Wednesday, August 25, 2010

Volumes: a huge problem

The response to my last post on "los dos" pushed me into finally finishing this one! The volumes given to babies are a huge part of what makes "los dos" so problematic, but are a problem on their own as well. We don't know exactly why breastfeeding is protective against obesity, but a big part of it may be the part with the breast. It's harder (although by no means impossible) to overfeed a baby at the breast. When you're giving a bottle, it's much easier to overfeed a baby and to override their own feelings of satiety/being full by persuading them to just finish what's left in the bottle, or what we think they should be taking.

This problem, unfortunately, frequently starts on the first day of a baby's life. Have you ever seen the belly balls made by Ameda? I think they are a nice way to visualize the size of a newborn's stomach on days 1, 3, and 10. Day 1 is a shooter marble, representing 5-7 milliliters(ml), and Day 3 is a ping-pong ball, representing 22-27 ml. As a frame of reference for those of us not used to metric, 1 fluid ounce = 30 ml, and 1 teaspoon = 5 ml.

These are tiny volumes, as is appropriate for tiny babies with tiny stomachs designed to handle small volumes of colostrum that empty quickly (the gastric emptying time of breastmilk is about half that of formula).

These volumes mean that at one feeding, even on Day 3, a baby should be getting a maximum of 1 ounce.

And yet over and over in the hospital and out of it, I am absolutely boggled (and sometimes horrified) by the volumes that people are able to push to a baby via bottle. I walked into a room the other night and a mom had breastfed her 1-day-old baby on both sides, and THEN given him 40 ml via bottle. All of us routinely see parents who are able to get babies to take 45 ml or more at nearly every feed. Even at day 3, these babies are literally eating double what they're supposed to.

What happens when babies get fed such huge volumes? First of all, they spit up. Give a brand-new baby a 10 ml feed (and remember, this is just 2 teaspoons!) and you may find most of it spilled down her front. It can be scary for the parents and probably doesn't feel that great to the baby.

Second of all, they don't eat. New babies forced to take one huge feed may not eat again for the rest of the day, spitting up constantly with distended abdomens. Babies consistently getting supplemented after breastfeeding, even with smaller volumes, take longer to wait for the next feed -- maybe 4-5 hours instead of 2-3. Physiologically, this isn't sufficient to establish a good milk supply in most women.

Third of all, they get hungry. Forced to take huge volumes over and over again, they start expecting huge volumes. Mom's colostrum can't possibly keep up, which leads to a fussy baby, which leads to more supplements, which leads to less breastfeeding, which leads to lower see where this is going.

Huge volumes are one of the banes of the hospital LC's existence, as far as I'm concerned. And yet it's so hard to address.

I don't want to be the mean LC who tells the parents they just overfed their baby and doomed breastfeeding, but I do want to educate appropriately on volumes. I want to tell parents that this is too much for a baby's stomach, and that it can create problems with breastfeeding. I want to convince the parents that such huge volumes are a bad idea.

Unfortunately, the babies don't cooperate.

Parents seem to expect a baby who takes a large feed quickly and then sleeps soundly for at least 2 hours and preferably 3 or more, and overfed babies do this very well. "Baby doesn't wake up to feed as often" doesn't really sound like a problem to them. And yet once I cross the line into warning her "You can compromise your milk supply" that risks mom hearing what she probably already believes, which is that she won't produce enough milk. AND I hear the eye-rolling message boards of the Internets in my head. ("The lactation person in the hospital told me if I gave my baby ONE BOTTLE of formula, I would NEVER produce enough milk! Boob nazi!")

Parents also expect that if the baby is hungry, she/he will keep sucking, or will be willing to take a bottle back into his/her mouth. Overfed babies will most certainly keep sucking if they have a constant flow of liquid down their throat (the bottle will flow by itself without any help from them) -- in fact, it's hard for them to stop because then they would choke -- and they have a firm stimulus in the back of their mouths. They will do this regardless of their own feelings of hunger or satiety. You can also often get an unwilling baby to accept a bottle nipple back in if you play around long enough (less frequently true for the breast).

