My archives might be a little outdated especially the older blogs. My links above are all new and current.

I have only positive things to say about Permission to Mother, an autobiographical account of a thoughtful mother and clinician who courageously writes from her heart, soul, brain, and personal experience; who is open to change in her views and opinions and is not guided by the safety of rules of any group or the status quo; she is guided by love and openness to the experiences life brings her and her family. Her process benefits her and those around her and those who read her words. And to add to that, the writing style and story telling ability here make it a very enjoyable read speckled with both the humor and seriousness of life. ~Laura Keegan RN FNP, author of Breastfeeding with Comfort and Joy

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Friday, October 7, 2005

Dads and Bonding


Fun Ways for Dads to Bond with their Baby

Dads and other familymembers want to bond and develop relationships with the newest member of the family, but may not know how to go about it.

  • Try a bath. As soon as the cord and circumcision are healed, bring baby right into the tub with you. The skin-to-skin touch is a great way to relax together. The flowing water also has a calming effect. Watch baby go limp and totally relax while holding their heads tilted back under comfortable warm running water or by doing this with a cup of water. Young babies actually seem to try to tilt their head back for more exposure. Baby can also come into the shower and be held close.
  • Burping although not necessarily "fun," men seem to get great satisfaction out of eliciting burps.
  • Nap time for baby is a great excuse to take a nap your self. Babies will have the security of constant contact just like in the womb and may even sleep more sound.
  • Wear baby in a sling. This is a great way to enjoy your precious little one while your hands are free to go about your own business and maintain a perfect view of baby at all times. Babies can and should be involved in your activities.
  • Take baby to the rocking chair. Some favorite family photos are the one with baby sleeping in a rocker over Pop-pop’s shoulder.
  • Play airplane. Lie on your back and hold your baby by the torso and lift baby like a push-up. Babies develop head control a little quicker in this horizontal, face down position. They also get a different perspective and you get to strengthen your pecs.
  • Sing, talk, and shake rattles. Babies quickly learn to follow familiar and new noises. Do this often and you can almost “see" your baby develop better eye and then head control almost daily. How proud you’ll be when your young baby turns upon hearing your voice.
  • Babies like other sensory, too. Rub a soft blanket on their skin, massage in lotion, or comb baby’s hair. The effect of any massage is very relaxing.
  • Give baby the first taste of solid food after 6 months. An excuse given for introducing bottle-feeding is that dads want to feed the baby too in order to bond. This “delayed gratification" for dad to feed baby will have tremendous health and psychosocial benefits to baby, as the AAP and WHO recommend 6 months of exclusive breastfeeding. Getting to know your baby by trying the above listed activities and subsequent ones you think of, will help baby get to know you and give mom short healthy breaks to care for herself.

    I am not including "diaper duty" because although not the worse thing in the world, it is unfortunately perceived as a chore and would not be fair to expect dad to do this all the time. Dads deserve to relax, bond, and have fun, too with baby.
  • Discovering Cloth Diapers

    Discovering Cloth Diapers

    When I noticed the cartoon print across the front of the disposable diaper, I seriously consider switching to cloth; the picture was of a baby lamb drinking out of a bottle. Every third or fourth diaper that I pulled out had the print. I didn't remember this with diapering my first two boys. But now I wasn't interested in dressing my third breastfed baby with an icon normalizing bottle feeds. I wonder if the formula companies had anything to do with getting this design on the diaper; just one more subliminal message to brand-new moms that bottles are 'cute' and 'acceptable.' 

    While my first two boys were in disposable diapers I was not aware of anyone who used cloth. I had no role model. I thought they were old-fashioned. About the only thing I had heard about cloth was that they were a burden to tote around. They are bigger, thus bulkier to tote, because they don't contain the expandable and absorptive chemical-laden beads like disposable brands.* Then you still have to store and carry the dirty ones home. I was told that disposable diapers were one of the greatest inventions for advancing motherhood. Now that I think back, perhaps a washer and dryer to expedite cleaning the soiled cloth garments would have helped more. For me washing a load of diapers turned out to be easier than carrying them to the trash can. And, it was not that much harder to take a plastic grocery bag with me when I went out to bring the dirty diapers back home in. Our garbage collection only came once a week, so it also meant that the diaper odor would accumulate! 

