Sunday, July 13, 2014

Breastfeeding and Contraception – The Progesterone Controversy

Sara Twogood, MD

As an OBGYN, I was well aware of the intense post partum changes that I should expect from my own body.  The biggest challenge of all, and one that my medical experience didn’t prepare me for, was the sometimes painful, emotionally turbulent, and occasionally wonderful experience of breastfeeding. Happily, I was going to the breastfeeding support groups at The Pump Station & Nurtury™. They provided me with a wonderful blend of camaraderie and information. Much of that information was new to me, but I soon came to realize that there was at least one area about which my group-mates often had questions in which I was well versed. At almost every class, someone would ask about contraception choices – what was the best to use while breastfeeding? What was safe? Knowing I was an OBGYN, our group leader would defer these questions to me. There are certainly many possible choices, but the most controversial seems to be the questions surrounding progesterone. The lactation consultant would inextricably tell women that it would decrease milk supply, citing expert opinion and legitimate sources. The medical literature I was familiar with told me that progesterone would have no effect at all on breast feeding.

So which one was it? Are progesterone methods of contraception friend or foe to the breastfeeding woman?

I did a thorough medical search and found a ton of information (some helpful, some useless). I am clearly not the only person trying to answer this question.

Before I go through this information, let me get you up to speed with progesterone contraception.

Progesterone forms of contraception:
·      The progesterone only pill: AKA “mini pill”. It is a miniature version of the combined oral contraceptive pill (our beloved “the pill”). It’s miniature because it only contains one hormone – progesterone. The combined oral contraceptive contains a combination of estrogen and progesterone. Everyone agrees that the estrogen component decreases breast milk supply, so we aren’t talking about this pill now.  The other difference is that the progesterone only pill does not have a placebo week – you take a hormone pill every day, and your period comes when it wants to (ie irregular bleeding is common … as it is with all of these forms with progesterone only). 
·      Depo provera injection: an injection you get every 3 months. It gets a bad rep because it’s been linked to weight gain (not sure if it’s causal or an association only) and depression (in a small percentage of patients only). Some patients love it. Some hate it.
·      Nexplanon: the implant. Former incarnations are Norplant and Implanon. It’s a small rod placed under the skin of your arm and secretes a small amount of hormone daily over the course of 3 years. It’s one of the most effective forms of birth control on the market today.
·      The Mirena IUD also contains progesterone. You probably recognize the name of this IUD from commercials, although I can’t guarantee your life will be like the ads - all flowers and sunshine - with its use.

Progesterone types:
There are many different types of progesterone used for contraception – names like norethindrone, levonorgestrel, norgestimate. They vary slightly depending on the delivery method (swallowed, injected, etc), but are sometimes lumped together for ease of analysis.

What do the studies show?
I don’t want to bore you with the extraneous details (I bored myself reviewing some of this information) … but here’s the gist:

Lactation is made possible, in part, because of a sudden drop in maternal progesterone levels the first few days post partum. Addition of a progesterone at this time may, theoretically, halt this natural process.


Current evidence to support either argument is weak. The studies are not uniform. The outcomes are not consistent.

·      A large international study conducted by the WHO tells us that the use of progesterone contraception, in various forms (including the pill, the injectable, and the implant), will not affect breast feeding performance or rate of infant growth.
·      A small cohort of women reported a significant decrease in milk production after taking the progesterone only pill. When most of these women stopped taking the pill, their milk supply returned.
·      In a different study with the progesterone only pill, there was no change in milk volume in the first months after initiation. At 18 weeks of use, there was a 12% drop (compared to a 6% drop for women not using hormonal contraception). However, supplemental feeding was the same in both groups.
·      In a study of urban women, when Depo Provera (the 3 month injectable) was given immediately after delivery, there were no detrimental effects on duration of lactation, frequency of lactation, or timing of introduction of formula within the first 16 weeks post-partum.

Still confused?
I don’t blame you. I haven’t given you an answer because there is no straightforward answer.

My Counseling:
I believe that large studies show us, overall, that progesterone only contraceptives CAN be a good option. They are unlikely to have a detrimental effect on breast feeding or infant outcomes. This is the information your OBGYN will site. I know I have. BUT, and I urge to remember this, some women may be sensitive to progesterone. Lactation consultants see this sensitivity consistently and with more frequency than the literature suggests. Although the data is unpublished and at this point anecdotal, I believe it is enough to question progesterone only methods. Breast feeding is hard enough as it is ... your choice of contraception should not make it harder.

