As you may have noticed, it has been a while since I have posted on this blog. Rest assured, I have a ton of great content in the works.
But what has been keeping me too busy to post and up at night? Well, Baby #3 for starters. (Now 8 months! How time flies… or with a new baby, how it passes in slow motion and sudden leaps.)
And in my stolen moments (read:naps) I have been writing content for a company called BloomLife. BloomLife makes a contraction tracker, just like those used in a hospital but for at home use. It syncs with your phone and lets you know if you are experiencing contractions, how strong they are, and how long they last.
Many of my posts for Bloom will be of interest to my readers, so I wanted to share them with you here. Hop on over and check them out!
Prenatal Genetic Testing and Screening. My take on the new kid on the prenatal genetic screening block, Non-Invasive Prenatal Testing (NIPT) and why it needs to be offered to all women, not just women over 35.
Stalled Labor. My first labor was going gangbusters until I arrived at the hospital, where it swiftly ground to a halt. This is a common birthing experience. At the time, I blamed the slowdown on stress, but another unexpected culprit may have been to blame: those glaring florescent hospital lights. Here’s more on how humans evolved to labor at night, and why laboring women would be wise to dim those darn lights!
Exercise during pregnancy. Should you avoid starting a new exercise program while pregnant? Do you need to keep your heart rate below 140? Will lifting weights prompt preterm labor? Contrary to what you may have heard, the answer to all of these questions is an emphatic NO. I discuss the all these exercise myths here, and talk about the latest research and recommendations on exercise for pregnant women.
Natural Remedies for Group B Strep. Anywhere from quarter to a third of pregnant women test positive for Group B Strep (GBS) in their third trimester. In the U.S., this means receiving IV antibiotics during labor, to prevent early-onset Group B Strep, a serious but rare infection that occurs when a newborn contracts GBS during birth. But nobody wants to receive antibiotics if they can avoid it, especially during birth, when mom needs to pass her microbiome–a diverse collection of healthy bacteria and other microbes–to her baby. So, is there anything you can do to avoid testing positive? I talk about the research on vinegar rinses, yogurt squatting, and probiotics here.
Because whether or not to sleep train can be such a fraught decision for new parents, I wanted to share my sleep training story, and to explain why, given everything we know about stress, the argument that sleep training causes long-term harm doesn’t hold water.
Sleep Training My Son
When my son was 4.5 months old, I decided to sleep train him. Even by baby standards, my son was not much of a sleeper. He’d snooze for at most 4 or 5 hours, and then wake up every hour like clockwork, wanting to nurse but not wanting milk, popping on and off my breast and screaming in frustration.
I had gone back to work a month earlier, so napping to catch up on sleep was out of the question. Worse, I was commuting an hour to the office each way.
By then, I had reached the end of my sleep deprivation rope. I was so tired I could barely string two thoughts together. I had to coach myself through even mundane tasks like checking out at the grocery store. Say hello to the cashier. Take out your credit card. Pick up the grocery bags. Leave.
I was terrified every time I got into my car to head to work that I would nod off at the wheel and kill someone, quite possibly myself. I joked with coworkers that driver’s licenses should be temporarily suspended for new parents, but the situation really wasn’t funny.
So there I was the first night of sleep training, dripping sweat as I listened to my son’s cries. Minutes ticked by, each seeming longer than the last. I pondered whether the Ferber method included soothing every five minutes just so that you would realize only five minutes had passed.
But I was determined to stick this out, to get it done. Doing it halfway was worse than not doing it at all, I reminded myself over and over. If I were to give in, I could teach my son that crying for 30 minutes was what it took to get mommy to pick him up.
That night, he woke two more times, but never again cried more than 15 minutes. The next night, he cried for 10 minutes at bedtime, conked out, and slept until morning. That morning we greeted each other with a smile, and for the first time since his birth, I really felt like smiling at his freshly woken little face.
