Book Review: Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family

La Leche League released a book about breastfeeding and bed-sharing. They suggest that it is the first infant sleep book directed solely to breastfeeding families. There is one thing I do love about very topic-specific books like these: they don't waste time apologizing. They don't need to spend any time on "Well, breastfeeding is best, so if you can ...", or "We're not making any judgement if you formula-feed, because every mother is different and every situation is different ...", blah blah blah. They jump right in with Given #1: You're breastfeeding, and breastfeeding is awesome. They assume you've already done your research and decided that breastfeeding matters to you. Because, really, are you going to reach out to La Leche League if you're dedicated to feeding with formula? Probably not.

The next "given" they talk about is an interesting one. The introduction describes how they started out writing the book intending to discuss ALL types of sleep arrangements including those where the baby sleeps alone, down the hall. But in combing through the research, they could not rationally make that suggestion, that bed-sharing showed such clear benefits to both mother and baby, the entire focus of the book shifted. Given #2: Bed-Sharing is awesome. (They also define "bed-sharing" in a scientific way, forgetting the too ambiguous term "co-sleeping".)

Getting those out of the way in the first few pages really set a great tone for the book. This is not a wishy-washy, "whatever works best for you" kind of book. It makes it clear that bed-sharing IS SAFE, and sleeping separately poses greater risks to the baby and to the mother-baby breastfeeding relationship.

I liked the layout of the book (and not just getting the "givens" out of the way right off the bat). The first chapter is, not kidding, two pages long. It is basically a 1-sheet for "I need to get some GD sleep right effing now" ... a "I'm tired as hell and I'm not going to take it anymore" cheat sheet. This is brilliant. How many of us have dragged our tired selves (and our tired babies) to the bookstore to find a solution -- any solution -- that will get everyone to sleep better TONIGHT? And in that state, I don't have time to read through a 450-page book (cause this book is pretty long). I need that cheat-sheet. It covers the very basics of the "Safe Sleep Seven", their criteria for bed-sharing:

If a mother is:

1. A non-smoker

2. Sober

3. Breastfeeding

And her baby is:

4. Healthy

5. On his back

6. Lightly dressed and unswaddled

And they:

7. Share a safe surface

Then the baby’s risk of SIDS is no greater than in a crib, and any breathing hazards have been hugely reduced.

The next page is the emergency "make your bed a safe surface tonight" guide, including having your partner and pets sleep somewhere else, remove everything except your pillow, the fitted sheet, a top sheet, and a light blanket, and place baby in the middle of the bed on his back. They make it clear that they'll get into more detail in Chapter 2, but for now, get some sleep. I love this. It's so real, and acknowledges the desperation many parents feel when they haven't slept in days (and this theme of desperation and real-life dilemmas came up a few times, which was refreshing).

Chapter 2 covers these criteria in more detail. They cover nearly all the nitty-gritty details you need to set up your bed-sharing safely -- mom is sober, non-smoker, and breastfeeding; baby is full-term and on his back; and bed is a bed (not a sofa or a chair) with no big blankets, cords, or gaps. Presumably, if you meet all these criteria, you'll be fine. If you've got more time (or are reading this book before the baby comes), the following chapters go into tremendous detail about the mother-baby dyad, "normal" sleep patterns for adults and babies, different arrangements for naps and nights, and infant personalities (and how that translates to calming and sleep).

Chapters 13 through 17 go through the baby's development and how that affects sleeping and nursing -- these chapters were chocked full of great, practical tips for calming babies, setting up patterns, and getting adult things done. I wished these chapters had been earlier in the book, maybe before the chapters detailing sleep gadgets (and why they're all terrible), and specific parenting situations like working outside the house, adopting, etc.

Interestingly, the chapters on Sleep Training and SIDS and Suffocation were at the very end of the book. Readers (including me) may have preferred them to be earlier, since these are big, real-life topics that come up most often: "She cries unless she's in your bed? You've just got to let her cry-it-out and she'll get the hang of sleeping alone" and "But the APP says a baby in your bed will die of SIDS. I don't know why, but that's what they say. Don't do it." But these chapters HAD to be at the end, because everything we learned throughout the whole book led up to these arguments. We needed to learn what normal sleep behavior looked like and what safe bed-sharing looked like BEFORE tackling sleep training and SIDS.

