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Monday, 20 August 2012

A breast abscess: the physical manifestation of postnatal depression

A small, silver scar at the top of my left breast, just down from my armpit, is all that remains of a story that could curl the toes of many.

If you're squeamish, read on with caution. There's no overly graphic photographs: but I'll spare no detail in the prose. So perhaps don't read this and eat.

I've never shared much of this story because it always seems so secondary to the bigger problems I was suffering at the time: the debilitating mindset of postnatal depression. (You can read more about that here and here.) I'm sharing this story now because I think it is an important illustration that even the most severe of breastfeeding complications needn't always equate to weaning; and that often, breastfeeding complications are intricately tied with what's going on in our mind.

When my first baby was about a week old, I awoke feeling a bit achey and feverish, with some pain in my left breast. My milk was flooding in, so both breasts were a bit tender anyway. My mum took one look at me and said I had mastitis. Instantly, I was terrified. The idea of going to the doctor, of getting dressed and getting out of the house with this baby was more fearful than I could contemplate. I was annoyed; I didn't need this. I was struggling enough with this new baby – I didn't have time to think about what was wrong with me, too.

Only a few days out of hospital, I called the midwives on the maternity ward, unsure what else to do. The midwife pithily told me to use cold packs between feeds for the pain, to use warm packs before and during feeds to aid milk flow, and to aim the baby's chin toward the blockage during feeds. She said to go to the doctor for antibiotics if my temperature rose above 38.1 degrees.

So now I had a basic set of things to do; but I still didn't know what mastitis actually was, what caused it, what I should expect, or how quickly I should recover. But, conversely, I also didn't know that I needed to know these other things.

This went on and off for a few weeks. Some days I would feel feverish and achey, others not so much. If I was feeling feverish I'd start with the hot/cold packs; but that was about it. It began to just become another annoyance of mothering; another straw on the camel's back that was my overwhelming burden.

The day before my 6-week postnatal checkup with my GP, I suddenly felt annoyed with this persistent lump in my left breast. My entire life had been flipped upside down and I felt like nothing was going right. So, in the shower, I dug my fingertips into it; pressing and pushing and feeling intensely angry that it wasn't going away. I remember crying.

Bad move.

The next day, at my GP's appointment, he asked me if I was happy, and I shrugged and responded that I didn't know. We talked briefly about postnatal depression, and I pretty much brushed it off. He then asked me how breastfeeding was going, and I mentioned the mastitis. Once he took a look at the affected area, now a blue-purple lump that was exquisitely painful to touch, he calmly said it had abscessed, and he recommended draining it with a needle – much like a big pimple. Was I okay with that?

Was I okay with that? With, you know, sticking a needle into the painful, festering bruise on my breast?

So whilst my husband held our 6-week old baby, I removed my shirt and lay on the clinic table. A nurse instructed me to put my left arm back behind my head, and she placed a surgical sheet with a hole in it over the raised purple lesion on my breast. She carefully covered my skin with antiseptic, whilst I winced with pain at her touch.

I wondered how my life had come to this.

My doctor came in, he was friendly and reassuring but I was still petrified. The nurse murmured to him, "Are you going to use a local anaesthetic?"
"No, the local would hurt more than the aspiration," he answered.
Oh, shit. "Just give me a stick to bite on," I joked weakly.
They all tittered. (Pun intended).

As I took some deep breaths, the sting of the needle bit into tender flesh. But I must admit, after the initial twinge, the pain was bearable – almost a relief. He spent a minute or so drawing up fluid, and he commented that more pus had come out that he had anticipated.

"You'll feel much better with all that out," the nurse said.

I hoped so, but I knew there were more problems filling me at that moment than just pus.

Over the following weeks, as the fog around me thickened, the abscess never seemed to truly heal. Some days it was itchy, some days it was tender, but it never seemed to get better or worse. The area stayed a red or purple, and sometimes was scabbed over.

This isn't my breast, but is quite similar to how my abscess looked
Image source
My baby was often fussy feeding from that breast, particularly on the days when I was feeling achey or sore. But we managed, the other breast seemed to compensate beautifully.

