Tag Archives: Newborn/Baby

Between Depression and a Hard Place

Between Depression and a Hard Place

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By Anna Blackmon Moore

winter2009_mooreAs soon as I learned I was pregnant again, I shut myself into the bedroom of my two-year-old son, gazed at his train car blanket, his shoes on the floor that no longer fit, his stuffed penguin. I thought about my brain. Then I called my psychiatrist.

“This is a surprise,” she said coldly.

“I discussed the possibility with you at our last appointment, remember?” I said. I had actually discussed having another child with her at our last two meetings. Our appointments occurred only every three to six months and took half an hour; I used them for refills of anti-depressants. Five months before, I had started taking Lexapro, a switch from Prozac, which I had been on intermittently for nearly twenty years.

“I just wanted to ask about my medication,” I continued. “Should I go down to five milligrams? How safe is it?”

“Most women try to get off anti-depressants before they get pregnant, Anna,” she said. She had not mentioned this—not once, not in doctorese, not directly or indirectly or vaguely—in any of the appointments we’d had in the last four years, which is how long she’d been my doctor. During my first pregnancy, I decided on my own initiative to stop taking Prozac but then resumed it in the second trimester. I had not planned to do so, but anxiety, one of the many characteristics of my depression, became too debilitating.

“I’m only four weeks pregnant.”

“Well, I guess it’s too late now.”

Was she in a bad mood? Why was she talking to me this way? Why was I so incapable of asserting myself with doctors? Apparently, she wanted me to believe that I had already damaged my baby’s developing organs somehow, that there was no turning back. Too late now, she had said, since your baby is already ridden with birth defects.

“But they calculate conception by the first date of your last period,” I argued. “So the baby was really only conceived about two weeks ago.” She didn’t know this?

Women like me are hardly alone in their frustrations. Those of us who take anti-depressants and become pregnant are forced to make wrenching decisions about medication. Every piece of literature I have read on this issue, from studies in medical journals to user-friendly websites to sections of baby books, whether the drug in question is an SSRI like Prozac or a psychotropic like Lithium, summarizes the nature of our decision like this: Along with our doctors, we need to decide if benefits from our medications are greater than any potential risks they could bring to our baby’s health. If our benefits win, then we should take anti-depressants. If potential health risks to our baby win, we should not take our anti-depressants.

What a shit sandwich.

By the time I called my psychiatrist, I had already been served that sandwich. I was familiar with it; I had ingested the thing. I was preparing to ingest it again. But if my doctor was going to treat me with such impatience and disdain while I was going through a pregnancy, when women at any level of mental and physical health need as much support as possible, then, I thought, Fuck her. The following week I cancelled our appointment, recalling a poster that my best friend, sixteen years earlier, had taped on our kitchen cabinet when we were roommates in a tiny apartment after graduating from college. The heading was 20 Ways To Be a Strong Woman; below it were twenty bulleted commands. The only one I could remember was the last: “Walk out of any doctor’s office you want.” Instead of walking out, I just didn’t return.

*   *   *

When I learned I was pregnant with my first child, Ian, I was on Prozac. The average daily dose, the one I was prescribed, is twenty milligrams, but sometimes I’d skip a day (or two), sometimes I’d go down to ten, sometimes I’d wean from it altogether. Changing doses of medication without a doctor’s guidance is part of having a mental illness. For some people with severe depression or other severe mental illnesses, changing or stopping doses is a symptom of the illness itself.

I adjusted my dosage because I do not like being depressed. I would prefer not to have this condition. So self-adjusting is how I prove to no one at all (since I do not discuss my adjustments with anyone) that I do not need this drug. I still think I might not. Maybe I just need a good kick in the pants, a transformation of attitude, or time alone in a dark room where I can analyze my worthlessness and all its manifestations over and over again until I figure it out or until it goes away.

Pregnancy, however, made me think about my depression in ways that were less self-absorbed. My thoughts about how or whether I actually had this condition were no longer relevant or even important, I realized, because what if after I gave birth, I dropped into a serious depression? My mother had. She describes it like this: She had me, broke down, and then got into bed. She got out again “when it was spring.” Since I was born in the spring, this means that my mother was incapacitated and largely absent for the first year of my life.