I know that responsiveness to hunger/satiety cues is an issue identified, and under research, by people out there in the infant feeding world. I think a key piece is being able to interpret NORMAL newborn behavior (fussy does not always equal hungry! frequent waking is not pathological!) and respond to a baby's cues instead of overwhelming them.

What do we do at the hospital to solve this? We try so hard to educate everyone at their first hi-I'm-the-LC visit if they are planning to do any supplementation. (Obviously we also try to educate them about exclusively breastfeeding, but this is harm reduction.) This takes different approaches, generally from the "your baby's stomach is only this big!" school of thinking.

I've also started taking a more direct route. If I'm the one bringing the bottle (you can't win every time) I pour out everything but what they baby should take at that feeding. (That a 2 oz bottle is considered the standard for a newborn nursery just shows how insidious the formula industry is). We would not give 4 pain pills to a mom and say "but only take one". Neither should we hand her a 60 ml bottle and say "but only give 10" especially because if baby keeps sucking they interpret that as "still hungry". This also prevents the practice of re-using the same bottle for multiple feedings (this happens all the time even though the bottle clearly says it should be discarded after an hour.)

It also helps to at least ask moms to give supplements via a supplementing tube at the breast (you can rig up a cheap, easy one with a 10 ml syringe and a 5 french feeding tube) or a similarly-sized dental syringe. The 10 ml syringe makes that amount look like a large amount, we have parents push it very slowly, and it at least keeps baby stimulating the breast.

I'm trying to get the nurses to do the same although this is more challenging -- I am winning a few interested parties over to trying it. Unfortunately, not every nurse sees these volumes as an issue, which leads me into my second group of overfeeders: the hospital staff.

Oh man, I wish with all this I could say that it was only the parents. But no, if a partially-breastfeeding (or even exclusively formula feeding) mom has asked baby to get a bottle in the nursery, there are nurses who will give 25 ml on Day 1 just like anyone else. (Or more, to the point of pathological...) One of the nurses who is now an LC told me it used to be a point of pride for her that she could get babies to finish the bottle, and I've heard similar stories elsewhere from nursery nurses -- getting that baby to eat who just wouldn't was (and sometimes still is) a valued skill, and getting them to eat a lot meant full, happy, healthy babies filling your nursery.

I will say, not all nurses do this! They will come to me and say "she asked me to give a bottle so I only gave him 10 ml, why don't you go see if he's hungry again and wants to breastfeed" or "she asked me to give a bottle before she came upstairs from L&D but I just made his bath take an extra long time, maybe you could get her started breastfeeding". They tell parents independently not to give too much and that it interferes with breastfeeding, or set them up with a dental syringe with a tiny amount of formula if they insist on supplementing, and they don't hand them 3 or 4 bottles at a time. Thank you, wonderful nurses!

How to solve this problem in the long-term? I heard the prolific and very smart breastfeeding researcher Kay Dewey speak last year, and she talked about her research trying to teach parents to interpret feeding cues correctly. Unfortunately, that education (done with WIC participants) was found to be ineffective at reducing overfeeding. It sounded like their next step with that research, to expand the education from just feeding cues to teaching parents how to interpret their babies' cues generally, was going much more successfully. I'm looking forward to reading more about it as they complete their research. I think it's the right direction to go in -- I believe a big part of the issue with volumes is the unrealistic expectations for "satisfied" baby behavior. Getting it to parents, however, will be a big step and take a long time.

In the meantime, what do you do to discourage parents from giving big volumes? Did you know how much babies were supposed to take in their early days?

Tuesday, August 24, 2010

"Los dos" and an awesome new campaign

From the moment my AmeriCorps team started doing breastfeeding education and support in Denver, we came up against "los dos" (literally "the two", better translated as "both"). The majority of our clients, particularly at newborn visits, were Hispanic (largely from Mexico). When we asked them if they were breastfeeding/planning to breastfeed, the answer was almost invariably "los dos" - both breastfeeding, and giving formula by bottle.

I've had a post coming about this for a while - it's a very frustrating thing to deal with and as an inner venting strategy I've composed this post many times in my head.