And then suddenly, one day when my baby was about three months old and I was staying at my parents house, my breast began to swell again. The area around the wound became hot, pink and inflamed, and it the pain increased tenfold. But I ignored it. I didn't have the headspace for a physical problem, and besides, it would hopefully just go away again.

Later that night, in bed I lay on my right side, rolled a little forward breastfeeding the baby from my left breast. I could hear her beginning to snuffle, and I thought nothing of it at first, thinking she must just have a runny nose. But over the space of a few minutes her snuffling became more pronounced, and she began to fuss.

I flicked on the bedside lamp, and to my horror, saw her face was covered in pus. Thick yellowish liquid was all over her eyelashes, and all over her mouth and chin and nose. Pus was streaming from the wound in my breast. I shrieked. My mum came into the room, she helped me clean up and we put a dressing over the wound on my breast. I'm sure I spent some more time crying and feeling like an enormous failure; but I just don't remember it.

A few days later, I awoke again in the middle of the night. My shirt felt slick and damp, and as I sat up, I could feel it was heavy and wet all the way around to my back. In the bathroom, I removed a t-shirt covered with pus and blood. As I cleaned the wound, more pus would ooze out. Bending over the sink, I gently applied pressure either side of the swelling, and like a big pimple, it ruptured. I managed to massage out as much fluid as I could, put on a clean shirt, dressed the wound and went back to bed, mortified.

More weeks passed, and sometimes the abscess would leak, but I paid very little attention to it. And then, at 16 weeks postpartum, I finally approached my GP for help with my mental state. As well as prescribing a mild anti-depressant, he referred me to a surgeon to have the abscess incised and drained. He apologised for letting it get this far. I knew he was just being nice; it was I, after all, who had kept it all hidden.

The ultrasound I had before meeting the surgeon revealed a fluid-filled cavity in my left breast the size of a cricket ball. I distinctly remember the sonographer's eyes widening when he enquired how long this had been there, and I apathetically replied, "about three months."

The day before I saw the surgeon for the first time, the abscess ruptured again. It was another huge drain, and left me feeling queasy and revolted. However, my depression was starting to lift, so I was finally able to see the abscess for what it was: a wound, a transient condition that I just needed to pay a little attention to and kick. Just as my depression was not who I was, I wasn't this abscess, and this abscess wasn't me.

Of course, the next day the surgeon saw me, cheerful and without a swollen breast, and decided he wanted another ultrasound. "I'm reluctant to slice you open if I don't need to," he said. I appreciated his sentiments immensely.

This time, the ultrasound was done in a bigger clinic, equipped for more than just imaging. A doctor did the ultrasound, carefully assessed the cavity, and inserted another needle under the guidance of the ultrasound image. I watched him draw almost 20mls of fluid from my breast.

But when the doctor saw the fluid filling the syringe, he seemed happy. Now, the fluid was clear, slightly pink, not at all like the thick, sickly yellow pus I'd become accustomed to. "This is good," he pronounced, "this isn't infected. I'll just drain all this out and you'll be fine."

And I was. I returned to the surgeon, who shook my hand with a smile and said he hoped never to see me again. The feeling was very mutual.

The abscess was gone. I had a handle on my PND. In my mind, it is absolutely no coincidence that the timing of the two recoveries was so well matched. The pressure and pain building in my breast, festering under the surface away from obvious awareness, was a physical manifestation of what was going on in my mind.

I have read many stories from women suffering severe or repeated bouts of mastitis, or abscess, who have felt no choice but to wean. Obviously, people did ask me if I was "still" breastfeeding during my treatments for the abscess. But truth be told, stopping breastfeeding never entered my mind. I knew that weaning would only exacerbate the problem: my milk could take months to dry up completely, and in the meantime, I'd have breasts swollen with unmoving milk, I'd have a baby whose health would be compromised by weaning from my breastmilk, but most of all, I would have nothing left to give my baby. Weaning wasn't an option – I simply had to breastfeed.

And besides, in my mind, I never really made a conscious connection between the abscess and the act of breastfeeding my baby: the abscess was more about my inner turmoil and pain, than the simple act of lactogenesis.

Stories of breast abscess are quite rare; stories of women continuing breastfeeding through treatment even rarer. So I hope my story may help other mothers, who may be going through something similar, and are perhaps hoping to keep breastfeeding: even when everyone around them wonders why.

