Originally published in The Ottawa Citizen September 14, 2004

What are some of the problems breastfeeding mothers face when they return to work or school? What are the solutions available to help them continue to breastfeed or provide breast milk to their infants?

In Canada, maternity leave can be 12 months for those who are not self-employed. Those who have the option may split this time between spouses.

Self-employed women may have to return to work weeks to months after birth. The recommendations to breastfeed for the first six months may be a difficult proposition for some based on their work situation and life circumstances.

Studies indicate that breastfeeding continuance rates decline precipitously when mothers return to work. In addition to maternity leave benefits in Canada, other factors may influence a working mother’s ability to continue to breastfeed: the office environment, number of breaks, travel, work hours, shift work, availability of local or office childcare programs, milk storage, use of breast pumps, and spousal and family support, among others.

Preparing a breastfeeding plan and sharing it with the employer and co-workers prior to returning to work can help everyone understand the situation.

Depending upon the circumstance, it would be ideal to have the infant brought to his or her mom at least once during her work day for a feeding. Sometimes a caregiver may be able to bring the infant in to the workplace for a feeding.

Should the logistics of the workplace environment or work day prevent on-site infant breastfeeding, then the priority should be production and storage of breast milk for later use.

This means having the opportunity to use a private room to use a breast pump. Different breast pump systems exist to accommodate the mother. The room should have a sink, refrigerator, chair and electrical outlets.

If the mother is unable to express milk during her work day, breast milk production will eventually decrease. The pumping schedule should follow the mother and infant’s usual feeding routine.

The stress during the initial days at work can contribute to reduced milk production. If possible, a graduated-hours work schedule for the first week or two will allow the mother to integrate a new routine that does not disrupt her ability to continue breastfeeding. Returning to work on a Thursday or Friday will help work out any bugs in the breastfeeding plan, minimizing disruption of the full work week.

Using a breast pump effectively requires practice. Incorporating its use two weeks before the end of maternity leave will increase proficiency. Pumping between feedings offers the best results. Although initial attempts may not produce much milk, with patient persistence the breast will respond by increasing production after a few days of regular pumping.

Breast milk can be stored at room temperature (less than 26 degreesC) for up to eight hours, remain in the back of the refrigerator for up to eight days and frozen in the back of the freezer for a maximum of three months.

The milk containers (glass or plastic bottle with a tight sealable top) should have a tag or space to write the milk production date. Playtex makes a system that attaches to a breast pump and collects the milk into a ready-to-use bottle that doubles as a storage container.

The milk fat in frozen breast milk will normally rise to the top of the container. The milk can be thawed either by gently swirling the container in warm water or placing it in the refrigerator a day before use. Thawing using a microwave oven is not recommended. Shaking the bottle will reconstitute the fat into the thawed milk.

A workplace breast pump kit should be prepared ahead of time and include:

* Breast pump;

* A small cooler if a refrigerator is unavailable;

* Milk storage containers;

* Extra clothes in case of breast milk leaks;

* A shawl or blanket for privacy;

* Water, juice and snacks to provide extra calories for milk production;

* A pillow for arm support while using the breast pump;

* A CD/tape player, favourite music, books or magazines to provide a relaxing environment. This will help with the milk let-down process;

* A picture of your baby.

Breast milk production is usually well underway by the time an infant is four weeks old. A motivated mother with good support can succeed with many types of breast pumps. A lactation consultant can help with the breastfeeding plan and any problems that may arise.

One other aspect is the division of household chores and cleaning. Family support is imperative so the mother can get some rest.

There are solutions to help mothers continue to breastfeed should they wish to do so. Support of this effort should be encouraged by all.

© Dr. Barry Dworkin 2004

Related articles:

1. The hazards of breastfeeding
2. The hazards of discussing breastfeeding
3. Economic models predict breastfeeding will reduce disease and health care costs

Originally published in The Ottawa Citizen August 19, 2003
Original Title: Medication safety during pregnancy

Moms-to-be should speak to their pharmacist and doctor about prescription medications and any other drugs they might be taking’ What medications are safe to use during pregnancy? Should I stop my prescription medications? How can I treat my heartburn? Can I drink coffee?”

Health care providers need accurate information to answer these questions. Some women have medical conditions that require ongoing treatment. If they stop, they could increase the potential risk to their baby and themselves.