I suggest you proceed with caution:
·      Non hormonal methods of contraception will avoid any risk to your milk supply.
·      If you do decide a progesterone form of contraception is right for you, follow these guidelines:
o   Wait about 6 weeks after delivery before starting, so your milk supply is established.
o   Use a rapidly reversible form, like the pill. You can stop and reverse the effects (hopefully) if you do notice a drop in supply. With the option of Depo Provera, if you notice a drop in your supply, you can’t reverse the effects any faster than the 3 months it will persist. The implant and IUD are quickly reversible, but it would be a shame (both physically and cost effectiveness) to remove these shortly after insertion.

Get educated on all forms of contraception. Come to my class, Sex and Contraception for the Post Partum Woman July 18th at 1pm at The Pump Station-Hollywood to learn more!

I write about additional reproductive and fertility issues on Dr. Sara Twogood’s LadyParts Blog. Visit me at LadyPartsBlog.com


Thursday, July 10, 2014

News from The Pump Station & Nurtury

Hello Pump Station & Nurtury™ Friends & Families,

We have some exciting news to share with our great Moms and Dads in the Conejo Valley and across Los Angeles. Over the years, we have expanded from our flagship Santa Monica location into Hollywood and then the Conejo Valley so we could support more new moms with our world-class educational programs and lactation support, and maybe even sell a cute onesie along the way. We're more motivated than ever to continue our mission, and we've been working hard to figure out the best way to do it.

As part of our planning, we've been listening to what you've been saying - which is that new moms want more of what we have to offer, closer to you. So we're excited to announce that over the next year we'll be opening up several new classroom locations across the Conejo and San Fernando Valleys, as well as in the South Bay and Pasadena areas, along with local lactation support services.

As you know, we're a small, family-owned business, and while we've enjoyed some success thanks to your support over the years, we can't open up and operate stores all over Los Angeles - it's just too expensive. So we're rethinking how we do things, and one of the important issues we've been looking at is our Westlake Village store. As some of you may have heard, our lease at that location is up at the end of the summer. We have decided to close that location in August, but we're not going anywhere! We are finalizing partnerships with other great family-oriented businesses in the area to continue to offer our parenting support classes, and we will still be there to help new moms with our breastfeeding support services. We should be able to announce these within the next couple of weeks - we're just letting you know what's going on since the word was starting to leak out and we didn't want you to be concerned.

So...we're still offering the same great classes, and consultations plus our breastfeeding support groups, with the same great teachers and nurses in the Conejo Valley. We'll just be doing it at more places. For anyone who is currently enrolled in any of our classes, we're continuing them as before. If for some reason our new locations don't work for you, we'll happily refund your remaining session balance once the move takes place, but we hope you continue to help us help you with your little ones.

We have a lot more to talk about in the next few months, including new customer-service-friendly systems and a completely revamped website on top of our new classes and locations. If you have any questions please don't hesitate to ask our wonderful staff and they will do their best to address your concerns.

Thanks for all your support; we hope you have a wonderful summer!

Cheryl Petran
CEO of The Pump Station & Nurtury™

Wednesday, June 18, 2014

Back to Sleep: SIDS & the Misconception of Choking

by Wendy Haldeman, MN, RN, IBCLC, Co-Founder of The Pump Station& Nurtury

New parents experience numerous emotions upon the birth of a new baby; overwhelming love, awe that something so small could be so very perfect, and fear that something might harm this little being. One such concern is the possibility of sudden infant death syndrome (S.I.D.S.) also known as crib death. The scary thing about S.I.D.S. is that the cause(s) is unknown. The good news is that there are a number of ways parents can protect their infants.

Research found that when babies were placed on their backs to sleep the baby was less vulnerable. The National Institute of Child Health and Human Development began a campaign in the 1990s called “Back to Sleep”. As a result over a 10-year period the incidence was reduced by 50%. In the past few years the rates for S.I.D.S. have not changed with over 2,000 infants experiencing crib death in 2010. Despite mass public awareness that infants must sleep on their backs, a new study has found that in the U.S. almost 30% of babies are placed on their sides or stomachs for sleep.