I especially appreciated how SIDS and suffocation were addressed, because they were addressed separately. The main issue in bed-sharing recommendations is that they combine SIDS and suffocation risks (or confuse the two), so parents don't know what they're protecting their child from. The authors separate these issues in a clear and concise way. Any baby is at risk for suffocation (which includes smothering, entrapment, strangulation, and choking), and we CAN prevent it by removing soft bedding, pillows, toys, wires and cords, ribbons and ties, and small objects from the baby's sleeping area, making sure the parents are sober (or not taking any sedative medications), and keeping other children and pets separated from the baby's sleep space. They also handle the discussion of SIDS -- which is an incredibly frightening topic -- with tact, making it clear that only vulnerable babies (with an underlying cardiorespiratory or brainstem problem) in that vulnerable time period (0-6 months) who are exposed to outside stressors (smoking, stomach sleeping, etc.) are at risk for SIDS. They lay out the four biggest risk factors (smoking, stomach-sleeping, unattended sleeping, and formula-feeding), hit on the other correlations (overheating, prenatal care, obesity, etc.), and address other popular theories and (off-gassing of mattresses). I finished that chapter with a much calmer and straightforward understanding of the real risks of SIDS and the real ways we can prevent it -- even when we can't detect which babies are "vulnerable".

The "Bedsharing Controversies" chapter was interesting, but really only relevant to professionals, since I'm not sure most moms care about research methodology or financial influences. Also the references index was 22 pages long, in size 6 font, which made my heart happy.

The main problem I had this with book was one that I have found in other LLL publications (and at meetings, sometimes). While the un-apologetic "just nurse the baby to sleep" advice was refreshing (and backed up with scientific discussion of hormones), the authors did not always fully address the real life issue that comes up in different family dynamics -- namely, Dad (or other non-breastfeeding caregiver) putting the baby down to sleep. Partners are only mentioned in context of "My husband doesn't want the baby in our bed" or "Partner can hold baby while you take a nap". There is a brief mention of "nudging" child to fall asleep without mom, but only after her is a toddler. And even then, when suggesting "substitutions" such as extra stories or a later bedtime, they negate the premise by stating "On the other hand, are you substituting something that actually takes more time and energy than just nursing?" (p. 188) In answer to the question about traveling without the baby for a business trip, they suggest taking the baby with you, instead of figuring out how baby can be cared for by dad. The tear-sheet for daycare providers was helpful -- suggesting a bottle and lots of rocking for the breastfed, bed-sharing baby -- but the chapter about working outside the house and having the child in daycare spends more time emphasizing how babies in daycare are at greater risk of SIDS and how their stress hormones may stay elevated through preschool if they go to daycare. Bottom line: it's best to delay it as long as you can. While this is probably the best evidence-based advice they can give, it's not exactly practical, and probably only serves to create more anxiety for mom.

I feel like LLL often falls back on the "just nurse the baby, and everything will be fine" argument, when sometimes that is just not practically going to happen. I was surprised that this book ignored the very real question of "but what if I want my partner to put the baby to sleep?", since the rest of the book responds to similar, popular questions (e.g. "My MIL says he's never leave our bed" or "Will co-sleeping ruin my sex-life?") with real suggestions ("try saying this" and "see if you can move baby to the pack n play after she falls asleep"). Additionally, the authors make a wonderful case for realistic policy recommendations -- since the majority of breastfeeding mothers ARE going to fall asleep with their babies, let's make it safe. Why can't we extend that logic: since the majority of mothers ARE going to leave the house someday, let's give some practical tips for someone else putting this breast-fed child to sleep.

Overall this is a great book to have on the shelf, and a great read for any breastfeeding parent. Even if you do not PLAN to bed-share, it's worth a look. Studies show that 60-75% of mothers will bring baby into bed with them at some point, even if they didn't plan to bed-share. One study found that 44% of mothers who nurse on sofas or recliners fall asleep there, which is not safe. Odds are you'll end up nursing your baby in bed -- why not make it safe now, just in case?