Minor health problems might require medical therapy, and pregnant women may use over-the-counter medications (OTCs) to treat them.

There is understandable angst and concern about medication use during pregnancy. One or two per cent of birth defects are due to drug exposure during that time. Ninety five per cent of defects are due to random chance or genetics.

It is unethical to subject pregnant women to clinical trials to establish the safety of a particular medication. The risk to the fetus and mother outweigh any potential benefit of the research — a lesson learned from the use of thalidomide.

In 1975, the U.S. Food and Drug Administration defined pregnancy risk factors for all drugs, and Motherisk (www.motherisk.org) provides a similar service to the public and health care providers.

In June, the Centre for Addiction and Mental Health (CAMH) released a booklet called Is it Safe for My Baby? It offers assessment of risk and recommendations for the use of medication, alcohol, tobacco and other drugs during pregnancy and breastfeeding.

This excellent guide reviews the safety of more than 200 substances when pregnant or breastfeeding. It includes a host of information covering over-the-counter and prescription medications, illegal drugs, herbal preparations, cosmetics, household chemicals, solvents, paints and cleaners.

The booklet’s release comes at a time when some prescription-only medications are now reclassified as OTC medications.

Pregnancy is not a static situation. Certain medications might be safe in the last trimester but not in the first. The reverse is also true. Let us look at some common concerns during pregnancy: pain, heartburn, nausea, constipation, caffeine, tobacco, marijuana and herbal remedies.

Tylenol (acetaminophen) is present in many OTC cold and flu medications. There is no known link between it and birth defects. ASA-containing products such as Aspirin and non-steroidal anti-inflammatory (NSAID) medications seem to be safe in the first two trimesters of pregnancy but only in low doses. However, greater doses might cause bleeding in the newborn, decreased birth weight and prolonged pregnancy.

Therefore, ASA and NSAIDs should not be used in the last trimester (28 to 40 weeks).

Infrequent use of Tylenol with codeine or other prescription narcotics is safe, but daily use can increase the risk of miscarriage, premature delivery and complications during delivery. If possible, stick with acetaminophen alone to treat pain.

Heartburn can worsen as the size of the uterus increases. Increasing pressure within the abdominal cavity can cause stomach acid to splash up into the esophagus. Antacids such as Tums, Maalox, Rolaids and Gaviscon are generally safe to use throughout pregnancy. If these options fail, the use of Zantac or Pepcid would be the next safe step.

For nausea, Diclectin (pyridoxine/doxylamine) is the only medication approved by the Society of Obstetricians and Gynecologists of Canada for use during pregnancy. The society does not recommend Gravol (dimenhydrinate) for routine use, but it is used in its intravenous form for severe vomiting and dehydration (hyperemesis gravidarum).

Fibre laxatives such as Metamucil or Prodiem and stool softeners Soflax and Colace are safe to use. The stimulant laxatives such as Ex-Lax, cascara and castor oil might cause uterine contractions and should be a last resort.

Caffeine in excess of 300 milligrams per day (three regular cups of coffee) can increase the risk of miscarriage and low birth weight babies. Caffeine consumption in a combination of other products such as 500 millilitre energy drinks (50 to 125 milligrams), a 45-gram chocolate bar (50 milligrams), 355-millilitre colas (30 to 90 milligrams) and a cup of tea (20 to 90 milligrams) can easily exceed the maximum allowable daily limit.

The harm from tobacco is dose-dependent. The more you smoke, the greater the miscarriage risk, premature delivery and low birth weight babies. It is the carcinogenic compounds and other chemicals rather than the nicotine that increase the health risk to the fetus.

Cannabis (marijuana) poses the same risk to the fetus as tobacco with an extra caveat: Newborns might have more sleep disturbances and other cognitive difficulties.

While some clinical data exists for some herbal remedies, the effect of others remains unknown. Ginkgo biloba can cause bleeding, dong quai (ephedra) and feverfew can induce premature labour.

Discuss your concerns with your doctor or pharmacist before taking medication and review all your prescription medications during your pregnancy.

The information booklet is available from CAMH for $2.50 (1-800-661-1111 or by contacting marketing@camh.net).