The Misconception of Chocking
If parents are aware that back sleeping is much safer for their infant, why do they continue to go against this recommendation? Ask any parent and they will tell you that they are more afraid that the baby will choke. This misconception is perpetuated by anyone who raised a child prior to 1990 as everyone believed that babies were much more likely to choke if placed on the back. This is simply not true for healthy, full-term infants.
Image Credit: http://www.healthybabiesjacksonville.org/fear-of-aspiration/

Babies are anatomically protected in several ways against choking while lying on their backs. First off, when a human is placed on the back, the trachea (wind pipe) is on top of the esophagus (food pipe). If stomach contents come up the esophagus, the baby will cough to prevent anything from getting into the trachea. Infants placed on their stomachs are actually more likely to choke then if they are lying on their backs. Second, nature further protects young babies in a unique way. Until a baby is about 9 months old she is able to breathe and swallow at the same time. This is possible because the larynx (upper end of the trachea) and hyoid bone are higher up in the infant’s throat. As the baby matures, the larynx and hyoid bone move down, allowing for increased vocal ability.
Placing babies to sleep on their sides can be just as risky as stomach sleeping. Infants can easily roll onto their stomachs from a side position. To prevent this parents will often roll up blankets or use some other device to prop the baby. Unfortunately, blankets and sleep positioners can also become a smothering hazard. Bottom line, infants belong on their backs while sleeping with nothing in the crib except for the baby.

What you can do to help prevent SIDS
Although back sleeping appears to be the most effective measure a parent can take to provide for healthy sleep there are other strategies that can be effective in reducing the risk of S.I.D.S. Don’t smoke around the baby. Provide good air circulation around the baby’s little body. Avoid overheating. Babies who sleep in their parent’s room for at least the first 6 months are less likely to experience crib death. Pacifiers are also thought to help reduce the risk. And lastly, we would not be The Pump Station & Nurtury if we did not also mention that numerous studies have shown breastfeeding to be an important factor in protecting babies against a number of things including S.I.D.S.

Tuesday, June 17, 2014

Tips to Help Your Child Swim Like a Fish By Age 3

by Lisa Cook, Founder & CEO of KidSwim

Want a three year old fish? Here’s how to get one!

1.    Start them at six months of age. Don’t wait! It is perfectly safe for most babies to hit the pool by six months. If chlorine and sensitive skin is a factor, use a private pool as the chemicals are much lower. Overall though, I have seen very few reactions in all my years of teaching that would keep a baby from enjoying the water.

2.    Ideally you want your baby to experience the water consistently (consistency is THE KEY to swimming at an early age and becoming water confident by age three or four) starting at 6 months all the way up to age 3 with only small gaps of time off. (no more than a two month break)

3.    When it comes to a child's brain, spaced study is preferable to learning in shorter, more concentrated blocks of time. This means that babies and young children learn better and retain more by small doses over long periods of time rather than intense doses for short periods of time.

4.    Don’t be Martin Scorsese, meaning, don’t direct your child. Once they start exploring and experimenting, let them take the lead. Additionally, don’t be their teacher. Your job is to bond with them in a new environment. When your child transitions into formal lessons, let the teacher teach. You should simply enjoy the time in the pool with your kids whenever you get it, without an agenda.

5.    Playing IS learning. Don’t mistake play for ‘goofing around’ or ‘lack of focus.’ We all know children learn through playing and the pool is no different. In fact children are more incentivized to learn to swim when it’s attached to playing.

6.    Breathe! Breathe! Breathe! I can’t say this enough times in enough languages. Breathing is the SINGLE MOST IMPORTANT skill for being water safe. If you skip it and rush your child through a program that does not teach breathing, you are doing them a huge disservice in their later years of life.

7.    Stay with what works. When you find a teacher you like and your child adores, do your very best to stay with that teacher until your child is at least 4.

8.    The most crucial component of creating a swimmer by age 3 is starting at 6 months and keeping them exposed to swimming and pools during the ages of 18-36 months.If you can do this fairly seamlessly, you will have a 3 year old who is familiar with all things water, with swimming, and beginning skills so you can simply move forward without regressing.

9.    Age 2 is the most challenging year for children to accomplish new skills. They are battling their own egos and are emotional creatures. Many children learn to swim by age 2 but may plateau for a good six months before having another breakthrough. Don’t be discouraged and remember that in the big picture, it’s a small price to pay for the happy water lover you’ll get by age 3-4.

10. Don’t compare apples to apples. Remember that your ultimate goal is down the road, having a child who, by age 6 or 7 is swimming confidently, adept at all strokes, diving, treading, etc... There is nothing that indicates how well your child will or won’t swim at age 2 or 3... and if your friend’s child started swimming at 2 but yours didn’t swim until they were 3, I can guarantee that by the time both kids are 6 you wouldn’t even be able to tell which was which.

One last tip - please approach this adventure with a sense of fun. Of course safety is the biggest factor and we as parents must always be vigilant, but it is our responsibility to be the lifeguards for our children.  It is not our child’s responsibility to be their own lifeguard at such a young age. For them, it should all be about fun and exercise.  Lastly, avoid using floatation devices at all cost. They give children a false sense of security and they become a crutch that you eventually have to wean them off of.  Better to not even introduce it in the first place.
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 Looking for a swim class for your infant, child or yourself? Check out Lisa's classes! Click here... 