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Book Review: "Expecting Better" by Emily Oster

There is no lack of pregnancy books out there, so when I heard about one more book expounding on the "newest" recommendations for prenatal health, I was skeptical. When I saw the post on Slate.com that it was about debunking myths about eating sushi and drinking alcohol and coffee, I scoffed - doesn't EVERYONE know that it's ok to drink alcohol once in a while, a few cups of coffee won't hurt, and sushi won’t make you any sicker than it would for a non-pregnant person? Then my dear husband had to remind me, as he so often does, "Babe. No, they don't. No one else reads pregnancy books for fun like you do." He had a point. And when I went on to actually READ the post on Slate, I learned that the author, Emily Oster, is an economist, not a doctor or a childbirth educator, and the book was about the actual studies that lead to the common recommendations about food, drugs, and general health during pregnancy. I was intrigued -- I do so love evidence-based care.

I picked up Expecting Better from the library when it was released. Again, I was surprised to find my name at the top of the list for it -- weren't other people as excited as me to find out the methodology that went into studying the effects of deli meat on pregnant stomachs?! Apparently not. Their loss, because this book was wonderful.

The author takes the reader through the story of her own pregnancy -- from stopping birth control through delivery day -- and discusses the research behind many of the common recommendations she received. For example, when asking her doctor when she would expect to resume a normal menstrual cycle after stopping hormonal birth control, the doctor gave her “vague reassurance” that it would not take long. Ms. Oster, a planner like myself, found phrases like "a little while" and “everyone is different” to be inadequate answers. She used her training as an economist to pull the studies associated with this “data”, dissect them, interpret them, and (lucky for us) explain them in simple, easy-to-digest language. (Turns out, 60% of women have a normal period the first month off the pill, and nearly 100% of women will have resumed normal cycles by nine months).

The author does a great job breaking down statistical theories in an easy way. For those of us who have forgotten (or blocked out) our last high school or college statistics class, she explains concepts such as false-negative and false-positive, how researchers arrive at those numbers, and why they are important when calculating your own risks. She also explains some of the more complex reasoning behind certain medical recommendations. For example, she briefly explains the different classes of drug restrictions, including how the Class C classification is pretty un-helpful. This information is a particularly useful nugget for a mother to have in her arsenal, even after the birth. Imagine a doctor prescribes a nursing mom a drug and says "This is a Class C drug, so you have to wean immediately." Wouldn't it be nice to know before going to the doctor that a Class C means there have not been any well-controlled human studies for this drug, instead of thinking it means it will immediately harm your baby?

Ms. Oster walks a fine line between giving us the data we need and making any true recommendations herself. She makes a good effort to explain HOW one would go about making a decision with all the facts, and gives examples of the decision SHE made vs. the decision her friend made with the same data and the same risk factors. While her personal interpretations come out at times (for example during the discussion on home birth), she stay mostly neutral on "controversial" topics, such as breastfeeding and pain management. To her credit, she guides the reader through the problems with the study responsible for the standard (negative) recommendation about home birth from the American Congress of Obstetricians and Gynecologists, pointing out where the flaws are and how their published infant mortality rate may not be accurate. Overall, the author’s tone is one of respect – mothers CAN be trusted to make informed decisions as long as they have the correct information.

My one issue with the author’s interpretation of the data is regarding epidural use and breastfeeding. Though it hard to argue with her data analysis (since that’s her job), I feel like perhaps she did not extend her analysis far enough. She states convincingly that getting an epidural does not delay the onset of lactation or cause babies to be lethargic (there is some anecdotal evidence that babies born after epidurals do not latch as well, though according to Ms. Oster there is not enough randomized data to conclude this). However, her conclusion that “there is no affirmative evidence that nursing is impacted by the epidural” is simply not accurate – lactation does not automatically equal breastfeeding success. She goes on to describe that a major complication of getting an epidural is maternal fever, and that the standard care for an infant in that case is to be given antibiotics. In addition, the infant is usually SEPARATED from his or her mother and placed in the NICU for observation. The simple act of separating a baby from its mother directly impacts their ability to breastfeed. So while an epidural may not keep a mother’s milk from coming in, it may lead directly to a practice that damages the breastfeeding relationship – a huge factor for many moms contemplating their pain management.

Overall, this book is a great resource and one that should be on any educator’s bookshelf (not to mention in a gift-bag to your newly pregnant friend). The studies used are current and well-interpreted, and Ms. Oster’s writing style is friendly and accessible. In order to give informed consent, one first needs to be informed. This book is a great way to get your questions answered and begin the process of making well-informed decisions about your care.