Related articles:

1. Safety of medication use during pregnancy
2. The grey zone of medication use during pregnancy
3. It’s vital to know how drugs interact

Originally published in The Ottawa Citizen January 15, 2002

Column draws fire from some readers and support from others

Last week’s column on breastfeeding difficulties provoked passionate responses. I was accused of being uneducated, unethical, unprofessional and a menace to medical students and residents because allegedly I promoted formula over breastmilk. Others whole-heartedly agreed with my comments.

Everyone has their heart in the right place. All of us care about the health and welfare of infants and children, mothers and fathers. It is our approach that differs. My assertion that breastfeeding is to be encouraged and is the standard for infants was not recognized by some.

The benefits of breastfeeding are legion. A 1997 report entitled Breastfeeding and the Use of Human Milk by the American Academy of Pediatrics presented a review of breastfeeding advantages: it promotes a strong mother-child bond and provides infants with antibodies to protect them from common infections. These babies are less likely to get sick from meningitis and ear infections, less likely to suffer from constipation and intestinal disorders. Breastmilk is easier to digest. Some studies indicate there is a reduction in asthma, sudden infant death syndrome, diabetes, iron deficiency anemia and allergy rates. Increased IQ scores are reported in later childhood, accompanied by enhanced brain and nervous-system development.

Women experience less bleeding after childbirth. They return to their pre-pregnancy weight quicker. They have fewer cancers of the ovary, uterus or breast. Osteoporosis is less common in women who breastfeed. Money is saved by not purchasing formula.

I believe that people should be presented with all relevant and factual information regarding any medical treatment or standard of care. It is up to each person to decide what is best for them. I have been accused of being unprofessional and unethical because I have brought up an issue that is indeed of great concern to parents.

I certainly encourage breastfeeding in my practice. I have delivered and cared for babies for 12 years. The majority have been breastfed. I cannot force or coerce a mother to breastfeed any more than I can force someone to stop smoking or lose weight.

After all is said and done, I respect the decisions my patients make for themselves. I may not agree with their decisions but I am not a judge and jury. I do not punish my patients for their decisions.

Sarah Byers of Ottawa said, “It angers me the pressure that society puts on mothers today.

“Society has so many opinions that are thrust upon a mother with such force. The health community is supposed to support you not make the decisions for you. They are there to offer the options, not cast judgments.

“Books, prenatal classes, public health, etc., need to stop pushing breastfeeding on parents, and simply inform them of its benefits. More information on lactation consultants is required. I may not have stopped breastfeeding after three weeks if I had understood what a lactation consultant was and what they could do for me.

“The benefit that I had with a lactation consultant is that they assessed my situation and didn’t push breastfeeding if it wasn’t right for my situation.

“They provided the information that my husband and I needed to make a decision that was right for the three of us.”

Beth McMillan of Ottawa said: “I had terrible latch problems with my first child so I understand the guilt and sometimes pain that many new moms experience.

“Support from at least two wonderful doctors (both mothers who had breastfed), a very patient lactation consultant and my husband, who helped very much with breastfeeding (checking the latch, encouraging, cooking), fixed all of the difficulties.”

Lori Thornton of Ottawa had both experiences: “The lactation consultant was a fanatic and chastised me for not being tougher and more diligent.

“She told me that formula-fed babies were sicker, stupider, less productive members of society than breastfed babies. She scorned the use of formula under any circumstances. She was horrid.

“She put me on the pump and I spent days breastfeeding, supplementing with pumped breastmilk (meagre as the amounts were), then pumping — I would just get finished and Angela would be ready to feed again. What a merry-go-round. I successfully breastfed my second daughter for a year — this time I had a different and wonderful lactation consultant come to see me in the hospital from day one — and what a difference it made!

“Every case, every child is different.”

Julie A. Matte, R.N., B.Sc.N, of Ottawa writes: “I am a new mother and know of the benefits of breastfeeding and figured that breastfeeding was a natural choice for my child.

“I did not anticipate all the stress and pain that would accompany it.

“My son has an unusually strong clench and suck that made it very difficult to latch him on without a lot of pain. In hospital, I had a lactation consultant come in numerous times each day, and my nurses waking me every 11/2-3 hours to get him latched on and feeding.