Friday, May 23, 2014

Nursing my babies: Can it help prevent Postpartum Depression?

Written by Susan Bordon, LCSW

By all accounts, I should have had Postpartum Depression. All the risks were there.  Family History of depression? Check. Pain during pregnancy? Check. Traumatic pregnancy/birth? Check. Breastfeeding issues? Check. Baby who wouldn’t sleep? Check. If I had all of the risks associated with PPD, why was I able to escape the Fourth Trimester somewhat unscathed, while so many other moms suffer in silence from PPD/Anxiety? After hearing new research presented by Dr. Kathleen Kendall Tackett, Ph.D., IBCLC FAPA, my answer is: Breastfeeding. All this time I thought that I was breastfeeding my babies as a gift for their future wellness, a completely selfless act of love between me and my child and bonding us in a way that is unexplainable. All of that is still true, but who knew throughout my babies’ first year I was also shielding myself from developing Postpartum Depression/Anxiety?

Now, I must preface this by saying there is no judgment here if you are unable or make the choice not to breastfeed. I have complete trust that every mother they breastfeed, bottle feed or use some combination is making the best choice for themselves and their little one at that time. For me, if I am honest, with my first child, my choice to continue exclusively breastfeeding had more to do with fear of the wrath of my own Le Leche League Leader mother than nourishing my child.  Research in the field of Psychoneuroimmunology presented by Dr. Kendall Tackett at the recent Breastfeed LA conference suggests that breastfeeding is not only protective for baby, but can also be hugely protective against the development of PPD/Anxiety in the mother.   

PPD/Anxiety affects 1 in 8-10 women who give birth, making it the leading complication of childbirth, and still women often suffer in silence. While PPD/Anxiety can affect any mother, regardless of her history, there are risk factors, as I mentioned above.  A well-meaning psychiatrist recently told me “the first thing I do when a women is suffering from PPD is get her off breastfeeding. She needs sleep!” This old news pervasive way of thinking is completely out of sync with new data that states that when thinking about PPD, all roads lead back to inflammation. You know those risk factors I mentioned: pain, stress, history of familial mood disorders, sleep issues, trauma? They all cause an inflammatory response in your body. Women that experience PPD have a high inflammatory response. Guess what has anti-inflammatory effects? Breastfeeding!

Now from a practical standpoint, ok I get it, reduce maternal stress causing inflammation and decrease chances of PPD. Well, I don’t know about you, but predispositions aside, having a newborn is stressful. That is like telling me to get more sleep and I will feel better. Thanks. I know. I have always heard from my slightly smug well-rested formula feeding friends that formula fed babies sleep longer. According to a study by Doan et al. J. Perinat Neonat Nars 2007, exclusively breastfeeding mothers are getting 40 minutes more sleep than formula or mixed feeding mothers. Even though EBF babies were having more frequent awakenings, the EBF mother was able to fall back into deeper more quality sleep quicker than the formula or mixed feeding mother. Because these mothers were getting slightly better sleep, they also had decreased inflammation. So, while some might advocate giving up breastfeeding to protect sleep, that treatment may backfire, increasing inflammation and the chances of developing PPD.

From a treatment standpoint, the take away from this conference for me was that in order to treat the Depression, we must treat the inflammation first. Chronic pain can lead to depression. If the pain during breastfeeding is causing the inflammation, then let’s see if we can fix that with a lactation consultant and reduce the inflammation. Known treatments that reduce inflammation are exercise, anti-inflammatory nutritional supplements such as St. John’s Wort and EHA/DHA, and, you guessed it, breastfeeding. Breastfeeding diminishes stress and protects maternal mood. In fact, all treatments for depression are anti-inflammatory and almost all are compatible with breastfeeding.


So, thanks, mom, for instilling in me an often dysfunctional fear of parental disappointment, and encouraging me to nurse those kiddos. All in all, I am adding this to the list of reasons why I am pretty convinced that boobs are absolutely the brains behind this operation.

Your Pool, Your Rules



My thirteen year old son and his friend are hanging out today, working on a science fair project. It’s spring break, I’m taking my younger son to a museum and the park. I have no problem with the older two being home alone for a couple of hours. My son knows the rules, knows who to call and has proven over time that he can be trusted. HOWEVER, when he asked me if they can go swimming while I’m away, the answer is a flat out “NO.” “But WHY?” he protests, “you know we’re safe, you know we can both swim, you know we won’t do anything stupid....”