Why so frustrating? Well, at my current work I see that often "los dos" begins in the hospital. Moms tell me "es que no tengo leche" - "It's that I don't have any milk" - even when I help them hand express abundant colostrum, they don't believe that their colostrum will be enough to sustain baby until their milk comes in. This supplementation often tends to feature HUGE volumes given by bottle (think 1.5 ounces on Day 1, with a baby whose largest feed should probably be 1/3 of an ounce. There is a separate, also long, post about volumes coming - not just about Hispanic moms either.)

Babies get used to the fast flow and firm nipple of the bottle, and they come to expect huge volumes which colostrum cannot provide the first few days. They become fussy at the breast and the mother tells me "es que no quiere el pecho" - "he doesn't want the breast" or "he's refusing it". There seems to be a perception (and believe me, this needs a lot more research) that a large percentage of babies just don't want the breast - with no specific cause or cure - and that if not, you should just give up and bottle feed.

(This, as a side note, is why I think all the people who say nipple confusion is a "myth" are full of it. Over and over again at the newborn clinic in Denver, we'd hear "es que no quiere", slap a nipple shield on, and baby would nurse happily with mom's newly-in milk supply and a nipple that felt more like what they were used to.)

If baby doesn't become nipple preferenced (which some manage to avoid) then continued supplementation often starts to affect milk supply. Mothers tell me they weaned their last babies at one or two months because "no tenía leche" - "I didn't have milk", and "se desesperó" - "he got frustrated" (although used slightly differently it would be mean "to lose hope" which seems so fitting for those babies!)

There seems to be a strong emphasis on babies getting fed a lot, as often as possible, and it's hard to convince/convey to many Hispanic mothers that their babies will get MORE breastmilk if they supplement LESS. Instead, the response to this frustration and dropping milk supply is of course to offer more bottles and fewer breastfeedings. Baby quickly learns where the real supply is coming from and the mother tells me that with her last baby after a few weeks, "no quiso el pecho" - "he refused the breast".

To me all of this is particularly notable as Hispanic moms almost universally tend to want to breastfeed, and when given cooperative babies and milk supplies will generally nurse for a long time - particularly as many stay home to take care of their children. Moms who give up on a nipple preferenced baby will happily nurse the ones who do tolerate "los dos" for a year or two. While many Hispanic moms have yet to make the connection between supplementation and early weaning, I think most of them would prefer to breastfeed longer.

So why is this connection not made? Why is there so much supplementation and so much expectation of "no quiere"? Almost every night at work I dream of rustling up an MPH student to do some focus groups with Hispanic moms on what it means to them to "have milk", for the baby to be satisfied, what they think formula adds to the baby's satisfaction/health, what it means when the baby "doesn't want" the breast, how milk supply is perceived to be driven, etc. etc.

That's still in fantasyland though, so I am so excited that the Massachusetts Breastfeeding Coalition has a new campaign going - the first that I've heard about - targeting "los dos". (Interestingly, they call it "LAS dos" which I've never heard, but maybe it just varies from person to person.)

One poster for the ad campaign has a picture of a baby and a speech bubble saying (in Spanish): "Both (lit. "the two")? Mama, you already have the only two I need! If you give me formula, you won't make enough milk for me." Below it says "Give me only the breast."

Another has the same dialogue with two smiley-faced breasts and a frowny-faced bottle - I love the happy breasts!

And check out the fun story behind the slogan at the Motherwear Breastfeeding Blog!

Will it work? Will moms like it? I hope to hear more about this... and if any MPH/anthropology/sociology/etc. students out there want to get a little qualitative research experience, PLEASE consider this topic!!

Wednesday, August 18, 2010

Pertussis vaccine for parents

From Tara Parker-Pope's Well blog of the NY Times, Vaccination is steady but pertussis is surging:

There are several explanations for the rise in pertussis, but the most likely is waning immunity after vaccination. “Immunity wears off, especially for adults who are decades past their most recent vaccination,” said Dr. Tom Clark, an epidemiologist with the C.D.C.

Moreover, adults and adolescents often wait weeks before seeking treatment for a chronic cough — and even then, doctors may not recognize it as pertussis.

This is especially important to note for parents of infants. Tara Parker-Pope talks about almost reaching for the phone to call 911 because her 11-year-old daughter's coughing fits are so frightening. For an infant, pertussis can mean far more serious illness including weeks of hospitalization - but they're harder to protect because they can't be fully immunized for months.

