“Gary is a reef shark. He keeps growing. One day he goes in the deep blue to eat blue fin tuna (my favorite kind of tuna!) and gets banned from his shiver (a shiver is a group of sharks). Then he finds a bunch of sharks that are rogues like him. They make a shiver called rogue shiver. Then they go to Goblin shiver’s territory. The leader finds them and they are made to join the shiver or die. He joins but soon learns it is an evil shiver (music: dun dun dun dun), and this is the beginning of more adventures.
I loved this book because I love sharks and other life in the ocean (except for starfish – that would be boring). It is the first in a series and I plan on reading all of the books.
I recommend this book to people who like adventure and those who like sharks.
Tips I often recommend to patients and friends and that I found extremely useful with my own children. I went from buying every device in the store for my firstborn (vibrating chair, white noise maker, etc) to simply keeping my youngest swaddled and wearing her in a sling. My youngest almost never fussed or cried, and at almost 6 is still the most calm of my 3 children.
Five dragonets (dragon children) are stolen while still in their eggs to be raised by the talons of peace (an organization that wants to stop the war ) because they are the dragonets of the prophecy. They are supposed to stop the war when they are full grown and choose one of three rival queens. The war has been going on for 18 years when the book starts after the prologue. The dragonets escape their caretakers and realize that the outside world is dangerous. The book is about the challenges the dragonets face.
The highlight of the book is when the dragonets are taken prisoner and they escape.
The book is awesome because there is a lot of adventure. It’s so exciting that I stayed up late reading it and finished the book in 2 days.
I recommend the book to people that like fantasy adventures. I give the book 5 stars.
Andrew Clements is one of my favorite authors. “About Average” is about a girl named Jordan who loves reading and is really nice and kind to people, but when she gets angry everyone is afraid of her because she looks like an exploding volcano. Marlea, a girl at school, grabs Jordan’s private papers from the recycling bin and one paper lists what she is okay at, great at, and bad at. Marlea teases her about what she’s great at and tells everyone in school about it. Jordan has to get through the last few weeks of school while Marlea is teasing her.
The best part of the book was when Marlea looked like at exploding volcano. I enjoyed the book because it was funny. The book teaches you to treat people nicely, and that you can hurt people’s feelings when you don’t.
I recommend the book for kids of all ages. I give it 4 stars.
In April 2012, the World Alliance for Breastfeeding Action (WABA) released a poster called “21 Dangers of Infant Formula”. It has since been making the rounds of social media. The intent is to create awareness and provide evidence-based information (the document includes references for each of its claims). Surprisingly, it has been the object of some pretty violent reactions. Some claim that campaigns such as this are ‘judgemental’ and ‘unfair’ to formula-feeding mothers who are being judged by society enough as it is.
Also in 2012, just a month before this poster was released, the American Academy of Pediatrics published an update of its policy statement on Breastfeeding and the Use of Human Milk. Here is a simplified version of the table that appears on the 3rd page of the document and lists the Dose-Response Benefits of Breastfeeding. The 17-page document discusses other benefits not included in this table. I have yet to read a violent response to this one.
Both documents contain similar information, the main difference being what each considers to be the norm/standard. The WABA document assumes that breastfeeding is the norm or the default choice. And so it lists what the baby loses/risks when giving up breastfeeding and choosing formula in its place. The AAP document enumerates how breastfeeding is superior, with formula as the base option. According to the AAP, a 6 month-old baby who is still breastfeeding exclusively has a 50% decreased risk of having an ear infection, and in WABA-speak, a 6 month-old baby on formula has twice the risk of getting an ear infection when compared with a breastfed baby. It really is just 2 sides of the same coin.
As far as feeding options for infants go, there really aren’t very many choices. The choices are human milk or infant formula. Things like juice, water, rice water, soup, condensed milk, evaporated milk, non-dairy creamer are absolutely inappropriate for infants (and yet many mothers who start with formula and cannot afford to sustain it end up feeding their children one or all of these – but let’s leave that for another post).
Surely, in order for a mother to make a good choice, she should be armed with the proper information. Honestly, if I had learned all this in medical school, I would have done everything in my power even then to help my patients breastfeed. It is information that is useful to all mothers – whether they choose to breastfeed or formula feed – and it is information that is useful to anyone who cares for babies, in the hospital or out. We demand nutrition labels on our food and warning labels on our medications. Why wouldn’t we want to know the effects of what we choose to feed our children for the first year of their life (or longer)?