For the rest of hers, she sought and received various forms of treatment at various times with varying levels of efficacy. She has always struggled with depression. As a result, my brother and I have struggled with it, too. (My alcoholic father shares plenty of responsibility here as well but requires too many additional words.) As a young adult, my brother’s mental illness institutionalized him for years; as a teenager, I was hospitalized for a suicidal gesture—I slit my wrist with a dull paring knife—and I was an in-patient in treatment programs for alcoholism and bulimia. I’ve been in and out of therapy since I was ten to “work through” the same “issues” that have influenced my feelings and thoughts for as long as I can remember. I’ve been on and off Elavil, Prozac, Paxil, Zoloft, Imipramine, Welbutrin, and Effexor. Despite my functional professional and social life—I’m a college instructor, a writer, a friend, a wife, a mother—I am always in some kind of emotional pain, or caught in a self-reflective ache, and in general I feel pretty bad about myself, who I am, how I behave, and how I think.

This state of being poses challenges for me and other depressed women when we become pregnant. Just a cursory glance through the various genres of pregnancy literature confirms that during pregnancy, a fetus needs a contented, functional mother. The mental health of the mother is even more important right after birth, because a depressed mother who neither smiles at nor interacts with her infants can easily be worse for them than most of the side effects they might experience as a result of anti-depressants.

And these side effects are a matter of mights. If pregnant women take Prozac or other selective serotonin reuptake inhibitors, or SSRIs, to regulate and adjust the activity of the neurotransmitter serotonin in their brains, their newborns might experience, according to the Mayo Clinic, “tremors, gastrointestinal problems, sleep disturbances and high-pitched cries.” These are withdrawal symptoms and go away within a few weeks of the baby’s birth. Knowledge of this dissipation, though, is hardly comforting to the almost eight percent of pregnant women who are prescribed these drugs during their pregnancies. No pregnant woman, depressed or not, could disregard visions of her newborn shaking uncontrollably or crying like a siren, especially if this suffering were caused by drugs she had passed into her baby’s system.

The possibilities of health risks grow mightier when we consider possible long-term effects on a child whose mother took SSRIs during pregnancy. According to my former psychiatrist, we do not know whether SSRI babies demonstrate a greater incidence of depression, attention disorders, mood disorders, or cognitive problems as children, teenagers, or adults. But I think we have to question the reliability of such implications, anyway: Since mental illnesses are often hereditary, children or teens could get them straight from the genes of their mother, whether she were medicated while pregnant or not. And if teenagers or even toddlers suffer from mood disorders, it would be impossible to prove definitively that fetal exposure to SSRIs was the cause.

What I do know is that my brother and I suffered from mood disorders—big ones—along with all kinds of other psychological and emotional problems; at the same time, while we were growing up, my mother’s depression was never consistently or properly treated. If it had been, I know my mother would not have been perfect, but it is fair to say that she would have been more engaged with her children, more attentive and supportive during our infancy, at least. Our family might have been stronger.

So we’re back to the shit sandwich. Treat it or don’t—which is worse, and which is better? Who knows?

Many doctors advise a weaning from anti-depressants before women become pregnant or early in the first trimester, when the baby’s organs are being formed. Both my GP and former psychiatrist advised me to stop taking them unless I was suicidal. I should “hold out” until the second trimester, they said, when the drugs would likely be safer for my baby. Their opinion is grounded not only in common sense, but also in the memory of the thalidomide catastrophe. From 1958 to 1961, pregnant women in the United Kingdom and Canada took thalidomide to ease first-trimester nausea, filling their prescriptions because the drug’s manufacturer and, subsequently, doctors espoused its safety. The manufacturers, in fact, had not tested the drug, and eight thousand babies were born with profound birth defects, from missing and deformed limbs to unsegmented intestines. According to Sandra Steingraber, in her excellent book Having Faith: An Ecologist’s Journey to Motherhood, what made thalidomide especially teratogenic—a cause of birth defects—was the fact that the drug interferes with the formation of blood vessels and protein production. Just as important was the timing of its ingestion: Pregnant women took it when their embryos were sixteen to twenty-one days old, during peak organ-formation.