It’s true, what he says. I do know he’s safe and his friend as well, who I’ve known for ten years. I know they can both swim and in THEORY I know they won’t do anything stupid. But in spite of what he classifies as ‘stupid’ (i.e. taking power tools into the water, jumping from our second floor balcony into the deep end, trying to hold their breath until they pass out... ) doesn’t mean that stupid things don’t happen.

It doesn’t mean that an attempt at a cannonball can’t result in a head injury, it doesn’t mean that a surprise leg cramp can’t rattle even the most confident swimmer making it difficult for him to reach the side, it doesn’t mean that just because they are responsible teenagers with years of swimming experience that accidents can’t happen.

I am frequently asked by my clients for my opinion on what I call ‘The Whens’: When can my child swim without me in the pool, when can my children swim while I read a magazine or talk on the phone without having to worry, when can I be in the house with them in the pool and not have to watch every move? They are legitimate questions and they deserve legitimate answers. The reality is that there is no one right answer to any of these (I know you saw that coming... it’s such a parent thing to say). It’s your pool, it’s your rules.

I had a client for years who would comfortably let her four children swim (ages 5-13) without her being present, although she could hear them from the kitchen and den. I have others who feel that until the child is of a certain age there must be a parent in the pool with that child at all times, including the parent of a friend who was over for a swim date. I generally feel this way about pool situations; when it’s your children without friends over, you figure out what works best for you. I typically prefer that an adult actually be present around the pool area during the entire time, even if the children are older and competent swimmers and you can read a book (heaven!) the entire time, just the fact that an adult is there is all that’s required. If however, you add other people’s children into the mix, it’s my recommendation that you act as lifeguard because you just never know what unpredictable thing may occur when it’s not your children.

Believe it or not, the general recommendation for swimming (even adults) is that you never swim alone. While swimming is often considered the lowest risk sport in terms of injury, there are many unknown variables that can cause an accident faster than you can turn a page in your beach read. When you are hosting a swim playdate at your house, don’t feel you have to be the ‘nice guy.’ Lifeguards are not there to be your buddy, they are there to keep you safe.

Establish your rules before anyone gets in and don’t compromise. If the kids in the pool are not listening and respecting your rules, GET THEM OUT. Don’t give more than one warning or they will know you don’t really mean what you say. Above all else, if I had to pick my top rules in terms of safety it’s everyone keeps their hands to themselves and no running on the pool deck. Those two things can create a myriad of possible lifeguard interventions.

Thursday, May 22, 2014

Spring is Here, Summer’s Coming! Tips For a Smooth Transition Back Into the Pool

Original post on KidSwim.org on March 28th, 2014

Everyone’s excited about swim season. It really is the best way for children to get several hours of exercise without even knowing it. To them, its all fun and games. Here are some tips for a smooth transition after the ‘cold’ winter LA months.

1) Do a test run with your pool heater and pump. Often after a winter of no use, pool heaters need to be serviced, pumps replaced, filters cleaned or fixed. Its always better to do it before you have a group of excited children ready to dive in, only to find that your pool is 74 degrees and the pump isn’t working.

2) Remember that initially it takes several days for a pool to heat up. Once your pool is at a temperature that you like, you can either maintain that temp or drop it back to a reasonable 80 or 82 so getting it back up to where you want it only takes a couple of hours.

3) Assume your swimmers have regressed. With the exception of children above age 6, most children forget a variety of their skills for the first couple of days. Younger ones (3-5) may even forget that they can swim! Don’t be alarmed, this is perfectly normal and with a few practice runs or some refresher lessons, they will be up to speed in no time.

4) Don’t forget your older kids too. Even though they are water safe, have been swimming for years, they will be going to camp (often sleepaway), end of school swim parties, beach activities, etc.. It’s a good idea to have them brush up on their skills as well and even make some refinements with technique (until age 11 or 12, technique should be the #1 focus for lessons).

5) Check your deck. Pool covers, gates, decks themselves... There may be wear and tear and often decks need some tiles or concrete areas replaced. Look for sharp, jutting edges in the tiles.

6) Resurfacing. For some pools, after a few years, the pool itself needs to be resurfaced. This is when the smooth bottom becomes rough and sandpapery, causing abrasions and general discomfort. You’ll know right away if you need it done. It takes a few weeks to complete the process; draining the pool, resurfacing, letting it dry, refilling, treating, heating.

7) Trim the trees. Believe it or not, this is a biggie. It is lovely to have lush foliage around the pool area, but often leaves, flowers, seeds will fall right into the pool, clogging the drains, causing the pump to back up which shuts it down and turns off the heat. You can solve this problem by having a retractable cover on the pool but in general, trimming back a bit before the season hits helps tremendously.


Hope this helps! Have a fantastic season and we’ll see you in the pool!