This information isn’t meant to accuse certain women of ‘bad mothering’. Obviously, every mother wants what is best for her child, and mothers make decisions based on the information available to them at the time. Many doctors, nurses and hospitals all over the world will readily say “there’s nothing wrong with giving a bottle of formula”. In the face of that ‘expertise’, how is a mother to know better? Well, that is what information like this is for.
The vast majority of mothers should be able, with the right information and support, to provide 100% of the breast milk their child needs. There will be a small number of mothers who, despite all effort, are unable to do so and may not be able to provide any breast milk at all. Sadly, an overwhelming number of mothers feel they belong to this category when they actually do not. They are the victims of poor information, an inadequate health care system, and lack of support. Information campaigns such as these aren’t designed to pit mothers against each other, or to allow us to condemn others for their feeding choices. This kind of information should instead act as motivation to seek more information and to make active decisions.
How does this kind of information make you feel? Will it change/would it have changed any of your feeding decisions? Do you feel this kind of information is important? Leave a comment to share your thoughts!
Step 4 of the Unang Yakap protocol is Non-separation of the newborn from mother for early breastfeeding. It is probably the most difficult step to implement because it requires teamwork, a change in the general mindset surrounding the birthing process, and revising hospital policies.
Non-separation of the newborn and mother are crucial to the success of the Unang Yakap initiative, and of all 4 steps, this has the longest-lasting implications and the greatest benefit.
Scientific Data Supports Breastfeeding as an intervention for preventing newborn death
In 2003, the medical journal The Lancet published its Child Survival Series which identified 15 preventive interventions that together could prevent 60% of childhood deaths worldwide. Breastfeeding topped this list, and it was projected that if 90% of mothers were to breastfeed exclusively for the first 6 months, 13% of worldwide deaths before the age of 5 could be prevented.
In 2008, a study by L. Mullany and peers involving 28,000 babies in Nepal (published in the Journal of Nutrition) demonstrated that delaying the initiation of breastfeeding increases the risk of newborn death from infections. Their findings showed that delaying the first breastfeed to anywhere from 1 hour of age to 24 hours of age resulted in a doubling of the risk of death from infection. Waiting until 24-48 hours for the first breastfeed tripled this risk, and delaying the first breastfeed until 48-72 hours quadrupled the risk of death. An earlier study from Ghana also showed similar findings.
A randomized control trial by J. Narayanan published in the Lancet almost 20 years ago examined the percent of serious illness among low birth weight infants (infants weighing less than 2500g at birth) who were randomly assigned to feed breast milk or formula. Results showed that serious illnesses occurred 400% more frequently in infants fed formula alone compared to infants on raw expressed breastmilk alone. Due to ethical considerations, this type of study cannot be repeated today.
Before and After
What is the traditional birth experience in a hospital in the Philippines without Unang Yakap? The baby is delivered, the cord cut, the infant taken to a bassinet or warmer for drying, then wrapped in a blanket and briefly shown to its mother and father. It is quickly spirited away to the nursery for weighing, measuring, a full physical examination, bathing, a Vitamin K shot and Hepatitis B vaccine administration. The baby is kept in the nursery in a bassinet or incubator until the mother is ‘ready’ or the baby is ‘stable and cleared for rooming-in’ (deemed normal and well enough to be placed in the hands of its mother). While awaiting this all-important reunion, the baby is fed a bottle of glucose water or formula every few hours.
What Step 4 proposes is that after the baby is dried, placed on its mother’s chest, covered in a bonnet and blanket; and after the cord is cut; that the baby be left in skin-to-skin contact with the mother until he/she is ready for the first breastfeed. This means delaying weighing and measuring, delaying a full physical exam (a quick one is performed when the infant is being dried, and both mother and infant are regularly monitored every few minutes after birth), delaying the Vitamin K shot and any vaccines, until the first breastfeed has been completed. Bathing should be delayed until the baby is at least 6 hours old or longer.
The goal of step 4 is to protect the first breastfeed, and to allow it to happen spontaneously at the appropriate time and in the appropriate manner. Weighing, measuring, unnecessarily handling the baby, and performing painful procedures can all disrupt the infant’s natural instinct to locate the breast and begin feeding. And while all these are important in newborn care, none of them are so important that they cannot wait until after the first breastfeed is complete.
The study by Dr. Sobel and colleagues that looked at hospital practices in the Philippines showed that most newborns were put to the breast by 10 minutes of age, but they were also removed from the breast a mere 2 minutes later. The truth is, most babies are not ready to breastfeed until they are about 20-60 minutes old, and it is a process that happens gently and gradually. The new baby who is placed on its mother’s chest begins to look around, lick its lips and will salivate. He or she uses smell to localize the mother’s areola (which is why we shouldn’t ‘clean’ the mother’s nipples with alcohol or other substances), kicks gently and moves over to the breast, finds the breast and latches on. A good first breastfeed can last 10, 20 or 30 minutes. Sometimes it will last longer.