Although by all appearances, sleep training went well for us, some critics of cry-it-out methods would contend that I was an inadequate parent who had permanently harmed my son by leaving him alone to cry.
The Cry-It-Out Controversy
“An emotionally available parent would probably not let their baby cry it out,” claims Dr. Teti, a researcher at Penn State.
“Letting babies get distressed is a practice that can damage children and their relational capacities in many ways for the long term. We know now that leaving babies to cry is a good way to make a less intelligent, less healthy but more anxious, uncooperative and alienated persons.”
When someone tells you that you have permanently damaged your child, it’s hard to shake off, no matter how much happier you and your baby seem once you start getting some solid rest.
Thankfully, as someone who has studied the effects of chronic stress in animals and in people, I knew that claims like Dr. Narvaez’s are not supported by data and instead rest on a fundamental misreading of stress research.
For most women, the first trimester is undeniably rough. After briefly honeymoon of revelling in being pregnant (two lines!), you start to feel sick as a dog, all day long.
At least, most of us do. An estimated 70-80% of pregnant women experience nausea during their first trimester, and about 50% also experience vomiting.
Not that it will make you feel any better, morning sickness does imply one big silver lining: Nausea often signals a healthy pregnancy. Women with nausea have a much lower risk of miscarrying and–as is less widely known–a lower chance of preterm labor.
These are sizeable effects. Still, a lack of morning sickness does not necessarily signal an impending miscarriage. A lucky 20-30% of pregnant women never experience any morning sickness but give birth to perfectly healthy babies.
Luck is not the only factor. The more babies you have had, the worse your nausea tends to be in subsequent pregnancies, and the more likely it is to last well into your second trimester. Your race and ethnic background also matter: White women are more prone to nausea than Black and Asian women, and Black women are more likely to have nausea that starts after the first trimester.
And finally, timing matters: Before 7 weeks, a lack of nausea does not predict miscarriage risk.
A Quick Note on Terminology
Although commonly called “morning sickness”, most medical professionals prefer the term nausea and vomiting of the pregnancy (NVP), because symptoms typically occur all day long, not just in the morning, as many first-time mums-to-be discover to their dismay. In fact, in one study, less than 2% of women with “morning sickness” had nausea and vomiting only in the morning. Others put the percentage of morning-only suffers at 14%.
The Onset of NVP and Miscarriage Risk
On average, women start to experience NVP 39-40 days after their last menstrual period, around the middle of the 5th week of pregnancy (counting from a woman’s last menstrual period), Symptoms typically begin to ease by around 12 weeks and usually disappear completely by 20 weeks.
That said, 39 days is only the average day of symptom onset. For an unlucky 10% of women, NVP begins much earlier, before they even miss their period. For the 90% women who will experience any morning sickness, though, that all day queasy, on-a-winding-road-with-a-bad-hangover feeling starts by your 9th week of pregnancy, or 7 weeks after conception.
It’s only then, in the 8th week of pregnancy, that a lack of morning sickness predicts higher chances of a miscarriage, according to a prospective study that tracked symptoms of 2407 pregnant women from early in their first trimester.
Whether symptoms start early or late did not seem to matter, provided nausea began by the 8th week. And once the first trimester was over, nausea no longer had bearing on the chances of a loss.
What Exactly Is Morning Sickness and Why Does It Predict Miscarriage?
NVP is one of pregnancy’s great mysteries. No one knows why it occurs. No one knows what, at a biological levels, causes NVP. No one knows whether NVP serves a purpose, as some evolutionary theorists have proposed, or whether it is just an unpleasant side effect of hormonal shifts during early pregnancy.
In terms of its biological underpinnings, rapid rises in hormones like estrogen, progesterone, and human chorionic gonadotropin (HCG)–a hormone produced by the embryo upon implantation and used to detect pregnancy–are often fingered as potential culprits, but the evidence for their role is only circumstantial.