    By the time my third son was born, I actually knew two Super-moms who had used cloth diapers. I felt inspired. They used diaper pins. However, the first cloth diapers I purchased were 'all-in-ones.' The waterproof liner is a part of the outer diaper and they have Velcro tabs similar to the ease of disposable. No pins were needed. They are shaped to fit. I hesitently ordered six off the Internet, without ever having seen them in person. When they arrived I was surprised and intimidated at how big they looked compared to the disposables. (Being bulkier also means many 'today's' baby clothes won't fit right. Today's clothing for newborns are designed to be worn over trim-fitting paper diapers. This doesn't help to set one up for cloth diapering success.) I was very impressed with the soft flannel lining that would be against my baby's skin. I put one on him. The dipes looked comfortable. We went through the six diapers really fast. (It made me realize how much waste is put into the environment!) I was hooked on the softness. I washed them all right away. The next round I did the wash after using five so I would not have to put the paper diaper on him. Then I ordered twenty more. I couldn't wait to get them because I was doing way too many loads of laundry keeping six clean. The initial investment seemed huge. Economically the investment was sensible. 

    Another mother heard I was using cloth and gave me her surplus hand-me-downs. She didn't know anyone else who would use them. (Looking back it is sad in a way, that not to many give cloth diapers a chance.) I received a wide variety of diapers from this mom. Experimenting with the variety she gave me, helped me to appreciate the cotton diapers in person. The variety of diapers found on the internet was overwhelming --And I did eventually need about four dozen in order to exclusively and comfortably cloth diaper. 

    No more running to the store for disposable diapers. What a great feeling to pass up the diaper isle in the store and leave those big boxes on the shelf! I was also using cloth wipes and warm water to clean my baby's bottom. No chemical-laden wipes for my baby. 

    She gave me Diaper Service Quality (DSQ) pre-folded (the white rectangles) and covers that fasten closed with Velcro. I was set for a long time. When I did need bigger covers, I could still use the rectangles; they are flexible to a baby's growth. DSQ diapers are economical. You can start with rectangles and covers from birth and just replace only the covers as your baby needs a larger size. When my older boys were babies, I had purchased what I thought was the white rectangle diapers from a baby department store. I did not appreciate the difference in quality, until I was handling the DSQ diapers. The chain store diapers look good at the time, but are only stuffed with non-absorbent polyester filling. They are probably designed for leakage and failure... that way you can go back and buy their disposables for a few years and they continue to profit. (This is analogous to producers of baby food and formula 'specializing' in making breast pumps. These pumps often don't work well or don't have good directions and sets moms up for breastfeeding failure... and you can then go buy more of their other products - baby formula and food—and they profit.) DSQ diapers have layers of cotton to absorb the moisture. I cut them open myself to verify. 

    Many toddlers can't last in a regular cotton rectangle all night. There are several ways to handle this. With the wide spread use of disposables, the art of cloth diapering has been lost in consumerism. 

    A concerned relative was concerned about rash caused by wetness. She actually thought paper diapers were healthier because they 'pull wetness away.' Perhaps they pull too much moisture away. With proper use and washing, cloth is healthier by being less irritating and chemical-free. Daytime cloth diapers should be checked every hour and changed at least every two hours or immediately if soiling occurs. If you are used to disposables you probably don't change and throw a diaper out that fast. You do your errands with the comfort that a diaper will last until you're done and won't be bothered with diaper changes while you're out. With cloth you do have to estimate how many hours you will be out and prepare to have enough diapers. Cloth doesn't hide the wetness. Once you realize how much urine your baby produces, it is gross, IMO, to think about the urine being held in a disposable diaper for hours so close to your baby's skin. A surprise benefit from changing the diapers more often was that it attuned me more to my baby's needs and elimination patterns. 