Once the first breastfeed is complete, measuring, weighing, examinations and injections can all be done at the bedside. Mother and newborn should be treated as a single unit – they should be monitored together and transferred to the room together.
Soon-to-be parents who are hearing about non-separation for the first time often worry that being with the baby from the very beginning means they will be more tired and that the mom will have no opportunity to rest. But feedback from mothers who have undergone the Unang Yakap experience, especially mothers who are giving birth for the 2nd or 3rd time, has been overwhelmingly positive. Many have said that the experience is beautiful and joyful, and that they wish they had been able to do it with their previous births. Nurses who were once concerned that monitoring babies and mothers together would be too taxing, have said that it is much easier to continue to assist mothers who were able to successfully breastfeed at the very beginning, rather than try to teach a mother how to breastfeed her baby who is already a day or 2 old.
Babies who are breastfed within the first hour of life have a lower risk of infection and death, and a higher chance of breastfeeding exclusively and for a longer period of time. This translates to numerous long-term benefits including an increase in IQ, protection against gastrointestinal infections, allergic disease, obesity, diabetes, childhood leukemia and lymphoma, and SIDS (Sudden Infant Death Syndrome). Breastfeeding benefits for the mother include decreased postpartum blood loss, improved child spacing, decreased risk for postpartum depression, chid abuse or neglect, type 2 diabetes, rheumatoid arthritis, cardiovascular disease, and breast and ovarian cancer. The economic benefits are significant as well.
Early reports from hospitals that have committed to the practice of Unang Yakap show that it does work – fewer babies are sick, less babies are admitted to NICUs. But in order to have the fullest impact, the program needs to be adopted by all. Ask your Obstetrician, Pediatrician or midwife about Unang Yakap. Talk to other parents and to your local health care providers about it and please help spread the word!
This post is a continuation of Unang Yakap, Part 1 posted a few days ago. Today I will discuss step 3 in the newborn protocol: Properly-timed cord clamping.
But before we do that, let’s review our steps. 1) Immediately after a baby is born, he/she should be dried thoroughly for at least 30 seconds. 2) Once the baby is dry (and at this point should be breathing well), he/she is placed naked on the mother’s bare tummy or chest. A bonnet should be placed on the baby’s head and a blanket on its back to help keep him/her warm.
At this point, the person attending the delivery (Obstetrician or midwife) should be holding the umbilical cord, feeling for its pulse and waiting for those pulsations to stop. When the pulsations stop, the cord is clamped and cut. This is step 3.
Until recently, cutting the umbilical cord immediately after birth was the standard of care in the Philippines and many other parts of the world. Studies have shown that this practice is not beneficial, and can actually deprive a baby of part of its blood volume.
While inside the womb, a newborn’s blood circulates through its own body, the umbilical cord and the placenta. When the baby is born, blood that is contained in the placenta moves through the cord and back to the baby. The cord pulsates during this time and pulsations stop when the job is done. This typically takes about 1-3 minutes. If the cord is cut immediately after birth, there isn’t enough time for blood that is in the placenta and cord to be returned to the baby, and the baby is deprived of a portion of his/her own blood.
Why does the extra blood matter? Blood carries oxygen, and this extra oxygen is very helpful to babies when they make the transition from life in the womb to life in the outside world. Blood also holds most of the iron in our body, so babies whose cords are cut immediately are 80% more likely to develop anemia in their first year of life.
In preterm babies, the standard practice is to cut the cord immediately. This is because doctors assume that the baby is going to need some assistance with breathing and may need even further resuscitation. However, more recent published data has shown that waiting 30 seconds to 1 minute to clamp the cord of a preterm infant decreases the risk of brain hemorrhage (a serious complication that premature babies are at risk for) and cuts the risk of anemia in half. There are many other potential benefits to preterm babies as well, including protection against infection.
Here is a wonderful video by Penny Simkin that clearly illustrates where a baby’s blood goes when it is born, and why it is a good idea to wait before clamping the cord.
Waiting to clamp the cord until the appropriate time is clearly helpful to babies and poses no danger to the infant or its mother. This is Step 3 in the Unang Yakap protocol.
I hope this was helpful. I will discuss step 4 ( Non-separation of the newborn from the mother for early breastfeeding) in my next post. In the meantime, feel free to comment and ask questions!