“I had so much trouble when I arrived home from the hospital that I started pumping for 24 hours to give my breasts a break. Then we tried again, and when my nipples were so sore and bleeding and my son was frantic to eat, I decided to continue to express and bottle feed him the breast milk. I had a few nurses and friends that think that this is not an appropriate option as I should ‘get him back on the breast.’

“I have heard comments such as, ‘I have seen worse nipples than that,’ and ‘persevere and the pain may eventually get better, but if not, this is the best for your baby.’ We certainly have to do a better job supporting and promoting breastfeeding.”

Colleen Kennedy of Prince Albert, Sask. adds: “Every woman should be encouraged to breastfeed, but at the same time, it is not an instinctive process. Mothers need access to competent trained breastfeeding counselors, whether they are physicians, nurses, lactation consultants or La Leche League leaders. No mother should have to feel guilty for not being a success at breastfeeding. Until there is an adequate network of support people out there, there will continue to be women who get inadequate information and end their breastfeeding relationship prematurely.”

Preparation for breastfeeding before birth increases success rates.

Michael Thompson of Kanata relates his family’s experience. “Our first son, Connor, turned one this Christmas Eve. After he was born, we followed the advice of the nurses and midwives and my wife tried all of the usual tricks to get him to latch on. We were told to not feed him formula, or he will surely experience nipple confusion and never breast feed.

“I’m sure that the health care professionals we worked with did not intend to leave my wife with the feeling that breastfeeding was the only option, but in their enthusiasm to encourage her to stick with it, she was left with the impression that only responsible, caring mothers breastfeed their babies.”

The story of my patient who supplemented breastfeeding with formula stands to be clarified. Some concluded that she weaned her son off the breast when the opposite is true. In fact, she is exclusively breastfeeding.

As these stories attest, there is inadequate support and information for some mothers. Others are turned off by zealous promotion. There are also good outcomes. We need to be flexible in how we promote breastfeeding.

References: From the American Academy of Pediatrics, both Breast Feeding: Hints to help you get off to a good start at http://www.familydoctor.org/handouts/019.html and Breastfeeding and the use of human milk at http://www.aap.org/policy/re9729.html .

Related articles:

1. The hazards of breastfeeding
2. Breastfeeding solutions for working mothers

Originally published in The Ottawa Citizen January 15, 2002

Many new parents have questions about infant nutrition. Do infants require any nutritional supplements? Are there different considerations for breastfed and bottle-fed babies?

Several nutrients essential to proper growth and development may require supplementing — for example, vitamin D and iron.

Normal infant and child bone growth requires a steady supply of calcium and phosphate. Vitamin D promotes the intestinal absorption of calcium and, to a lesser extent, phosphorus. Lack of vitamin D will lead to reduced blood levels of calcium. The body, in order to maintain a normal blood level, will break down or demineralize bone to release the calcium leading to osteoporosis in adults and rickets in children. Indeed, the bones function as a calcium reservoir.

The incidence of infant vitamin D deficiency rickets is increasing in Canada. The Canadian Pediatric Surveillance Program reported 51 confirmed cases from July 2002 to June 2003.

The first sign of rickets occurs in areas of rapid bone growth: the knee, the distal forearm (where the forearm meets the wrist) and rib cage. Each of the ribs on the front of the rib cage near the breastbone will have a noticeable bump or lump of bone. Indeed, it will appear as a line of beads running top to bottom along the rib cage.

The wrists will become enlarged and the forearm will appear bowed. The legs will also bow outward.

The sides of the skull will soften and the forehead will appear sunken and small. The closing of the skull’s fontanelles, or soft areas, will be delayed.

The areas affected will depend on the child’s age. The crawling infant will have deformities of the wrist and forearm, whereas the toddler will demonstrate bowed legs.

Rickets can cause a reduction in muscle tone leading to delayed motor development milestones. Severely low calcium levels can lead to seizures. These children are also prone to infectious diseases.

Most are breastfed infants not receiving vitamin D supplements. Breast milk is not a rich source of vitamin D. Sunlight exposure, food (fortified milk, fatty fish, cod-liver oil, and eggs) and infant formula are sources of vitamin D. The Canadian Pediatric Societies recommends breastfed infants receive a daily supplement of oral vitamin D (Di-vi-sol).

Breast milk is the optimal nutritional source for term infants during their first year of life, and provides adequate amounts of calcium and phosphorus. Infants exclusively breastfed during the first six months after birth and supplemented with solid food between six and 12 months of age will receive adequate amounts of these minerals, resulting in appropriate bone mineralization.