    It took a few weeks to get into a changing and laundering routine. I've had some challenges in staying all natural. For example, I traveled out-of-town with my baby. But I had the fore thought to plan when I would be near a washing machine. So we made it ten days traveling in cloth - no disposables. Another time, I was on crutches for two weeks. It turned out to be much easier to wash the diapers than go downstairs and down our sloped driveway to take bags of garbage out. People warned me when you start work or when he starts eating solids you will tire of the cloth. I have started working outside the home and he has started eating solids. And I am not tired of the cloth. In fact my baby gets to model off his dipes at work so he can show other moms that this is do-able. We went from conservative all-white to experimenting with the print patterned diapers. My toddler loves the prints. Diapering is fun. I can't resist patting my sons little but with each diaper change. 

    I now have people calling me Super-mom because of cloth diapers. I have piece of mind that I am doing something else good for my baby and the environment. What a good feeling! All because of cloth! I don't want my baby days to end! 

    *A friend living in Atlanta was whining that her boyfriend lived and worked out in the country and could not move close to her. He worked at the factory that made the stuffing for disposable diapers and that the factory couldn't be in Atlanta because if it blew up, it would destroy Atlanta. Interesting, that is the stuff we put on our babies bottoms for 2-4 years. 

    Original October 2004, Revised December 2005 

    I encourage new parents to stay away from convenient chemical laden wipes. The breastfed baby tends to soil nearly every feed from the first week or so of life through 6-8 weeks of age. Think about it: feces, cloth diaper, chemicals in the wipes. That is a lot of repetitive irritation on a newborns bottom adding up to a lot of diaper rash. Naturally the question follows, "What do you use, if you don't use a wipe?" 

    My strongest recommendation: warm wet cotton baby-size wash towels and a daily bath. Warm water on cloth is so much more soothing. You may find that your baby doesn't cry getting a diaper change. Adult size wash cloths tend to be too thick to get into small crevices. Baby wash cloths easily launder. They can be washed with cloth diapers. You can keep a few wash cloths in a sealed bag with a little water to have when away from home. I also observed in cases of messy blow-outs which might need a half a bag of wipes, that cotton cloth is much more efficient and absorbing. This means less irritation to baby, quicker clean-ups, and less garbage. 

    For those who must have a wipe for traveling or emergencies, Lansinoh and Mustela have a gentler wipe. The wipes can be used alone or for the final touch. Mustela also has a rinse-free cleanser for diaper change. 

    Contrast disposable diapers and chemical laden wipes to the softness of cotton diapers and wash clothes and a soft pat on babies butt. Diaper changing can be a time of continued bonding for you and baby. Your baby won't assosiate diaper changing with harsh skin irritation. Cloth diapers and wash cloths increase our awareness for babies needs. Some parents state they don't have time to change a wet cloth diaper every hour or two. But once you see how much urine is in a cloth diaper, realize, it is the same amount going into a dispoble diaper--just covered up by absorbtive beads. Do you really want your baby carrying around that much urine for three or more hours? 

    One last note on cloth diapers: Bummis covers make excellent swim diapers! Consider buying a size smaller. 

    If switching cold turkey to cloth is overwhelming--just go slowly. Try the diapers or the wipes first. Just get a few and see how it goes...It's worth the "investment." 

    Tuesday, March 8, 2005

    My Son's Tongue-tie

    Freeing the Infant Tongue: Frenotomy and Breastfeeding

    Original version published in Birthkit Fall 2005
    by Denise Punger

    Firsthand Experience

    Birth experiences and other events often alert us to our lack of knowledge and motivate us to initiate change. My second son was born with ankyloglossia (tongue-tie). At the time I didn't know much about the issues surrounding this minor congenital defect. My son's cry caught my attention. There was something aesthetically bothersome about his cry: His tongue was held back by a piece of tissue in the midline underneath his tongue - a sublingual frenulum. As he tried to move his tongue forward, the tissue held his tongue down, making his tongue look notched or "heart-shaped" at the tip and wide-based laterally. I just didn't like the looks of it and knew something had to be done to fix this. I asked the postpartum nurse if she knew anything about it. "That's a tight frenulum," she explained, "but no one does anything about them anymore." 