Further information on mastitis and breast abscess:–mum/mastitis

Friday, 18 May 2012

Breastfeeding to Sleep: Peaceful and Natural… and How It Does Pass

This article was published in the Australian Breastfeeding Association's Essence Magazine, May 2011. An update on sleep in our house appears at the end of the article. 

Breastfeeding. The best sleep prop. Ever.

I think almost every new (or even not-so-new) breastfeeding mother has been given the well-meaning advice of “don’t feed him to sleep!” at one time or another. Tales of ‘bad habits’ or ‘spoiling’ are quite common in our society regarding infant sleep, with a trend of encouraging baby to fall asleep independently and alone.

But it is becoming more widely-accepted now, with advancements in neuroscience and attachment theory research, that babies actually can’t put themselves to sleep easily when they are tired – it is a developmental skill that they must mature enough to acquire, just like other milestones such as walking or talking. In their book Helping Your Baby to Sleep, Anni Gethin and Beth Macgregor say “contrary to popular opinion, humans are not designed to be able to go to sleep without assistance in early life. Making the transition to sleep is rarely something babies’ immature brains can do without some form of help.” (1)

When it comes to sleep deprivation, I am, like many parents, an expert in that field! My now-three-year-old woke 1-2 hourly from birth, starting to sleep longer only recently. The first few months of her life were a blur of constant breastfeeding, walking and rocking – day and night. I tried learning her ‘tired cues’ but found these all looked the same – Feed me! Hold me! By the time she was about six months old she was more settled, but the only way to put her to sleep was with a breastfeed. She slept alongside me every night from birth, waking and breastfeeding anything up to ten times a night. I worried that I had created a terrible habit. How would she ever learn to fall asleep on her own? Was I going to be feeding her to sleep forever?

Humans have two states of sleep. REM sleep (raipd-eye-movement, or active sleep) and non-REM sleep (quiet, deep sleep). During the night, we move through these different sleep states several times. It is in the transition between REM and non-REM sleep, that a person (ie. baby!) is easily roused. Babies have a high percentage of REM sleep, and it can take several months before they start to sleep more deeply, and for longer stretches. Even then, adult levels of REM and non-REM sleep are not attained until about 2-3 years of age (2). Unlike adults however, babies enter sleep through a REM state, which explains the reason why our babies can need so much help going to sleep, and so frequently.

When a baby breastfeeds, a number of wonderful hormones are at play. Oxytocin, the hormone that causes the mother’s let-down reflex, is released in both the mother and baby, as well as being present in breastmilk itself. Oxytocin is sometimes known as the ‘love hormone’, and is responsible for feelings of warmth, comfort and pleasure. Another hormone released in both mother and baby during breastfeeding is cholecystokinin (CCK). CCK release also happens when the stomach is full – it is what causes that drowsy feeling when you’ve just had a big lunch! In babies, sucking-induced CCK peaks at the end of a feed, often causing them to feel sleepy or drift off to sleep. These lovely hormones, combined with the pleasure of sucking and a cuddle from mum, all form the basis of a perfect infant-sleep-inducing atmosphere. Nature provided us with this clever concoction to use, to help our babies sleep, until they mature enough to do it on their own.

I soon discovered that one of the keys to coping with constant waking was realizing that it was perfectly normal, and accepting that it would pass – eventually! At three months of age, around 80% of babies wake up at night and need a parents help to get back to sleep. At six  months this figure is 75% of babies, at around one year it is 50% of babies, and up to four years old about one third of children still wake and need a parents help to get back to sleep (3). Once I learned this, I spent some time altering my attitude to one of acceptance, and suddenly found life a lot easier. So she was just wakeful. It was nothing I had done wrong – it was biologically normal, completely human, infant behaviour. I made a point of finding and talking with other parents of wakeful babies, which provided support when I needed it (often!) and also helped normalise this behaviour for me.