Dietary iron is required for proper development of the infant nervous system. Many infants do not get enough iron in their diets. Indeed, low-iron infant formulas generate 30 per cent of sales in Canada. These formulas increase the risk of iron deficiency anemia.

Dr. David Mack, head of pediatric gastroenterology at CHEO, notes: “Public health policy successes include the introduction of iron-fortified infant formulas in the 1970s with the prevalence of iron-deficiency anemia being dramatically reduced, but Canadian infants and children are still at risk.”

This anemia, or reduction of oxygen-transporting red blood cells, reduces the delivery of oxygen to the developing infant, especially the brain and nervous system. Iron-deficiency anemia is associated with problems in cognitive, behavioural and physical development in infants and children.

In 1999, the journal Pediatrics published a paper indicating that the rate of iron-deficiency anemia in nine-month-olds fed low-iron formula was 28 to 38 per cent even with iron-supplemented foods. The rate plummeted to 0.6 per cent with iron-fortified formula use.

There are no known medical contraindications to using iron-fortified formulas. They do not cause constipation. Professional organizations do not advocate using low-iron formulas. Even the formula company representatives discourage its use.

Some parents continue with low-iron based formulas because hospitals stock and distribute them to parents for newborn feeds. Looking for reasons why low-iron formula use is so common reveals few answers. There is no scientific evidence to support these products.

Breastfed infants will require some form of iron supplement after four to six months of age. An average of two ounces of iron-fortified cereal per day is sufficient to meet an infant’s daily iron requirement. The iron drops, Fer-in-Sol, can be administered if the infant does not eat enough cereal to meet his or her needs of one milligram per kilogram per day.

Discuss with your doctor when is the best time to begin infant vitamin D and iron supplementing. They are an inexpensive and important means of maximizing your infant’s growth and development.

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2. Common Infant Problems
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Originally published in The Ottawa Citizen January 8, 2002

Mother’s milk is best for a baby, but it’s not a mother’s only option.

The American and Canadian pediatric societies advocate breastfeeding for the first 12 months of life. Health care professionals universally support this recommendation. Breast milk is the best source of nutrition for newborns and infants.

In my practice, I observe many mothers equating breastfeeding to their competency to be good mothers. This narrowed perspective — the dependency upon one aspect of newborn care — can be damaging to the mother’s well-being. There can be tremendous guilt if breastfeeding does not go well, their baby is not gaining weight, not latching properly, or their technique is poor.

The stress from these problems can in themselves make matters worse.

Despite the best of intentions, women are bombarded with messages that lead them to believe if they stray from breastfeeding they are potentially harming their newborn child. It may not necessarily be an overt action, but nonetheless it is damaging to the mother’s self-esteem. She begins to question her ability to be “a good mother.”

There is a minority of breastfeeding advocates/consultants who imply the harm aspect. This happened to my wife after the birth of our first son. A consultant told her she was “jeopardizing the life and health” of our baby because she was not breastfeeding him every two hours. This message makes its way into many of my patients’ homes.

Parents have enough on their plate without having to contend with the guilt or the feeling that they are inadvertently harming their newborn child. There must be a balanced approach to newborn feeding. If a mother is unable to breastfeed, and yes this does happen, she should not be made to feel that she is a failure.

Any form of dogma implies an inflexible attitude. Of paramount importance is the survival and health of the newborn. Newborns should gain about 30 grams (one ounce) per day. Family doctors and pediatricians use standardized infant growth curves to monitor weight, length and head circumference measured at each well-baby visit. Appropriate infant growth and development indicates appropriate nutrition.

The use of lactation consultants and the advice of experienced mothers can rectify many issues, leading to successful breastfeeding. Using a breast pump is a reasonable alternative, especially if mothers suffer from severely cracked nipples or poor milk flow. It can stimulate more milk production. Failing that, for those who are unable to produce enough milk, I often suggest formula supplementation.

I have yet to see nipple confusion if there is an altering schedule of breast and bottle feeding. Formula supplementation after breastfeeding provides the infant the extra few ounces needed to encourage growth. In fact, the more quickly they gain weight, the stronger they become. Their suckling ability and breastfeeding usually improves.