As a result, the medical community now has clear directives on medications and pregnancy: Steer clear of as many as you can. The logic of this instruction is obvious. But as a person with a mental illness, I see perspectives and biases emerging on this issue that have little to do with thalidomide and untested drugs and lots to do with how we tend to blame mental illness on those who suffer from it. In a post to “Taking Anti-depressants During Pregnancy” on the Berkeley Parents Network website, an anonymous writer articulates perfectly what I was feeling: “There is a lot of discrimination against treating mental illness in pregnancy. Do you think a doctor would suggest someone with high blood pressure or diabetes just STOP [her] medicine while pregnant? Absolutely not.”

 *   *   *

After the incident with my psychiatrist (who I saw primarily for medication), my therapist helped me by discussing the Lexapro issue with two doctors she has worked with in the past. As I sat in my usual spot on her couch, she informed me of my options: Go off Lexapro completely or stay on ten milligrams; five is non-therapeutic and, therefore, would not help me. Since I had already adjusted on my own to five milligrams a week before, I wasn’t sure where to go from there. I was stuck: If I kept taking such a low dose, I’d be exposing my fetus to the drug, and I wouldn’t be getting any benefit from it. It was ten milligrams or nothing.

“I guess,” I said, “it’s time for me to decide what to do.”

She nodded.

That night, I looked through various articles and websites on Lexapro and pregnancy. I found mostly information I already knew, since Lexapro is an SSRI and the research on these drugs lumps SSRIs together. Eventually, however, I found a public health alert put out by the U.S. Food and Drug Administration in 2006, which summarized the results of two studies published that year. The first, in the Journal of the American Medical Association, tracked a group of women who stopped taking anti-depressants while they were pregnant and a group of women who did not. The women who went off their meds were five times more likely to have a relapse of their depression.

The second study, published in the New England Journal of Medicine, found that fetuses exposed to SSRIs after twenty weeks had a six-times greater likelihood of developing persistent pulmonary hypertension. The disease is very serious and sometimes fatal, but “[the] risk has not so far been investigated by other researchers.” So it would seem that going off Lexapro in the first trimester actually carries less serious of a risk to the baby than my resuming the medicine later on. All right, but what about me? Whose risks finish first?

It was time to decide. But with whom? I live in a large town. We have other psychiatrists, but not many. Even if I lived in an urban area, getting in to see a psychiatrist can take months, especially as a new patient. There were other options—GPs and obstetricians are doctors, of course, but the ones I had seen discouraged medication in general and offered little support. So I made what I thought was the most informed decision I could about my health and the health of my family: I decided to discontinue the Lexapro, at least for the first trimester. For the next week, I took my five milligrams only every other day, and then I stopped it altogether. Maybe I could do it this time.

*   *   *

Now, in my ninth week of pregnancy, I sleep poorly, cry often, and feel deeply angry all the time. This anger has been characteristic of my depression all my life. I have to watch what I say and how I carry myself and how I react for fear of alienating my students, friends, and colleagues. I yell at the dog, snap at my husband, shout at my windshield. With my son, I am less patient. It’s cute when he explores the potential of his toothbrush and brushes the drain, but must he do it every single night? Must he always choose to read The Biggest Book Ever? If I do lose control, I feel disturbed, unhinged, and terribly guilty. The most difficult parts of my day are transitions, which require what feels like tremendous effort of body and mind: bed to bathroom, car to office, desk chair to kitchen, couch to bed. I feel more than ever like I am a failure.

Come on, woman, I hear in a deep authoritative voice of some distant patriarchal figure, pull yourself together. But I’ve been pulling since I was a teenager, and my depression has not seemed to budge for extended periods of time without the help of drugs. I have pulled myself into pieces. I work against a cavernous sense of negativity, and this in particular has never felt transitory. I cannot therapize it away, or overcome it, or counter it through cognitive exercises. As I get older, my depression feels more and more biological, more deeply folded into the fluid of my brain. Stopping medication when my hormones are in flux, when I’m sick, when I’m teaching a full load, when the stress of another baby grows by the day … this seems more and more like a bad idea, my husband says. And I agree.