HCG, the hormone with the most evidence for a role in NVP, rises exponentially during the early weeks of pregnancy and reached peak concentration between 8-10 weeks of pregnancy. This rise, perhaps not coincidentally, coincides with when NVP symptoms are usually at their worst. Conditions which cause high HCG levels like Down’s Syndrome, molar pregnancies, and twin pregnancies often cause particularly severe NVP. Still, HCG levels do not reliably distinguish women with and without NVP, and no one understands why, at a biological level, HCG would induce nausea.
Pregnancy often comes with a bloodhound-like ability to detect odors. This heightened sense of smell likely also contributes to NVP. In a small study of 9 women who had congenital anosmia–they were born with without the ability to smell–only 1 of the 9 suffered from NVP during pregnancy, a rate substantially lower than the usual 70-80%.
Despite our poor understanding what causes nausea biologically, few researchers believe that a lack of symptoms causes miscarriage.
Why not? For one, treating NVP does not lead to worse pregnancy outcomes. If anything, the opposite is true: Women who take anti-nausea medications have better outcomes, on average, than women who do not take anti-nausea medications–not because treatment itself improves outcomes, but because severe NVP severe usually indicates a healthy placenta.
So nausea and vomiting are good. But they are also bad. I mean, they really suck.
Let’s be clear: nausea and vomiting are more than a simple inconvenience. Just for starters, women with NVP, even those with so-called “mild” NVP accompanied by little or no vomiting, commonly report decreased productivity at work, taking sick time, strained relationships with their partners, and heightened anxiety and depression.
And for around 1 in 100 pregnant women, NVP is life-threatening. Women with especially severe NVP, a condition known as hyperemesis gravidarum, suffer from such severe nausea that they cannot keep food or water down, and require hospitalization. In the U.S. each year, around 50,000 women are hospitalized for severe NVP. If you are vomiting several times a day, seek help. Early treatment may help prevent NVP from becoming dangerously severe.
What Can You Do?
Women with NVP are advised to eat small, frequent meals of bland low fat foods like dry toast, bananas, and rice, to eat before getting out of bed in the morning, and to avoid strong odors (as if that were possible during early pregnancy!).
If these efforts fail to bring relief, an FDA-approved treatment is now available, for the first time in 30 years. (Many women take Zofran off label, but the FDA has never approved Zofran for use during pregnancy.)
In 2013, the FDA approved Diclegis (a delayed release combination of vitamin B6 and doxylamine, the active ingredient in Unisom) as pregnancy category A, meaning it is safe for use during pregnancy, including in the first trimester.
Diclegis is not a new drug, but an old one, pulled from the U.S. market in 1983 because its manufacturer could not afford to defend itself against what we now know to be groundless lawsuits alleging the drug caused birth defects. At its height, around 25% of pregnant women took it for NVP.
If you prefer natural therapies, some limited evidence suggests that ginger and vitamin B6 help alleviate nausea. Acupuncture, although popular, does not appear to be effective.
Three years ago, sitting with my 15-month-old son and my husband during a long layover, on our way back home from Norway, I felt a sudden gush of warm blood.
So much for my miracle pregnancy, I thought. I was only six weeks along and certain I was miscarrying.
Our return trip was already off to a poor start. United Airlines had cancelled our original flight from Newark home to San Francisco. Then, to rub salt in the wound, they refused to refund our first-class tickets.
We never fly first class, but had made an exception for this trip. We were travelling overseas with my 15-month old son and facing a 9-hour jet lag. The chance of sleeping on route, we decided, was worth the extra cash. We had bought our tickets a year in advance to lower the cost.
But United, being United, told us wewould have to request a refund, and then maybe theywould grant it. And–perhaps just for kicks–they refused to let us access the first-class lounge while in Newark, because our replacement tickets were now in Economy.
My husband–who nevers argues with anyone behind a counter and hates it when I do–spent half an hour arguing with their “customer service” that they should give us passes to the first class lounge. After all, we had paid for first-class tickets even if we no longer had them. But no dice.
So there we were, exhausted and enraged. I had not slept in over 24 hours. My son, sick for the last 3 days with a high fever, had nursed continuously the entire flight from Oslo to Newark. And then I started bleeding.
At that point, I contemplated tweeting, “United, you ate my baby,” but decided against publicly sharing my pregnancy or what I assumed was an impending miscarriage.
The pregnancy had been a surprise, but a welcome one. We had taken over a year to conceive my son. This time we had not been trying. I was still breastfeeding, and my cycles had only resumed a month earlier. We were planning to wait a few more months and then start trying for #2, expecting that it could easily be another 6 to 12 months before we conceived.
The bleeding tapered off by the next morning. I had no pain or cramping, so little fear of an ectopic pregnancy. And I still felt pregnant: nauseated, tired, and lightheaded.
I called my OB, but they could not fit me in for another 5 weeks. Until then, they told me, just sit tight. Oh, and assume that I was still pregnant, because a miscarriage would have caused several days of heavy bleeding.
I found another OB.
My new OB ran tests. My HCG levels were normal, but my progesterone was low, perhaps because of the nearly constant breastfeeding, the lack of sleep, and the stress. She could not say for sure. She prescribed progesterone supplements for the rest of my first trimester.
Progesterone helps build up and maintain the uterine lining for implantation of the fertilized egg. High levels of progesterone are required to sustain an early pregnancy. But taking progesterone supplements during the first trimester to prevent a miscarriage is controversial.
Over half of miscarriages result from chromosomal abnormalities, and no amount of progesterone will save these pregnancies. A 2013 review of randomized trials, however, found that while progesterone supplements did not alter the risk of miscarriage for pregnant women as a whole, they did significantly lower the chances of miscarriages for women with 3 or more prior miscarriages.
And for women like me, with a threatened miscarriage (defined as any bleeding within the first 20 weeks of pregnancy), who have more than double the normal odds of a miscarriage*, progesterone supplements appear to cut the risk of miscarriage in half, and oral progesterone, as opposed to suppositories, may be especially effective.
So, although I will never know for sure, my OB may have saved my pregnancy.
A Subchorionic Hematoma
At that initial visit, she also performed an ultrasound. The fetal heartbeat was loud and clear, fast and reassuring, racing along like a rabbit’s. When I heard my baby’s heartbeat, I fully exhaled for the first time in days.
Less reassuringly, the ultrasound revealed a subchorionic hematoma–a blood clot next to the placenta and the cause of my bleeding.
Pregnancies with a subchorionic hematoma are considered high risk. They have a higher risk of miscarriage (17.6% versus 8.9%), stillbirth (1.9% versus 0.9%), and placental abruption (3.6% versus 0.7%). They have a slightly higher risk of preterm delivery (13% versus 10%) and for the waters breaking before labor starts (tv-style labor).
The risk varies by the location of the hematoma. Pregnancies with recurrent bleeding or with hematomas located between the placenta and the uterine wall (retroplacental hematomas) have a higher risk of miscarriage and other pregnancy complications like placenta abruption. Because of the risk of placental abruption, bleeding in the second and third trimesters require immediate medical attention.
As worrisome as these statistics sound, most subchorionic hematomas resolve on their own, as mine eventually did. By 11 weeks, we could no longer see the hematoma on an ultrasound. And thankfully, rest of my pregnancy was uneventful. I gave birth to healthy baby girl, who in a few months will turn 3.
Do you have a story of bleeding in early pregnancy? Was a cause detected, and how did things turn out?
*About 20% of women experience bleeding during early pregnancy. Figuring out their chances of a miscarriage is far from simple.
One commonly cited statistic states that roughly 50% of these women eventually miscarry. Some digging reveals that this claim derives from a 1981 obstetrics textbook rather than recent research. (Lots of researchers cite papers that cite papers that cite this textbook, and I am willing to bet that none of them have read the original research behind this claim.)
If bleeding starts after detection of a normal fetal heartbeat, most prospective studies find a much lower rate of miscarriage, of 3.4-5.5%.
Stand at our neighborhood playground for a few minutes and you are almost sure to hear remarks like these:
“My child started walking at 8 months.”
“My two-year-old is speaking in full sentences.”
“My son was potty trained at 18 months.”
Some of these remarks have been made to me. And some, I am ashamed to admit, have been made by me. But no longer. I refuse to take part in these conversations any longer.
Why? Because they always make someone feel bad. Someone’s child always ends up on the downside of the comparison.
And that sucks.
Of course, intellectually we all know that our children are not going to be the best at everything. And for a while, I was mentally stuck there: Why was I letting these kinds of conversations make me feel bad? Surely, I know my kids were wonderful. Surely, I love them for who they are and not for what they accomplish.
But, then, I realized I was asking the wrong question.
Here’s the right question: Does talking about our children’s accomplishments lend itself to good conversation?
My goal in writing that post was not to nurse some long-standing grudge against breastfeeding advocates. Nor was it an attempt to justify my own parenting choices: I breastfed both my children for well over a year.
(And yes, as some readers have inquired, I know just how wonderful breastfeeding can be. How breastfeeding your baby can be calming and joyful, even magical. But whether I found breastfeeding magical or a chore–or, in actuality, both–has nothing to do with whether it lowers the risk of asthma, or heart disease, or anything else.)
In response to my post, someone shared this comment on Facebook:
“Anyone who thinks this [my post] a solid piece of work needs to read my latest book, Milk Matters: infant feeding and immune disorder. No one has to prove that breastfeeding (the evolutionary and physiological norm that provides free stem cell transplants) makes a positive difference. Those who assume, claim or promote artificial feeding as safe or adequate need to prove that deviating from such basic physiological norms is safe, that there are no short or long term harms from doing so. …”
I am sharing this comment not because I find it particularly compelling, but because I think it nicely illustrates the problem with arguments made by many breastfeeding advocates: They start with the assumption that breast is best. And then, inevitably, they fail to scrutinize the evidence, no matter how flimsy, that supports that assumption.
And the evidence is flimsy indeed. Most of the alleged benefits of breastfeeding are found only in observational studies, which are widely acknowledged as biased. On average, breastfeeding mothers have a higher levels of education, higher incomes, and live in safer neighborhoods than formula-feeding mothers, granting their children an early leg up in life. Separating the effects of breastfeeding from these other advantages is next to impossible.
How do we know that these observational studies are biased? Primarily because we do not find the same benefits in better-designed studies–sibling comparison studies and the PROBIT randomized controlled trial. The only clear-cut benefit seen in these studies is a lower risk of severe vomiting and diarrhea during infancy. (For a detailed summary, see my earlier post).
To be fair, breastfeeding advocates are right, in a way. Breastmilk does contains numerous hormonal, antimicrobial, immunological, and nutritional factors not found in formula. This is why breastmilk helps protect against vomiting and diarrhea during infancy.
Before the advent of clean water, sanitation, and modern medicine, breastfeeding was frequently life-saving. In countries where access to these resources remains limited, it still is. There’s no bigger possible benefit than survival.
But these beneficial properties do not imply that breastmilk has any long-term benefits for the panoply of modern ailments: allergies, asthma, obesity, type 2 diabetes, and cardiovascular disease. We cannot claim such long-term benefits without sound empirical evidence. And that is entirely lacking.
If the American Academy of Pediatrics, and others were to say, “We recommend breastfeeding because it reduces the risk of severe diarrhea and vomiting during infancy, and because breastmilk contains unique immune, hormonal, and nutritional factors not found in formula, the long-term benefits of which are unknown,” I would have no problem with their claims.
But instead, they have chosen to present poor quality evidence as fact. Playing fast and loose with the evidence in this way undermines their credibility. Worse, it violates the trust that women have placed in them.