I stress to parents that the emotional well-being of the mother is of paramount importance. A depressed mother, secondary to guilt and sleep deprivation, is not healthy or helpful to anyone.

Recently, one of my patients was breastfeeding for two hours per feed because her newborn son had difficulty suckling. He had not gained weight after his first week of life. She cut down the time to 10 minutes a breast and bottle fed formula thereafter. Her son is now growing well. She gets more sleep and her mood is improved. Her husband assumes some of the feeding responsibilities.

I do not want anyone to misconstrue what I am advocating. Breastfeeding remains the gold standard. The emphasis on breastfeeding can at times distract us from the effect it has upon the mother. Fathers feel useless because there is little they can do to help with breastfeeding problems. Our focus should be broadened to include the emotional well-being of the mother and father and the growth and development of the infant.

There are many methods and alternatives to achieve this. Some mothers are able to breastfeed without any complications. But no biological system is without flaws. To state that every woman can breastfeed is not accurate.

Every woman should be encouraged to breastfeed but should not be subjected to judgment of her maternal skills in a punitive fashion. We must not lose sight of the main goal: a healthy growing newborn and a supported mom. It is a difficult enough job without the added pressure.

Related articles:

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Originally published in The Ottawa Citizen August 14, 2001

It is 2 AM and your two week old infant’s breathing sounds raspy and congested. You also notice a strange rash on their body. First-time parents face a multitude of these anxiety provoking events. What can you do to assess if this is normal or not?

Infants prefer nose breathing. They can become fussy, uncomfortable and noisy when a few drops of mucous accumulate in their narrow nasal passages. How do you differentiate normal noise from something more ominous?

Let’s check your infant’s breathing. Remove your babyâs shirt or top. Lay them down on their back. Make sure the room is adequately lit. A well-child’s chest should smoothly rise and fall. Normal breathing (respiration) rates for newborns ranges between 22 and 30 per minute.

An infant that is in respiratory distress will have these four signs:

1) The skin between their ribs tugs inward (indrawing).

2) Their stomach area (abdomen) pops outward while their ribcage pulls inward with each breath, then the reverse happens (paradoxical breathing).

3) There is in drawing at the semi-circular notch at the top of the breast bone (sternum).

4) Their nostrils flare in order to maximize air intake.

If all these are present, go to the ER immediately.

Do they have a fever? Rectal temperatures are preferred for accuracy. The normal temperature is 38¡ C. A serious fever in newborns and infants is greater than 39.5.

Rashes in the newborn are disconcerting. It is difficult to know whether it is a serious or benign condition.

Rashes are another common concern. In the first week of life you baby may develop these red elliptical eruptions with a small white dot n the middle (find definition in derm book AFP Article) that can spread over their entire body. This rash is called Erythema toxicum neonatorum. Despite its name it is harmless and disappears after about a week.

At three weeks some will develop baby acne. Their face upper chest and back can be covered with many small pimples. The cause of this is due to the mother’s hormones that were transferred into the baby’s blood stream. The acne miliaria lasts about a month and disappears. Interestingly it can be an indicator of the severity of the acne when they become teenagers. sucking blister mongolian spots.

Vomiting is one of those signs that causes great consternation. Is my baby getting enough to eat? Most vomiting is more aptly described as regurgitation. It may appear to be their whole feeding has graced your floor or shoulder. However, as long as your infant is gaining weight and following their growth curve, they are getting enough food.

Vomiting that results in weight loss needs further investigation. This problem is uncovered early due to the frequency of well baby check ups early in an infants life.

When do you bring your infant in to see the doctor if they have a fever. If you baby is not eating like they usually do, do not hesitate to go to your doctor. If they are more irritable and do not want to feed as usual, please see your doctor. Many times fever are caused by viral infections but in the first six months of life it is important to make sure that it is not something more serious. I recommend that you ask your doctor as many questions as you think is necessary to be comfortable with your baby’s condition. The more knowledge available to you the better you capacity to determine the seriousness of an illness. Make a list of questions for your well baby visits. Many parents forget several questions they wanted to ask because they did not write them down.