One way to protect them is for all the adults and older children who regularly come in contact with them to update their pertussis vaccinations, so that those people can't transmit it to the baby. The pertussis vaccine is often given in combination with the tetanus vaccine now; check to see if you've had a "Tdap" shot in the past few years.

The hospital where I work, and many pediatricians' offices, are now checking with parents about their immunization status - but if yours doesn't, make sure you do it on your own! And if someone else (relative, friend, etc.) is regularly coming in contact with your baby, ask them to check their immunization status too. I encourage doulas and anyone else who regularly comes into contact with moms and babies to do the same, to protect their clients. I got a Tdap update when I started working at the hospital. I didn't love the sore arm, but it was worth it. And that's your public health message of the day!

Wednesday, August 11, 2010

Choosing and getting into MPH programs: Part 3: Which MPH program(s) should you apply to?

This is Part 3 in my series about choosing and getting into (and funded by!) MPH programs.
(Part 1 is here, Part 2 is here.)

So you've decided you want to go to grad school, and that you want an MPH, and now the question is - where?

I am going to assume, for the purposes of this series & the people I imagine are reading it, that you are interested in maternal and child health in some aspect and want that to be incorporated into, or at least relevant to, your MPH program.

Still, let me start with a disclaimer: I have done only one MPH, and that was in a maternal and child health track. While I applied to a range of concentrations and schools, I could only enroll in one department at one school. I can't speak personally to the pros and cons of all the paths I didn't take. So this post, in true doula style, is more about raising the questions that you should ask yourself or others when choosing programs, than about telling you what you should or shouldn't do.

So what are the questions you should be asking? When you apply, you generally apply to a specific track at a specific place - it's not like undergraduate where you can just apply to the school and then pick your concentration later. Individual departments/tracks make their own admissions decisions, and you can even apply to multiple departments in the same school at the same time. So you have 2 questions to answer: 1) Which type of track/department(s) do you want to apply to, and 2) At which school(s)/program(s) do you want to apply to do them?

So, question 1: Which type of track/department(s) should you apply to?

MCH is somewhat unique in terms of public health specialties in that it is defined by a content area instead of a methodology. People in epidemiology or health behavior may apply their skills to MCH topics, or to any public health topics, but MCH thinks about content first, and then what skills you might need to deal with that content second. I'm sure there's an interesting history to why things evolved the way they did, but right now that's just the way it is.

So if you're interested in MCH, that doesn't necessarily mean you should be applying to only MCH tracks/departments. I also applied to tracks in health behavior/health education, general public health, international health, community-based health, etc. with the idea of applying the methodologies of those fields to my specific interests.

Public health schools offer all of these tracks and more - and sometimes don't even have an MCH track/department. If there's somewhere you really want to be/stay, you may need to think about whether the non-MCH options available will give you what you're looking for. Also be open to degrees offered by public health programs that aren't MPHs but are fairly similar; they tend to go by names like Masters of Health Science.

Consider your current skills and the ones you want to gain: Do you love number-crunching? Do you have a very strong interest in global health? Do you want to be very research-focused, or very practice-focused? Different tracks will have different focuses.

They will also afford you more or less flexibility to pursue your own individual interests. Some tracks are very prescribed and have few electives. Some are have a few requirements and for your other courses you can select anything else you want in the school of public health, or at the whole university. Consider whether the track you're looking at will give you enough wiggle room to get into your MCH interests, and if not whether there's another way you could pursue those interests (e.g. student group, volunteering, research with a professor, etc.)

I ended up choosing an MCH department for several different reasons, including the knowledge that I would be able to easily focus on the topics I felt most passionately about. Even our more general methods classes in the department used examples from MCH-related issues, and I really liked that. I also liked that the department had relatively few requirements and I would be able to design my own educational program a little more freely.

On the other hand, I know very MCH-oriented people who felt like they knew the MCH content area well and chose, say, health behavior/health education. They wanted to focus on familiar areas with new skills. So keep an open mind about departments and consider other tracks besides MCH - they could be a good fit.

Important questions to ask when considering a track:
  • What is the class schedule like? (mostly evening classes for people coming after work? mostly day classes, so you can only work part-time at most?)
  • What are opportunities to work on research or other activities with faculty in the department? What about in your specific areas of interest?
  • What are the required courses/core curriculum, and how many of the total required credits will they make up? How many electives are available, and what do you have to choose from? (ask to see a current course schedule or a link to their course catalog)
  • What is the educational philosophy, especially in core classes? (lecture, discussion, problem-based learning, etc.) How many students per class on average?
  • Is a practicum/field placement required? (The answer is almost 100% yes, so then you need to know:) How many placements are required? How long are they required to last? When is it usually done? What kind of assistance does the school give in finding placements? Where do students usually work?
  • Is a thesis or master's paper/project required? What is the time frame for this? How intensive does it tend to be, and what types of work/research do students tend to do? Who mentors/approves it and how long does completion usually take?
  • Are there comprehensive exams (aka "comps") for masters' students? What form do they take (oral, written, etc.)? How much time do students generally dedicate to preparing for them?
  • How many semesters do students usually take to graduate? Is it possible to graduate early and if so, how often is it done?
  • If you're interested in continuingon to a doctoral program, does the program prefer to accept doc students from their own graduates, or prefer not to accept doc students from their own graduates?

On to question 2: What school(s)/program(s) should you apply to?

A bit of a primer on something that confused me initially: there are schools of public health and there are programs in public health - what was the difference? The Council on Education in Public Health (CEPH) accredits both schools and programs of public health. They state that:

"The major difference visible to prospective students would be that schools of public health generally offer many more concentrations or specializations and degree offerings than public health programs. Schools must offer at least the MPH in the five areas of public health knowledge defined as core areas. Programs are only required to offer a single MPH degree; though many programs choose to offer multiple concentrations, they are not required to. Also, schools must offer doctoral programs, while programs are not required to. As a result, schools are often larger than programs."

As you can see from CEPH's list by accreditation category (opens a PDF), there are understandably many more programs than schools.

(For the purposes of the rest of this series, when I refer to MPH "programs" I'm referring to both classifications. I know, I know, it's confusing.)

I applied to both programs and schools, although many more schools than programs; programs tend not to have an MCH concentration, or many specific concentrations in general, and the resources of a larger school were attractive to me. However, I seriously considered one program, in part for the benefits of how it seemed very small and collegial. There are benefits and disadvantages to both.

Where you go is most obviously limited by geography and money. If you are not very geographically flexible for family or other reasons, you need to either find your best option in the area accessible to you, or look into online programs - more and more accredited public health schools/programs are offering online MPHs. (However, based on what I know about online for-profit, non-accredited programs in general, I would encourage you to avoid them.)

You also may have a dream school and feel limited by funds. I encourage people to apply to every school they're interested in if they can afford the application fees - you don't know whether they're going to offer you financial aid or not, and how much. I was surprised by some of my offers (in both good and bad ways). But in the end your options may be limited by whether or not you want to take on loans with many zeros at the end. I'll discuss more on getting in/getting funding in the next installment.

If you have the choice of multiple schools, consider asking some of the following questions:
  • What are the tuition and fees per year? If it's a state school and you are not a resident, how likely is it you could get residency while you're still in school?
  • What kind of help with job placement/career advising is offered? Are faculty accessible to students for contacts and networking?
  • What partnerships with outside organizations do you have - is there a pipeline for graduates to certain organizations in the area or internationally that can be helpful in getting practicum placements/jobs?
  • What's the student life like? Is there a student association/government? Does anyone organize social events and do students tend to socialize outside of class?
  • How is campus safety, particularly if you'll be attending a lot of evening classes? Are there affordable/safe housing options nearby? Is there parking nearby, (nearly 100% of the time: no, so:) is campus easily accessible by public transportation/bike?
For both the above lists of questions, please post more questions that I'm not thinking of in the comments! This is a mix of questions that I have noted from my own grad school search and ones I look back and think I should have asked, but I may still be missing some important ones. Particularly post ones that I may not think of coming from a fairly privileged perspective - white middle-class girls from liberal arts colleges are the rock-solid majority in public health programs.

When all is said and done, my most important recommendation on choosing schools to apply to is to think as a consumer. It's easy (I made this mistake too) to focus on whether you'll get in or not. Just because you can get into a competitive school does not mean it's the right place for you! When looking at schools, imagine you're guaranteed acceptance and then decide whether you would actually want to go there or not. Is it worth your application time and money?

Last, a list of programs that were recommended to me or that I looked at, to start your search:

Specifically for MCH:
Columbia University
University of Washington
University of North Carolina
UC Berkeley
University of South Florida
Emory University
Boston University
University of Illinois - Chicago

Recommended in general:
Johns Hopkins
University of Minnesota
University of Michigan
Oregon State
George Washington University
University of Arizona
New York University

Again, please add further recommendations or personal experiences in the comments!

Tuesday, August 10, 2010

Two stories from China

First: Female babies in China grow breasts as a result of drinking hormone-tainted formula:
The official China Daily newspaper reported today that medical tests indicated that the level of hormones in three 'test case' girls, ranging in age from four months to 15 months, exceeded those found in the average adult woman.

All the babies who showed symptoms of the phenomenon were fed the same baby formula.

Second: Chinese Formula Maker Prepares for Stock Offering:
As Yashili moves toward a public listing, potential investors will be keen to see how much market share it has clawed back from foreign brands, which Chinese consumers came to see as safer during the scandal.

Yashili's sales and profitability have recovered and overtaken pre-melamine scandal levels. But it has had to raise prices to cover the cost of the cleanup, a common theme across the industry, according to Mr. Siewert.

The factors driving growth in the industry are the growing affluence of the Chinese and a declining breast-feeding rate.

In 1998, 76% of mothers exclusively breast-fed children, according to Unicef, but that dropped to about 50% by 2008 as they sought to supplement their babies' diet.

The Chinese infant-formula market is the world's second-largest, surpassing Japan, and is expected to overtake the U.S. shortly, according to a report by Oppenheimer. The market is expected to grow at a double-digit rate in the next five to 10 years, the report added.

Friday, August 6, 2010

Tips for working nights

One of the things slowing down my posting rate, even post-IBCLC exam, is my schedule working nights doing lactation support. I thought it would be so easy going in! After all, I'm a doula and have now lost count of the number of nights I've powered through on a PowerBar and some adrenaline (I don't even do caffeine). Then I'd go home, sleep it off, and be fine. How different could this be?

Color me naive. It is so different to work nights regularly than it is to jump in for a night or two, power through, and then go straight back to your normal schedule. At the end of the first two weeks of nights, I was on the cliff's edge and totally unable to figure out why. Two things helped me realize why this was so hard:
1) To shift from sleeping, say, 11pm-8 am and then start sleeping 8 am-4 pm, then switch back 3 days later, is like having a 9-hour time zone jump twice a week. Hello, jet lag!
2) Apparently, your brain makes melatonin during the day and serotonin at night. When your sleep schedule gets screwed around with and you don't get any "day", you don't get any serotonin. Hello, inexplicable depression!

I was basically a wreck - miserable for no reason, other than of course the reason that I was tired all the time and felt like I could never get enough sleep.

Now, however, things have improved greatly and I attribute this in large part to my new plan for handling nights. I found Rural Doctor's post on working nights very helpful - she has instructions from sleep to eating - but I've made some modifications.

First, I tried to do her method of splitting up sleep - getting up fairly early in the morning and then going back to bed and sleeping in the afternoon. I may try it again, but 1) that means the entire day is shot for me - and this is unfortunately not my only job, so that can make schedules challenging and 2) my body has yet to agree that, for example, 5 + 4 = 9 when it comes to sleep. I can sleep 5 hours, then break, then sleep 4 hours, and feel equally crappy both times I wake up and for many hours afterward. I have to get long consecutive sleep stretches. This has been the #1 most important change from the first 2 weeks, where I was still trying to convince my body to do simple addition.