    Being fresh out of residency and never having encountered any discussion on newborn frenula, I tended to believe her. But I wasn't satisfied and kept asking around. The hospital lactation consultant was familiar with the breastfeeding problems a tight frenulum can cause. I wasn't having a nursing problem, but I still wanted my son's tongue released. In retrospect, I think breastfeeding was not a problem for him because my milk supply was well-established; my 22-month-old nursed throughout my pregnancy and beyond. All my baby had to do was open wide, and the milk poured in! 

    I asked an otolaryngologist (ENT doctor), with whom I had rapport, about releasing this tissue, and he was willing to do it. The lactation consultant thought I was lucky to get my needs resolved. She concurred with the postpartum nurse that physicians generally don't treat tight frenula, but further explained that there is a huge void in resources to help babies who are having breastfeeding problems because of a tight frenulum. It concerned me that it was easier to get the frenulum released for cosmetic reasons (perhaps a little vain of me!) than for greater ease and success with breastfeeding. 

    My baby was scheduled to have his frenulum clipped in day surgery with a small dose of mask anesthesia. I thought this a bit much. I had a notion that I should just do this at home with a scissor, but being a vulnerable postpartum, I went along with the medical protocol. At the last minute we found out that day surgery didn't take babies under a year, so we were delayed a few more weeks and rescheduled for the operating room (OR). The OR required the formality of a hospital admission, so we admitted my little six week old to pediatrics and obtained blood work from him. The OR procedure also required NPO(nothing by mouth) status "to prevent aspiration." All this for a tight frenulum really did seem like overkill! The procedure my son actually had was a z-plasty. A frenotomy is a simple snip with scissors of a thin membrane, but my son's surgeon actually cut into the base of the tongue, realigned and put in a stitch. The procedure was very brief. 

    Research and Practice

    As the months passed and I continued to tandem breastfeed, I found myself involved more and more in the professional lactation community. I was surprised to hear how many babies had a tight frenulum and resultant problems breastfeeding (and subsequent weaning in the first week of life!) and how hard it was to find providers to snip the frenulum - just as the lactation consultant had told me. As I researched the references current at the time, I found that most of these babies need just a simple cut (with curved Iris scissors) of this transparent tissue. The tissue has no blood vessels or nerves, so cutting the thin membrane doesn't hurt the baby. The first office frenotomy I did was on an obstetrician's baby. I told him of the references I had studied, including the highly recommended "how-to" video by Evelyn Jain, MD, IBCLC. He watched the movie, too, and agreed it didn't seem to be a major operation. Like me, he wasn't interested in doing a procedure on his own baby. His wife was reporting breastfeeding problems, and the release helped. Their family had a history of tongue-tie, which is common. In our case, we could trace it to my father-in-law. The most uncomfortable thing for the baby is to be held down and have the tongue retracted. I find that simply swaddling the baby in a receiving blanket is sufficient restraint. If the baby cries, it actually puts the tongue in the best position for cutting the frenulum. No infection or life-threatening bleeding after a frenotomy has been reported, but I am required as a health care provider to warn parents of potential for bleeding, infection and even death in any procedure. Parents must sign a routine consent form. 

    I explain, "The breastmilk will provide anti-infective properties, and the action of breastfeeding will apply appropriate pressure to stop bleeding." Professionals respecting lactation will let the baby nurse immediately after. There is no NPO before the office procedure, either. In my professional experience, the most blood I have seen is one controlled drop the size of a pearl under the tongue after the snip. In some cases I have seen no blood and second guessed whether I cut the tissue. 

    I keep Hurricaine (benzocaine) gel in the office in case the baby needs an anesthetic, although I prefer not to use it. In a young baby with breastfeeding problems, an anesthetic can make it even more difficult for the baby to nurse and for me to assess the latch and transfer of milk afterwards. The Hurricaine® gel can also be applied afterward to control a bleed, if necessary. In addition, I have gel foam in the office as an option to control bleeding. 