The is an excellent reference for parents and physicians alike published by the Canadian Pediatrics Society entitled “Little Well Beings” It is a veritable cornucopia of information written in a succinct and readable style

• Diaper rash (rash in the diaper area) is a skin irritation caused by prolonged dampness and the interaction of urine and feces with the skin.
• Heat rash (caused by the blockage of the pores that lead to the sweat glands) is most common in very young children, but can occur at any age. With an increase in heat and humidity, the sweat glands attempt to provide sweat as they would normally, but because of the blockage, this sweat is held within the skin and forms little red bumps, or occasionally small blisters in young infants.
• Erythema toxicum can cause flat red splotches that appear in up to half of all babies. These blotches rarely appear after 5 days of age, are usually gone in 7 to 14 days, and are nothing to worry about.
• Baby acne is caused by exposure to the mother’s adult hormones. The little white dots often seen on a newborn’s nose represent an abnormal amount of normal skin oil that is a result of these hormones. Acne usually occurs between 2 and 4 weeks of age but may appear up to 4 months after birth and can last for 12 to 18 months.
• Cradle cap causes greasy, scaling, crusty patches on the scalp that appear in a baby’s first 3 months. It usually goes away by itself, but some cases may require treatment with medication.
• Prickly heat causes rash or blotches during hot weather or in a hot environme

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Originally published in The Ottawa Citizen, June 21, 2001

Post Partum Depression (PPD) is a severe debilitating illness. It occurs in about one in ten childbearing women. It can cause women untold and unnecessary suffering and guilt. It is important to keep in mind the difference between the “baby blues” and PPD. The “baby blues” usually shows up three to four days after delivery. Mothers may feel a little down, have lost their appetite, have difficulty concentrating or have problems sleeping even while the baby is sleeping. These symptoms usually resolve by the tenth day after delivery. These blues are considered normal.

When these symptoms persist for more than two weeks PPD has to be considered. The family and friends who support the new mother are essential in detecting PPD. Family members may observe that the new mom is “just not quite right” or “not like their usual selves”. This information helps the mom’s caregiver investigate the risk of PPD. Recent news events have brought to light how overlooking the early signs of depression can lead to disaster. PPD can show up as late as six months after the delivery but there are usually warning signs before the full blown illness occurs.

Depression comes in many forms. These are signs and symptoms that are commonly seen in PPD:

* Mood swings (depression, panic and anxiety) and agitation
* Fatigue and loss of energy
* Loss of enjoyment or interest participating in activities that were once enjoyed
* Feelings of guilt, shame and worthlessness
* Suicidal thoughts
* Difficulty concentrating and indecisiveness
* Lack of motivation and drive
* Difficulty falling or staying asleep
* Loss of appetite and weight loss
* Thoughts of harming the baby
* It is important not to overlook or minimize the symptoms that you are feeling or for that matter what one tells their doctor.

Some women are more at risk for PPD. These women have either had PPD before, have a history of depression not due to pregnancy, marital problems or severe premenstrual syndrome. Isolation from extended family or friends or lack family support structures can increase their risk. Life circumstances and stressors such as loss of a job, recent death of a friend or relative or financial pressures during and after the pregnancy should alert you to the risk of PPD.

If anything this brief outline of PPD should be remembered for this reason: PPD is a medical illness. The hormonal changes that a woman experiences after birth can have a tremendous impact upon their ability to function. They are not “going crazy” as some might say. They are experiencing a lack of brain chemicals (neurotransmitters) necessary for normal mood. They can no more be held accountable for their depression than someone with Diabetes or Thyroid disease. They cannot will themselves to make the necessary brain chemicals for normal mood anymore than someone can will their thyroid gland to make more thyroid hormone.

Think of it this way. When someone is drunk, can they sober-up immediately after drinking just because you have asked them to do so? Obviously they can’t because the alcohol affects brain function by temporarily altering brain chemistry. In the case of PPD it is the lack of certain chemicals that affects their mood and behavior. If you can accept how alcohol affects the brain then logically one has to accept how the lack of certain neurotransmitters can alter behavior. This illness must be aggressively and compassionately treated. It is important to listen and offer support to the mom who suffers from PPD. Medications available today can make the difference between needless suffering and a normal healthy post partum period. They can completely reverse the depression, are non-addictive and can give the mother her life back.

Do not feel afraid or embarrassed to talk about your concerns. Talk to friends, family and your doctor or caregiver. It may just save your life.

Related articles:

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