Also, I don't do caffeine so that part is skipped. I tried it one night when I was really sleep-deprived with a big ol' cup of highly caffeinated tea before work. I still can't definitively pin this on the caffeine, given that I was also so sleep-deprived, but I got a horrific headache at work. Like, when I bent over patient beds to help with latch and positioning, my head would feel like it was going to throb apart when I stood up. One of the lovely nurses dug into her personal stash of ibuprofen for me (and I vowed never to be without it at work again), I was capable of bending over to assist with feedings again, and decided no more caffeine.

So my schedule, with modifications from the original, is more or less this:

Night before first night shift:
  • Stay up as late as possible, generally about 3 am.

Day of first night shift:
  • Sleep till 11 am or so. Then have afternoon/evening available for getting other work done (my shift begins at 11 pm, unlike most shifts which start at 7 pm).
  • Pack lunch, put together outfit (I don't own many scrubs and tend to go the business casual route the way most of the other LCs at this hospital do.)

For each night shift:
  • Packing a lunch: helpful, although the cafeteria at night has a couple reasonably healthy, although not-super-appetizing options (I can't think of much less appetizing than hospital cafeteria packaged sushi at 3 am). But there's not always time to run down there, so it's good to have the food nearby.
  • Snacks!: Helpful for staying awake. I also use them to health it up if I caved and brought a frozen entree. So last night I had a frozen burrito but brought cherries and carrot sticks to go with it. (I also rarely go into the nurses' lounge, where lurk the donuts...)
  • Hydration: I have learned to skip, for reasons related to sleep. How to put this delicately? Wait, I'm a doula, I don't do delicacy: if I drink all night, it makes it hard to stay asleep during the day because I get up to pee too often and then it's hard to get back to sleep. I try to drink water before or at the beginning of my shift, and then really limit it. I'll chug all I want if it's my last night shift in a set, but the other nights I value sleep over thirst-quenching.
  • Get out as soon as you can: One of the best tips I got from the Rural Doctoring post was not to hang around and chit-chat with the oncoming shift. It really does feel like being rescued from Gilligan's Island, or having fresh troops arrive at a beleaguered battlefield. Especially being the only lactation person on overnight, I want to recount complicated cases, tell them something crazy a nurse said, ask about the schedule, chitchat about the weather, etc. etc. Instead I push myself to mention anyone who I think needs more explanation than easily fits on the follow-up list I'm leaving, and then wish them a good day and head out. Again: sleep takes priority.
  • Mid-shift slump: I tend to have a slump around 4 am, especially the first night in a set. Those moments of tiredness can feel a little desperate - that "oh my god, if I don't sleep RIGHT NOW I am going to cry" - but it's happened enough times now that I remind myself that it will pass and I'll feel better within an hour. By the time shift change happens, I could probably stay up the rest of the day (not recommended).
  • Keeping it dark: I keep forgetting to bring sunglasses with me to wear home at the end of the shift to keep my body thinking it's night. Knock on wood, I've had no trouble falling asleep even without this (fortunately it's a short drive home). However, keeping my room dark has made a HUGE difference in the quality of my sleep. I got Eclipse 0% curtains at Target, and while they don't actually let in 0% of the light, those + a sleep mask make a big difference. I also use two fans (ceiling and box) to stay cool and for white noise. Heaven! (I add the Rural Doc's recommendation of a cat who is a good napper.)

After the last day shift:
  • Short nap in the morning, no more than 3 hours. Stay up till a normal bedtime and then go to bed and sleep as much as needed.

The other thing that has been helpful with all this is just time and getting my body used to it. The first time I tried to pull an all-nighter to write a paper, I couldn't function past 3 am. College (and my last-minute paper-writing habits) beat this weakness out of me quickly and while I always rued my procrastination and felt fairly nauseous the next day, I could do an all-nighter when needed. This proved invaluable when I started working as a doula. I spent the first couple weeks of this job feeling queasy and crappy almost constantly, whether I'd worked the night before or not. And just got better. My body figured it out.

So my recommendation to any of you who are dealing with transitioning to a new sleep schedule, or trying to figure out how to do long doula calls and still remain upright, is to give yourself time and patience. I had some panicky moments where I thought I was going to feel like this forever/as long as I had this job (which at that point didn't seem like it could possibly be very long). It passed, and now I feel reasonably functional even on my more sleep-deprived days.

Of course, it messes with posting...I promise I'm working on those, albeit slowly...