    Some conservative sources claim that if the frenulum is nontransparent or you can see structures like blood vessels, this is a contraindication to frenotomy. But experienced providers have ways to handle this. While I admit that I have cut through some tissue somewhat thicker than my protocols state, I have not seen any extra bleeding or other complications. I think time, more experience, more case reports of safety from frenotomy providers and a more relaxed legal community may redefine contraindications. I have also released a few frenula only to observe tight bands hidden underneath. Sometimes I have snipped deeper and sometimes not. Reducing the obvious one is a good start and may be all that is needed to improve breastfeeding. A referral to an ENT or Oral Surgeon can always be made to release the tighter, thicker bands if problems continue. 

    Neglected Procedure

    After doing about 15 frenotomies the first year, the hospital's malpractice carrier wanted "research" behind this "non-routine" procedure and told me to stop until they received this information. That was not the last time a malpractice carrier challenged the safety and appropriateness of my doing this office procedure. As a family practice doctor, I can easily get malpractice to cover laceration repairs, mole and skin tag removal and punch biopsy, all of which involve an injection of lidocaine and stitches, but the frenotomy they challenge because it is not routine. The only reason it is not routine is because most physicians are quick to suggest a bottle to correct any breastfeeding problems, negating the need for frenotomy. As with natural birth and breastfeeding, the medical community discards the importance of something they don't know. 

    While doing my research, I had heard that midwives in the old days would cut the frenulum when ankyloglossia was identified immediately after birth. This is the best time to do a frenotomy. Prevention of an incorrect suck and the associated pain can go a long way. Since my practice is office-based family medicine, most of the frenotomies I have done have been on babies a few days or weeks old. Often parents will come to me as soon as they are discharged from the hospital, but I've done them a few hours old if the baby was home. 

    Is a frenotomy a panacea to correct breastfeeding problems? No, a few babies needed further referral to oral motor therapy. A delay in doing the frenotomy may compound the condition, leading to a cascade of problems including weak suck, poor milk supply, mastitis and so on. I would prefer to do them as soon as the need is identified--as soon as possible after birth. The oldest child I have done a simple sublingual frenotomy in my office on was a three year old with speech delay. I did an upper lingual frenotomy on a two year old. 

    Will all tongue-tie cause breastfeeding problems? Probably not, but another risk of not doing a frenotomy is potential speech problems (try talking while holding your tongue down at the base of your mouth). Brian Palmer, DDS, is also concerned about cavities and occlusion and sleep apnea. A tongue free to move involuntarily sweeps the gums and teeth, freeing food particles. Without this tongue lateralization, cavities are more likely. A tight frenulum also puts pressure on the gums and developing teeth, making the need for braces more likely. This was the case with the two year old. Mother wanted it released to help prevent buck teeth. 

    Further Reading

    Tongue-tie: Impact on Breastfeeding - Complete Management Including Frenotomy (video), by Evelyn Jain

    Procedures for Primary Care Physicians, by John L. Pfenninger and Grant Fowler

    Neonatal Ankyloglossia, The Academy of Breastfeeding protocol.

    Frenum Presentation, by Brian Palmer.

    Congenital Tongue-Tie and Its Impact on Breastfeeding, by Elizabeth Coryllos, Catherine Watson Genna and Alexander C. Salloum. American Academy of Pediatrics,

    Updated March 2006 

    If you enjoy this article, you will enjoy the book Permission to Mother which includes the updated version. 

    (This is a video of the assessment and procedure. I'd like to point out a few differences in my procedure. For the frenotomy, we swaddle the baby in a blanket. One of the parents may stay in contact with the baby at the baby's head the entire time and my office assistant can be at the torso holding the babies arms under the blanket. The "snip" is the same. I give the baby right back to the mother for comfort and a feeding. 

    I don't spend that much time blotting like the video shows. The baby in the video is real angry. I try to minimize the crying with parental comfort, swaddle, and speed. --D.P.)

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