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Book Review: "Mother's Milk: Breastfeeding Controversy in American Culture" by Bernice Hausman

Synopsis: (via Amazon.com)

    Mother's Milk examines why nursing a baby is an ideologically charged experience in contemporary culture. Drawing upon medical studies, feminist scholarship, anthropological literature, and an intimate knowledge of breastfeeding itself, Bernice Hausman demonstrates what is at stake in mothers' infant feeding choices--economically, socially, and in terms of women's rights. Breastfeeding controversies, she argues, reveal social tensions around the meaning of women's bodies, the authority of science, and the value of maternity in American culture. A provocative and multi-faceted work, Mother's Milk will be of interest to anyone concerned with the politics of women's embodiment.

Review:
    The author described the conflicting attitudes of breastfeeding advocates and feminist critics very well, highlighting how this poses a problem for everyday women and leads to "Mommy Wars", something very topical in today's media. According to Hausman, the only vocal breastfeeding advocate group is La Leche League, whose continuing ephasis on "immersion mothering" and not working outside the house is off-putting and unrealistic for many families. Conversely, feminist critics, who so readily discuss pregnancy and birth and fight for better treatment of laboring mothers, do not support breastfeeding, as it serves to encourage domesticity and exacerbate the gender differences between parents. When these two groups fight against each other, there is no one fighting for the everyday nursing mother (especially one who works outside the home). The author (eventually) made an excellent point about bridging the gap between breastfeeding advocates and feminist critics by encouraging "Health Advocacy" instead of breastfeeding advocacy. This perspective will help to keep the health benefits of breastfeeding part of the discussion, encourage practical advice, and reduce the judgement of women who choose not to breastfeed. Hausman quotes from Penny Van Esterik's Beyond the Breast-Bottle Controversy, and I think this nicely sums up the goals most breastfeeding advocates and educators: 

"The trajectory goal becomes not to have every woman breastfeed her infant, but to create conditions in individuals, households, communities, and nations so that every woman could. The first step is to create conditions that make breastfeeding possible, successful, and valued in a given society."

    Hausman touched on many different points regarding how women make the decision to breastfeed or not, including physician authority, popular texts for pregnant women, formula marketing, mass understanding of evolutionary theory, and race and class. Her overall theme seemed to be that women do not make this decision "in a vacuum", that the constant collision of culture, medical expertise, and personal beliefs make this decision so much more complicated that "what should I feed my child?" I appreciated her respect for women who choose to formula-feed, stating that they choose to not breastfeed not because they are uneducated or ignorant, but because they have taken into consideration their own circumstances and decided it's better for themselves, their baby, and their family to formula-feed. Hausman also made a nice attempt to deconstruct the bottle-feeding paradigm that women see every day. Her analysis of pregnancy books and formula marketing was eye-opening and a concrete example of how culture affects breastfeeding choices.

    While the author's overall point was well-taken, I found her tone and writing style very difficult to read, especially in the early chapters. It took until the end of the over 200-page book to understand her overall message; her initial thesis was written in such abstract terms, it took a complete deconstruction of the sentence to understand her point -- and even then, it did not seem to match her overall argument once I had finished the book. She claimed the book was for mothers (as well as for doctors, educators, advocates, etc.), but I would be surprised if most mothers would find her style accessible. The book seemed aimed more for educators and advocates than for breastfeeding mothers. As she states herself, mothers need practical advice and real social support from doctors, other mothers, and the workforce; mothers do not need ideology. As this book is mainly focused on discussions of culture and the ideological meaning of women's bodies, it seems as the book itself is an example of what would be unhelpful to an everyday nursing mother.

Hausman clearly did her research on feminist theory and breastfeeding benefits; however she seems to only site a few sources. She also has a clear bias towards La Leche League, and implies that they are the only breastfeeding advocates out there. It would have been nice to see an analysis of other advocates' texts as well. Also, while the author made a good attempt at an overall flow of the book (chapter one discussed public media, chapter two physicians, chapter three texts for parents, etc.), there were times when her discussions seemed random and not fitting to the chapter as a whole (for example, the discussion of the sexuality of motherhood and breastfeeding in the chapter about physicians, authority, and scientific motherhood seemed, while interesting on its own, a bit out of place).

Overall, this book was helpful to me as an educator and breastfeeding advocate, but it would not serve to help a nursing mother feed her baby or even help her to make an informed decision about feeding, as the book is so dense and difficult to digest.

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Like what you've read? Pregnant and looking for a class in Western/Central Massachusetts?
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