about her milk supply is akin to walking across a minefield.

Breastfeeding is a learning process.Rest and fluids for mom are a good start, but you are an essential part of the team that will be assessing success. The first several days are really tough. Most mom’s think that for some reason this process is supposed to be the most natural thing in the world, they put the baby up to their breast, the milk will flow and the baby will feed. Think again. It takes a good bit of learning for 90% for the mom/babies.

Aside from plumping pillows, offering a drink (not whiskey although you will be tempted) and helping with positioning, it is hard to watch the frustration of a new mom and a crying baby who are both trying to figure it all out. Having a lactation consultant set up in advance is useful. There is a lot of learning that can be done before the baby arrives that can mitigate some of the common issues. Email nurse Lainey if you are interested in prenatal support. She will schedule classes on demand.

For families that choose to breastfeed, we want to do everything we can to support the success of nursing, but it is essential to recognize when it is not working. Breastfeeding moms have so much emotional “stuff” that creeps into the equation that sometimes it is hard to hear and accept the first and most important rule of breastfeeding: It is simple. “FEED THE BABY.” If there isn’t enough breast milk or the baby can’t seem to transfer the milk, then we need to offer some form of supplementation or feeding method.

When the milk is in, you can see drops of milk coming from the nipples. You should actually also be able to hear the baby swallowing during feeding. A nice glug glug glug is a great sign. After a feeding it is typical for them to appear sleepy and almost drunk. There will be wet diapers and nice poops. The baby will be gaining weight. A satisfied baby will be calm and have periods of being alert.

If an infant is NOT gaining weight, and this is where it gets tricky, please help support your partner to accept that being a good parent is not about the breast milk. Sometimes a little bit of supplement gets things moving in the right direction. This is often a bridge to successful breastfeeding and should not be looked at as a sign of failure. More times than not, it is a baby learning problem.

You are both in agreement that you want a happy, healthy baby. Babies who are not getting enough to eat are neither of those. A mom who is spending her entire day pumping and nursing is also not getting enough rest. Exhaustion will impact her ability to produce milk, enjoy the baby and stay emotionally balanced.

Partners and daddies. You can't actually birth a baby or have breast milk flow out of your breasts, but aside from that, your role as co-parent can be anything you make it to be.

Your relationship with your partner will change (hopefully strengthen). Each parent will have a distinct relationship with each of your children. Parents often take turns being the favored parent. Don’t take it personally when you don’t get picked….go read a book. Enjoy your moment of freedom. Nurse Lainey reminds you that it likely won’t last long.

There are some great resources out there for you fathers-to-be. Armin Brott, known as Mr Dad has some books just for you. Armin also does classes monthly through newborn connections for expectant dads:

I asked him for his favorite piece of wisdom and this is was essentially his best advice.

Jump right in and start doing things. Change that diaper, soothe the fussy baby. You will become more comfortable the more you do. Mistakes will happen, and you will learn lessons. Don’t be afraid of that.

Finally, feel free to check out these Father's Day posts from Sandy, aka Mr. Nurse Judy, describing his philosophy of parenting, leading to the outstanding relationship he has with our daughters, through all stages of their respective lives: