Finding the right caregiver for your baby has to be one of the most stressful experiences as a new parent.
To make the prospect a little less daunting, I’d like to share some tips I sent to a friend back when she first started looking for a nanny.
1. Start looking for a nanny at most 1-2 months before you need her to start. Most nannies are looking to start work immediately or within a few weeks of starting their search. Unless you are willing to pay someone to hold them, or know someone who has a great nanny and is planning to let them go because of a move, finances, and so on., I would wait until close to the time you need them to start.
2. Parenting groups and word of mouth are the best ways to find nannies. Local parenting listservs are a great place to find excellent caregivers, because people who love their nannies will often help them find their next position.
When reading through posts about potential nannies, you should prioritize those that are posted by employers, as opposed to the nanny herself, and those that are genuinely glowing.
Back when my husband and I decided to try for a baby, I remember feeling so impatient. I basically wanted a baby right then. Today. That instant. The inevitable nine months seemed too long to wait, let alone the time it would take for us to conceive.
I am sure I am not alone in this sentiment.
So, if you too are feeling impatient to become pregnant, here are some science-based tips to help maximize your chances.
As women, we hear a lot about the difficulty of getting pregnant as we age, but staying pregnant can often be the bigger challenge, especially as our fertility begins to wane.
The risk of miscarriage rises as a woman ages, with a dramatic rise starting after age 37, with the steepest increase occurring after age 40. By age 45, less than 20% of all recognized pregnancies are viable.
The man’s age matters too. Having a partner over the age of 40 significantly raises the chances of a miscarriage.
My second baby slept in bed with me, all night, every night, from the time we took her home from the hospital until she was 3 months old. At first, I was almost too terrified to fall asleep, for fear that I would roll over and suffocate her.
After all, nearly all major medical organizations warn against bedsharing, on the grounds that it increases the chances of Sudden Infant Death Syndrome (SIDS).
“The safest place for your baby to sleep is in the room where you sleep, but not in your bed. Place the baby’s crib or bassinet near your bed (within arm’s reach). This makes it easier to breastfeed and to bond with your baby,” according the The American Academy of Pediatrics.
Statements like these sound definitive. But, in fact, considerable scientific controversy surrounds the role of bedsharing in SIDS.
Trying to figure out your chances of miscarrying? Sadly, you are going to have a hard time finding good information.
Many websites claim to tell you your risk of miscarriage, citing statistics that look like these:
But problems abound with their numbers.
Problem 1: These sites rarely provide their sources, so you cannot tell whether their information is reliable.
Problem 2: These sites do not breakdown miscarriage risk by other known risk factors, like the mother’s age.
Problem 3: Nearly all these sites derive their statistics from just two small studies, one which tracked 222 women from conception through just the first 6 weeks of pregnancy, and another whichtracked 697 pregnancies, but only after a fetal heartbeat had been detected–a key point, because heartbeat detection dramatically lowers the chances of a miscarriage.
The lack of good information frustrated me when I was pregnant, and I bet it frustrates you too. So I have compiled a summary of the best research on risk of miscarriage. Where possible, I break down the risk by…
A few months back, a friend asked that I write about egg freezing:
“As a single woman in my mid-30s who has always been a strong maybe on kids (with preference for yes with right partner/financial circumstances), I’m now in a place where I feel like I need to start planning for either children and partner or freezing my eggs or SOMETHING before the options run out in the next few years… But most people online seem to be writing personal horror stories with multiple IVF fails.”
Many women face a similar quandary, wondering if they should freezing their eggs before it’s too late. Here’s what you need to know about egg freezing to make an informed decision.
A few weeks ago, I was all set to write about the vitamin D needs of pregnant and nursing women. Increased sunscreen use and less time spent outdoors means that few women can meet their vitamin D needs through sunlight exposure alone. As a result, many pregnant women are insufficient in the vitamin.
The medical community is clearly concerned about women’s low levels of vitamin D: The American Pregnancy Association recently raised their recommended vitamin D intake for pregnant and nursing women from 400 IU to 4000 IU, a tenfold increase. The change was precipitated by a recent randomized control trial, in which supplementation with 4,000 IUs a day was shown to be safe and highly effective at reducing vitamin D deficiency among pregnant women.
I only wish these changes had come sooner.
I say this because last weekend, my daughter Sydney, who turned two this month, was diagnosed with Type 1 Diabetes–a disease that may be staved off, in part, by high levels of vitamin D during infancy.
By now, you’ve probably heard about the recent study, which showed that early consumption of peanuts lowers the risk of peanut allergy by as much as 86%.
The study, led by Gideon Lack of King’s College, London, and published in the New England Journal of Medicine in February, is the first randomized clinical trial conducted on preventing peanut allergy in children. Widely hailed as a game changer, the study’s findings are already affecting the advice given to parents.
Just last week my friend’s pediatrician counseled her to “stir a little peanut butter” into her 6-month-old’s rice cereal. She barely managed to avoid gaping at him in astonishment. Just two years earlier, with her first child, he had told her to avoid introducing peanuts for the first year.
After decades of conflicting advice and vague admonitions, parents may wonder whether such a dramatic change is actually warranted. Is the evidence any better now than it was ten years ago? And if the guidelines were so mistaken before, why have confidence in them now?
And, perhaps the biggest outstanding question of all: what, if anything, does this study mean for when to introduce other highly allergenic foods, like fish, tree nuts, or eggs?
Several years ago, before I was married or had even begun dating my husband-to-be, I was chatting with a reproductive endocrinologist about when I needed to worry about my fertility going into decline. I was about to turn 30. Should I be worried? And how many quality reproductive years did I have left?
She told me most women were fine at 30 or 35. At her clinic, she said, she rarely saw women with problems related to “advanced ovarian age” before they turned 37 or 38.
Despite all the chatter, I was not actually clear on why 35 was an important cutoff. Was it because getting pregnant was more difficult after 35? Or staying pregnant became challenging after 35? Or was that the age when the risk of chromosomal abnormalities like Down’s syndrome rose dramatically?
It turns out that none of these reasons are correct. Because in fact there is noreason; age 35 is not actually a cliff. It is not even a sharp bend in the curve, a point at which birth rates go into a steep decline. Those sharp bends come later, after 37, and again after 40.
One of my former colleagues became pregnant her first shot out of the barn, the first month off the pill. Her story would hardly be noteworthy, except that she was 41 at the time.
She wanted to tell other women about her experience, she confided to me. She saw it as a sign that women can have children after age 40.
I simply nodded in response, while I privately wondered if she had not just been very lucky.
But–and this is key–how lucky?
Having a baby in your 30s and early 40s–and earlier, for that matter–is always a chance event. There will be outliers. Some women will give birth naturally at 44. Some women will suffer from early menopause at age 30. But outliers tells us little about the norm.
Anyone who wants to play the conception game, especially if they are postponing childbearing, needs to put anecdotes aside and try to grasp the actual odds. Here’s what every woman needs to know:
Do couples have an easier time getting pregnant after they have already had a child?
I’ll confess, my interest in this topic is personal. We were one of these couples. We took over a year to conceive my son, but our second was a surprise.
Back when my first was born, as we were getting ready to head home after three long days in the hospital, with round-the-clock wake ups, I made the mistake of telling our delivery nurse that we were not planning to use birth control.
She immediately launched into a lecture that we needed birth control. “Giving birth can reset your fertility,” she stated matter-of-factly. And then added sternly that we needed to start using birth control as soon as we resumed having sex.
Although she briefly made me feel like an errant teenager, I did not take her advice very seriously.
Various reputable sources of medical information, such as WebMd, state that the prior births do not “reset” a woman’s fertility,asserting that the notion is a myth.
Two recent studies, however, suggest there might be something to this idea after all.
Kenneth Rothman of Boston University, led a prospective study, which followed 2820 Danish couples who were trying to conceive for up to 12 cycles.
Rothman then calculated how the woman’s age affected a couple’s fecundability ratio–a statistical estimate of a couple’s ability to conceive each menstrual cycle.
Couples in which the woman had given birth before–about half of the couples in their early 30s and two-thirds of those in their mid to late 30s–had much higher fecundability throughout their 30s:
My first labor was long. Really long. It lasted from Friday night to Sunday evening. Pain I had anticipated, prepared for, given myself multiple pep talks for, but the duration… It undid me.
As I recently watched a good friend go through a similar labor, some old nagging questions resurfaced: How uncommon is it for women to labor for days?What is a “normal” length of labor, if such a thing exists?
Oddly enough, the medical answers to these questions have just changed dramatically. This is because of a recently completed landmark study of nearly 100,000 labors. The study, which used medical record data collected between 2002 and 2008 from hospitalsm across the U.S., showed unequivocally that we labor much more slowly than we used to. Much, much more slowly.
In fact, our labors have slowed down so much that in 2014 the American College of Obstetricians and Gynecologists (ACOG) revised its definitions of normal and overly slow labor. Until then, the definitions were based on data from the 1950s and 1960s. These data were used to define a “normal” labor duration, how long it takes most women in active labor to reach a full 10 cm of dilation and then to push the baby out. By the same token, these data were used to defined abnormal labor: labors that lasted longer than 19 out of 20 of these labors (the 95th percentile for duration) were considered overly slow or stalled.
Kudos to people who can wait until the birth to find out if they are having a boy or girl. The feminist in me feels guilty about this, but I never wanted to wait that long. Pretty much the second I learned I was pregnant, I started trying to figure out if it was a boy or or girl.
The good news for people like me: ultrasounds can now detect a baby’s gender as early as 12-13 weeks gestation.
Genetic testing through CVS remains the most accurate way to determine fetal sex in the first trimester. But since this test carries a slight risk of miscarriage, many of us choose not to have it performed. (New blood-based tests that rely on cell free DNA can detect your baby’s gender as early as 9 weeks, without increasing the risk of miscarriage, but these are only about 95% accurate in the first trimester).
Until recently, forging genetic testing meant we had to wait until the second trimester screening to learn our baby genders, sometime around 18 to 20 weeks gestation. By that time, the penis, testes, and labial folds are clearly visible on an ultrasound.
The latest research, however, suggests we can learn the gender months earlier, during the ultrasound for the first trimester screen, which is performed sometime between 11 weeks 0 days to 13 weeks 6 days of gestation. The key is scheduling your scan towards the end that window.
Male and female fetuses look pretty similar throughout most of the first trimester. The genitalia are just starting to develop from their root, the “genital tubercle,” which slowly develops into either a penis or clitoris. This genital tubercle is same size in boys and girls until around 14 weeks gestation, when the penis begins to elongate.
A sonographer therefore has to rely on more subtle clues to determine gender in the first trimester. The angle of the genital tubercle is one important clue. By 12-13 weeks gestation, the angle of the penis begins to point up, towards the baby’s head, while the clitoris remains flat or points slightly down.
The ultrasound images below illustrate this. A male fetus is shown on the left, a female fetus on the right. The angle of the genital tubercle is noted with faint white lines.
In small study of 172 pregnancies, sonographers were able to accurately detect fetal gender using this angle from about 12 weeks on. Before then, sonographers correctly identified only 70% of fetuses. They were most prone to misclassify the boys: roughly half of the male fetuses were misclassified as girls. So at 11 weeks, when the sonographers guessed that a fetus was a boy, they were usually correct. But when they guessed it was a girl, they were often wrong.
But by 12 weeks this method’s accuracy shot up to 98%. By 13 weeks, there were no more misidentifications; 100% of their classifications were correct. In a follow-up study of 656 pregnancies, sonographers were again perfectly accurate by 13 weeks.
At this point in pregnancy, using the angle of the genital tubercle is more accurate than trying to detect the labia or testes, the method commonly used to determine gender in the second trimester. Classification by the latter method was only about 75% accurate until 14 weeks.
(Incidentally, several websites, like this post at CafeMom and this one at About Health, claim that fetal gender can be detected with nearly 100% accuracy at the 6-8 week ultrasound using “Ramzi’s Method”. I tracked these claims down. All of them appear to derive a paper written by Dr. Saad Ramzi Ismail, which was posted to obgyn.net last year (and has since been removed). In it, Dr Ismail claims that the placenta is almost always on the left side for girls and on the right side for boys. While her paper is formatted and reads like a legitimate scientific article, it was never published in an actual scientific journal. Moreover, it seems extremely unlikely that, if we could determine gender by something as simple as the location of the placenta, we would already know this and use this method all the time. So, as far as I can tell, “Ramzi’s method” is pure junk science.)
The Bottom Line
If you want to learn your baby’s gender, schedule your first trimester scan for 13 weeks gestation. The methods used to detect gender at this fetal age are pretty new, so some sonographers may be hesitant to give your their best guess. But don’t let this deter you. Ask! They are very likely to get it right.
Like this post? You may also like my take on fetal sex tests based on cell free DNA. With a simple blood draw, these tests can determine fetal sex as early as 9 weeks.
Efrat Z. Akinfenwa O.O, and Nicolaides K. H. (1999). First-trimester determination of fetal gender by ultrasound. Ultrasound Obstet Gynecol 13:305–307.
Efrat Z., Perri T., Ramati E., Tugendreich D., and Meizner I. (2006). Fetal gender assignment by first-trimester ultrasound. Ultrasound Obstet Gynecol.27(6):619-21.
Emerson D.S., Felker R.E., and Brown DL. (1989). The sagittal sign. An early second trimester sonographic indicator of fetal gender. J Ultrasound Med. Jun;8(6):293-7.
In 2005, the American Academy of Pediatrics (AAP) changed their recommendations from gradually introducing solids between 4 and 6 months of age to exclusively breastfeeding for “about the first 6 months of life. For the first 6 months “your baby”, they assert, “needs no additional foods (except Vitamin D) or fluids unless medically indicated.”
You might think that these recommendations were updated because of a new evidence showing substantial benefits for the baby of delaying the introduction of solids.
But, nope, this is not the case. Instead, these changes were motivated by studies showing an absence of harm to the baby and someminorpotential benefits for the mother.
The World Health Organization was the first major medical organizations to recommend exclusive breastfeeding for 6 months, for reasons they outline in a 2002 research review (updated in 2007):
No evidence exclusive breastfeeding for 6 months results in poor growth
No apparent increase in the risk of allergies*
A longer period of lactation-induced infertility, about an extra month on average
Greater postpartum weight loss between 4-6 months, about a pound on average
Lower risk of illness for the first six months, and possibly throughout the first year
When weighing the pros and cons of exclusive breastfeeding for 6 months, the social and environmental context matters. The WHO crafted its guidelines to maximize health outcomes in both developing and developed nations. But benefits that have a large public health impact in the developing world, where access to basic medical care, birth control, clean water, and nutritious food is limited and inconsistent, can have little or no impact in the developed world.
Benefits of Exclusive Breastfeeding for Six Months
For mothers living in the developed world, the benefits of exclusive breastfeeding for 6 months are small, arguably negligible.
We have been blessed with access to birth control, so lactation-induced infertility is not a critical means of pregnancy prevention and birth spacing.
And, when it comes to weight loss, although almost every mother I know would gladly shed an extra pound or 2 of baby weight, the benefit is really small, just an extra a pound on average. Surely there are other activities that do not require 8-hours a day, round-the-clock efforts that would be just as effective forms of weight loss.
Certainly neither of these two benefits warrant the stress placed on introducing solids “at the right time.”
Of the reasons given by the WHO, the only truly persuasive one is a reduced risk of illness for the baby during its first 6 to 12 months of life. Here again, though, there are important differences between the developing and the developed world.
In the developing world, exclusive breastfeeding for 6 months is literally life saving. Within the 42 nations with the highest child mortality rates, widespread adoption of exclusive breastfeeding for 6 months would prevent an estimated 13% of the deaths of children under the age of 5. This is a larger percentage than would be saved with improved access to antimalarial medication or antibiotics.
Within the developed world, the picture is more nuanced. Here, completely weaning from breast milk before 6 months, or introducing solids before 4 months, or introducing formula before 6 months substantially increases the risk ear infections, diarrhea, pneumonia, and bronchitis.
But gradually introducing solids between 4 to 6 months while continuing to breastfeed does not. Studies that compare the outcomes of infants who were exclusively breastfed until 6 months (EBF or exclusively breastfed) with those who were exclusively breastfed for at least 4 months and then partially breastfed thereafter (MBF or mostly breastfed) find that 6 months of exclusive breastfeeding neither harms nor benefits growth and development.
The only apparent benefit of delaying until 6 months was a 25-50% lower risk of diarrhea in the first year of life. The effects on ear infections, pneumonia, and bronchitis were unclear: A couple of observational studies found a lower risk, but the majority of studies, including the only two randomized controlled trials, found no effect. And longitudinal study conducted in Belarus found no differences in weight, height, BMI, asthma, allergies, or other illnesses by age 6.
“Exclusive breastfeeding for six months does not seem to confer any long-term (at least to early school age) protection against obesity or allergic disease, nor any benefits in cognitive ability or behaviour, compared with exclusive breastfeeding for three to four months with continued partial breastfeeding to six months.” – Kramer & Kakuma, 2012
Costs of Exclusive Breastfeeding
Lower Iron Status. EBF infants tend to have lower iron levels than mixed fed or formula-fed infants. Two randomized controlled trials, one conducted in Honduras and the other in Iceland, found significantly higher iron levels among MBF than EBF infants. Reassuringly, at 6 months of age, iron levels in both groups remained within the normal range, and the EBF infants were not more likely to be iron deficient or to develop anemia.
Still, iron needs rise sharply in the second half of the first year when newborn iron stores have been depleted, and lower iron status in the first six months could place EBF babies at higher risk of iron deficiency as they age. This is why the CDC considers “breastfed babies who after age 6 months are not being given plain, iron-fortified cereals or another good source of iron from other foods” to be at high risk for iron deficiency and anemia.
Increased Risk of Food Allergies. On this point, the advice given to parents has seesawed from it is best to delay solid foods, especially highly allergenic ones, to it is best to introduce these foods early, between 4 to 6 months. This is because the evidence behind the advice is of poor quality and inconsistent. A handful of observational studies find that early introduction increases the risk of allergies. A comparable number find that late introduction increases the risk. And not all of the studies find when solids are introduced matters at all.
Some researchers to speculate that there is something of a sweet spot in infancy, between 4-6 months of age, when introducing solids lowers the risk of allergies. This protective effect may be strongest for peanuts and cooked whole eggs. But until proper clinical trials have been done, it seems wise not to make too much of these findings. (UPDATE: A randomized controlled trial has now shown that introducing peanuts before 1 year of age lowers the risk of a peanut allergy substantially. More on this study here.)
Like so many parenting decisions, the actual evidence suggests that we can all relax a bit. For those of us lucky enough to live in the developed world, introducing a small amount of solids between 4 to 6 months is unlikely to harm our babies, and equally unlikely to benefit them.
That said, when giving your baby solids before 6 months, it makes sense to provide small amounts. The immune benefits of breast milk are dose-dependent: the more milk the baby takes in, the greater the protection from illness. This is why solids during the first year should not be used to replace but to supplement breastfeeding. And when introducing solids, especially to exclusively breastfed babies, it makes sense to emphasize iron rich foods like broccoli, meat, eggs, fish, and fortified cereals.
Here is most sensible statement I found on the 6-month rule, from a review article in The BMJ, the flagship journal of the British Medical Association:
“From a biological perspective, the point when breast milk ceases to be an adequate sole source of nutrition would not be expected to be fixed, but to vary according to the infant’s size, activity, growth rate, and sex, and the quality and volume of the breast milk supply.” – Fewtrell, Booth, & Lucas, 2010
When did you first introduce solids? Did the risk of allergies or infections play a role in your decision?
Pregnant women often fear that having their labor induced will lead to a c-section. In her bestselling book, Expecting Better, Emily Oster cites fear of a c-section as the primary reason she opted not to have her labor induced. Other reputable sources like the Mayo Clinic Online and March of Dimes claim that inductions increase the odds of a c-section.
But, according to the latest scientific research, these fears are unfounded. Past 39 weeks, labor inductions do not appear to raise the risk of having a c-section. Instead, being induced lowers your chances of a c-section by about 20%.
How did we get this so wrong? Until about 5 years ago, almost all the evidence on inductions and c-sections came from observational studies, which were all subtly biased, because they compared women who went into labor on their own with women who were induced.
What was wrong with this comparison?
Observational studies typically control for gestational age. This means that, in effect, they match women by the week they delivered, because the risks associated with giving birth climb as pregnancies continue past 39 weeks. Women who went into labor spontaneously at 39 weeks were compared to women who were induced at 39 weeks, and so on.
And, when matched by delivery week, women who go into labor spontaneously are less likely to have c-sections.
So what’s the problem? Pregnancies that go into labor spontaneously by a certain week are different from those that don’t.
Think about it this way: What is choice women actually face past 39 weeks? Women cannot will themselves into labor, or there would be a lot fewer pregnancies going past 40 weeks. Instead, pregnant women can only choose either to be induced or to wait it out.
So the proper study design compares these two options: being induced versus waiting it out. This is the approach taken by recent randomized controlled trials on inductions.
In these trials, pregnant women are randomly assigned to be induced past a certain point in pregnancy, for example, at 41 weeks, or to wait it out. Women assigned to wait may go into labor on their own or be induced at a later date. Using this approach, studies find, almost without exception, that relative to waiting and delivering at a later point in pregnancy, inducing labor leads to a lower chance of a c-section.
A 2009 meta-analysis (combined analysis of multiple studies) was the first to convincingly reveal the problem.
The analysis compared the results of observational studies and randomized controlled trials (RCTs). The observational studies found a roughly 20% increase in the risk of c-section following inductions; the better-designed RCTs found a roughly 20% reduction in the risk.