By the time my little-one was about one year old, we had night-times down to a fine art (well, most nights!). After dinner, my husband would bathe her, whilst I caught up on some quiet time. Then we would lie in bed, breastfeed to sleep, then I would creep back out and enjoy some more time to myself. Usually, within an hour or two, she would wake and I would be back in bed, quickly feeding her to sleep again. Sometimes I would get back up again, but more often than not, this was when I would go to sleep myself. And then anything from about hourly, she would stir and fuss, I would roll over, she would attach and then we were both back to sleep. Our sleep cycles became well synchronized – I would often rouse just before her, so my own sleep felt less interrupted. I would only wake enough to ensure she was attached and comfortable and safe, before drifting back to sleep myself. People often asked me “how many times does she wake up at night?”. I would respond “lots!” but I couldn’t tell them when, or even give them a number, I was never awake long enough or fully enough to actually pay attention!

This state of zen acceptance wasn’t always easy to uphold. There were plenty of hard times, convinced I was the only one going through this. I felt like all the babies around me at her age were now sleeping through the night, often even in their own beds! What had I done so wrong? But these were the times that I found I was not looking after myself adequately during the day.

Coping with a wakeful babe is not possible without looking after yourself. Ensuring that you are well-supported and rested during the day is what makes this exhausting biological norm bearable. For day naps, I would lie down with her and read a book while she breastfed to sleep, getting much-needed rest and relaxation myself. Ensuring that a priority became taking care of me, while this early high-needs phase passed, was what made her very real needs so much easier to meet. In his book, Nighttime Parenting, Dr. William Sears says “sleep problems occur when your child’s night-waking exceeds your ability to cope”. So I conserved energy by keeping extra activities to a minimum, saying ‘no’ if necessary, and just spending as much time resting and enjoying this phase as possible.

When my toddler turned 25-moths old, my menstrual cycle finally returned. She was still waking and attaching very frequently at night, but going longer stretches during the day without a breastfeed. Her feeds at night now were often just a quick comfort suck, rather than a lengthy breastfeed. And sometimes, she would attach for just a few moments before rolling over and going back to sleep. By now she was quite verbal, and I would often remind her “it’s night time now, time for sleep.” A few times I tried offering her just a cuddle – but it was met with vehement and very loud protesting! Clearly, the need for that comfort was still very real.

A few months after she turned two, I became pregnant again. My milk supply dropped considerably by about the end of the first trimester. Although this didn’t really reduce the night waking, it made it difficult for me to fall back to sleep, as I was getting uncomfortable with her on the breast. We talked often about her breastfeeding, and about having  ‘just cuddles’ at night time. Over the space of a few months, the idea was introduced. She would suck until sleepy, but not asleep, then I would gently detach her. If she cried, I would allow her to re-attach. Sometimes she cried, other times she would just fuss a little and then drift back to sleep with a cuddle.

In the last trimester of my pregnancy, when she was almost three, it began to feel like I was actually interrupting her by attaching her when she roused. One particularly tired day, after a conversation with a fellow ABA counselor, I spent all day chatting with her about ‘just cuddles tonight’. It felt right, and she was very open to the idea. So that night, I breastfed her to sleep in the evening, but after that, at each waking I reminded her that we had milk in the daytime, and cuddles now at night. She barely whimpered. She was clearly ready to accept this now, at almost three years old. I felt she had the capacity to understand what I was asking of her, and the ability to go back to sleep without sucking.

If she ever became distressed, I would offer her a “quick 1-2-3 milk”. That three seconds was often enough to offer her the comfort that she needed, without being too much for me. Then she would be happy with a cuddle.

She is only having one breastfeed a day now, at night before sleep. I lie with her and breastfeed for a few minutes, then ask her to detach and we cuddle and I usually sing a song, or read her a story, or draw pictures on her back. That is how she goes to sleep. She sleeps with us, but since the new baby arrived, she decided that she wanted to sleep in the side-car style cot. So now she has her “own bed” next to ours. She still wakes a few times a night, but she is perfectly happy with a cuddle back to sleep.

She often tells us now, after dinner, “I want to go to bed”. If we have guests they usually cannot believe that a three-year-old could not only be so happy about going to bed, but actually initiate it! It seems, sadly, that bedtime and toddler tantrums are the accepted norm in our society. But bedtime and sleep has only ever been a safe, warm and loving space for her to go, and she now recognizes when she needs it.

During those early years of intensely wakeful nights, I just couldn’t imagine how this phase would ever pass. But waiting until she was ready, including her in the process, and doing it gently and patiently, was the best thing we could do to ease the transition from sucking to sleep, to falling asleep without the breast. Peacefully and naturally.

UPDATE May 2012:
I wrote this almost two years ago, when my daughter was just 3-years-old. Almost five now, she is weaned, (well, pretty much. She still asks for "milky" on a rare occasion), and goes to sleep happily every night with a cuddle from myself, her Dad (this is the most common, as I'm usually breastfeeding her 2-year-old brother to sleep), or even her Nan. She loves bedtime, she loves everything about it - the stories, the cuddling. Although she has her 'own' bed - a single bed, next to the king bed in our family bedroom - she usually rolls over next to me at some point during the night. Unless she is sick, she sleeps all night. There is never any 'bedtime battles' that are so common with toddlers. She still tells us when she's tired, when she wants to go to bed. Bedtime, in our house, is truly, truly, blissful. I would never do it any other way.

1. Gethin, Anni & Macgregor, Beth Helping Your Baby To Sleep, pg 11
2. Bodribb, Wendy Breastfeeding Management, pg 100.
3. Gethin, Anni & Macgregor, Beth Helping Your Baby To Sleep, pg 3

Monday, 14 May 2012

The Liberation of Mothering Instinctively

Although, as you will see, it arguably saved my life, I don't like the term 'attachment parenting.' With all due respect to Dr. Sears, I think it's not only an easily misunderstood title, but additionally, why should we categorise parenting into styles?

Five years ago, if you'd told me I'd one day be breastfeeding a four-year-old, I probably would have fallen over from shock and shame. What? Breastfeed a four-year-old? Isn't that ... weird? Isn't that inappropriately indulgent? Isn't that just...wrong?

But it doesn't stop there. Tell me that I'd also be sleeping with this child, I think I would have headed straight to the GP to book in my preemptive tubal-ligation.

Before I had a child of my own, my views on pregnancy, birth and motherhood were those of the majority of our western culture: That pregnancy and birth are a delicate, dangerous, and revoltingly undignified medical condition; that breastfeeding was "best, but hard, and so formula is fine"; that mothers should not let their babies 'change' them, that they should ensure their lives get back to normal as quickly as possible (including returning to paid work outside the home - after all, children need the socialisation of day care). And that, under no circumstances, should she let that baby into her bed.

So how, then, did it come to this? Where my almost five-year-old still has the occasional brief breastfeed, and sleeps right alongside me in our family bed, along with her home-born two-year-old brother (who is also 'still' breastfeeding)... and I am not working?

Well, it happened like this:

By the time my first baby was merely a few weeks old, I was contemplating ending my own life. Although I like to think that I wouldn't have gone through with it, the truth is, at the time, I couldn't see any other way out. All this child seemed to need was me. My body. My every breath – all day, and all night. I was so confronted by her intense need for me. Don't babies just eat and sleep? Everywhere I turned, people were either going about their lives, without a child clinging bodily like a leech, or with so said child sitting quietly in a pram. No one seemed to have a crying, constantly breastfeeding, constantly awake baby. Except me.

People told me to 'put her on the bottle' – so I could get 'space' from her. 
People told me to 'put her in a routine' – so my days could be 'predictable'. 
People told me to 'leave her to cry' – so she would sleep alone, or for longer periods.
People told me to 'put her in child care' – so I could achieve, potentially, all of the above.

It seemed, my choices were these: 1) Emotionally and physically detach from my baby. OR 2) Somehow, stop existing.

The incredibly tragic thing is, although I managed to find a way out of the fog by giving myself permission to mother instinctively, many mothers believe their only options are these –  1) Disconnect or 2) Death.

It goes without saying, that's just not good enough.

Here's an example of the common line of thinking in our culture today:

In an introduction to yet another book on sleep training an infant, Mia Freedman writes:
"Night feeds were almost a novelty. I felt womanly and invincible, filled with love for my little girl and the world. I willingly slept on a crappy mattress on the floor of her room so my beloved husband could sleep undisturbed in our giant bed. I was so grateful to him for helping create this beautiful creature, it was the least I could do.  I was a happy martyr. And hey, since I was breast-feeding and he didn’t have breasts, what was the point of him getting up at 2 am? Let alone 3, 4 and 5 am."
There is so much wrong with this statement, I almost don't know where to begin. Notice how, in the beginning, she feels "womanly and invincible, filled with love"? Isn't that wonderful? So what happened? How come she came crashing down, so much so, that the baby was the one who, inevitably, had to suffer through the harsh consequences?

Lets pull it apart a little.
"I willingly slept on a crappy mattress on the floor..."
What? Why on earth is a woman who has just given birth to the next generation sleeping on a crappy mattress on the floor?
" my beloved husband could sleep undisturbed in our giant bed."
Oh. Because her husband needs sleep, too? Right. Well, considering he's an adult, and has not just given birth, perhaps he wouldn't mind scooting over a bit? After all, it's a "giant" bed – surely there's enough room for the two of them and the long-anticipated baby they've lovingly produced? 
"I was so grateful to him for helping create this beautiful creature, it was the least I could do."
While I'm sure it wasn't a huge hassle for him to donate that illustrious sperm, how come she doesn't see herself worthy of the same sacrifices from him? 
"And hey, since I was breast-feeding and he didn’t have breasts, what was the point of him getting up at 2 am? Let alone 3, 4 and 5 am."
He may not have breasts, but he does have a brain, and arms, and the ability to give love, support, comfort, nurturance - in the form of fetching the baby or rocking an unsettled baby, fetching drinks or snacks for his beloved, cleaning the house, cooking food, and providing the mother with love and nurturance, encouragement and support, so that she may actually have the capacity to provide the nurturance her normal human baby needs. 

Which brings me to what I feel is the crux of this issue. Natural, instinctive mothering isn't seen as valuable - it's not something that should be protected – because women aren't valued. And therefore, if a woman is struggling with her baby's needs (as they often do in our culture, but not in others), the answer is, inexplicably, to make it a problem of the most vulnerable and least mature person in the household – the infant. 

If this is what motherhood invokes in so many of us, how has the human race not only survived for half a million years - but actually thrived?

Here in Australia, we consider ourselves a developed, first world, 'lucky' nation – but what is happening to our mothers? With an epidemic of depression and anxiety, substance abuse, bullying in schools and an increasing list of behavioural and personality disorders – what is happening to us?

For a moment, I want to talk to you about a psychological construct known as cognitive dissonance.

When we are presented with a situation that goes against our intrinsic beliefs or values, it can create a real feeling of inner turmoil. You know, that feeling of "this is wrong, but I have to do it?" Psychologists have argued that US soldiers who partook in horrific torture of prisoners were suffering from cognitive dissonance - knowing it was wrong, but feeling compelled for whatever reason to do it. On a less extreme scale, perhaps you decide to speed a little because you're late for work - you know it's wrong, but you have to do it. How do you feel? Probably a little tense, at the least.

So when people told me that my wakeful, crying baby was a result of my inadequate breasts, my inadequate mothering, and that if I didn't do something - and soon – I was going to be ruined forever – I felt pretty damn awful.

Why? Because: breastfeeding her whenever she cried felt right, and holding her, and keeping her close all day and night, felt right. I tried spacing out her breastfeeds – but she just screamed more. I tried placing her in her cot, but walking away from her cries - even for 10 seconds - made me feel physically sick. How many parents have you heard say: "controlled crying was hard, but I had to persist..." or "I sat outside her door crying, while she cried..."

Doesn't seem right, does it? 

While I am the first to acknowledge that sleep deprivation from a wakeful infant can be incredibly difficult, and that the intense needs of a young infant can be beyond exhausting, and that breastfeeding an older child, or staying at home, or choosing to validate and respond to my three-year-olds tantrums is not all beer and skittles – I can say that acceptance and self-love are the key to coping. And support. The right support. 

The answer to our parenting woes should not become the issue of the helpless infant or young child. We are the adults who chose to bring them into the world.

Imagine a world where mothers were held in high esteem, valued and respected for their wisdom? Imagine a world where infants were brought peacefully from the womb, embraced lovingly in their early days of dependence, guided gently into society with compassion and reverence? 

Cognitive dissonance. It shouldn't happen to our mothers.

We need to value women, value the art of motherhood. Attachment parenting isn't about martyrdom - it's about liberating women to do what biology has gifted us with. And doing so, we liberate ourselves to love the fact that we are women.
That can only make for a better world.