So yesterday, I went to my unaccommodating GP and asked for Prozac. Prozac has been around a long time, so doctors and researchers have published hundreds of studies on it. Prozac and Zoloft are the safest of all SSRIs.

During my first pregnancy, I took twenty milligrams of Prozac per day in the second and third trimester. I also breastfed my son while I was on the same, consistent dose. When I was in the hospital, recovering from childbirth and learning to breastfeed, several nurses expressed concern. What were the possible effects of Prozac on the baby? Did I know? Had I consulted with my doctor? (Why they didn’t learn the answers themselves and then share the results with me, since I was consumed by worries of feeding my baby properly while fuzzy with painkillers and lack of sleep, I do not know. Perhaps they expected more from me.) I explained that I felt very safe in what I was doing because of what I was told by a lactation consultant in the hospital following his birth. The consultant explained that any side effects Ian might have—the same he might have from exposure to Prozac in the womb—would go away within a month. (Ian was a product of the good odds: He experienced no side effects and seems fine in every way, developmentally and temperamentally.)

According to the specialist I spoke with at the nonprofit Organization of Teratology Information Specialists (OTIS), to which I was referred by the FDA’s Office of Women’s Health, SSRIs are indeed the most studied of all the anti-depressants on the market.

The specialist started answering my questions by first explaining that the baseline of birth defects for every pregnant woman is three to four percent. This percentage goes up with factors like age, health problems, and the genetic history of the mother. Then she summarized what the studies say about mothers who take SSRIs during pregnancy. During the first trimester, women who took high doses (between sixty to eighty milligrams) of Prozac increased their risk of having a baby with a low birth weight by one percent. (These results were not found in newborns whose mothers took other SSRIs at similar doses.) The babies of mothers who take SSRIs in the third trimester have a ten to thirty percent rate of toxicity withdrawal—and the withdrawal is limited to the newborn period.

Okay, I thought. Okay. I felt suddenly relieved—not because I thought SSRIs might be totally safe, but because I understood the studies more clearly. I realized later that what I felt was not a rush of relief; what I felt was a rush of informed.

*   *   *

The studies I have read on anti-depressants and pregnancy are structured, more or less, like this: Over a period of years, scientists and doctors gather records on a group of infants with birth defects and a group of infants without birth defects. The doctors then conduct interviews with the mothers or review medical documents to learn about what drugs the mother took before and during their pregnancies. They then compare the interview results or the medical documents to the birth defects and look for correlations.

They have indeed found them. One study of 13,714 infants (9,622 with birth defects and 4,092 without) was published in the New England Journal of Medicine in July 2007. The correlations the authors found between the infants with birth defects and SSRI exposure were very low—low enough to conclude “maternal use of SSRIs during early pregnancy [is] not associated with significantly increased risks of congenital heart defects or of most other categories of birth defects. [We observed] associations between SSRI use and three types of birth defects, but the absolute risks were small, and these observations require confirmation by other studies.”

This study and others like it did not keep my GP, when I saw her on my Prozac mission, from suggesting that she would “prefer” I didn’t take the drug until week twelve or thirteen.

“But if you can’t make it,” she said, typing notes into her computer, “I’m okay with prescribing it now.” She then stopped typing and looked right at me. “As long as you know the risks.”

My doctor has my baby’s health in mind, I realize. But—way to be supportive.

“Perhaps I’ll just hold the bottle lovingly for the next few weeks,” I said. “Like a teddy bear.”

She laughed.

I understand, I went on, that as a general rule women should stay off everything in the first trimester. But isn’t there any evidence that a depressed mother can also be harmful to her fetus? Not really, she said, because that’s harder to quantify. What I understood her to mean was this: We see toddlers with emotional problems; we determine that all of their mothers were depressed or anxious during their pregnancies. But since so much happens between birth and toddlerhood to influence a child’s emotional state, it’s much more difficult for anyone to verify a concrete link between maternal depression and childhood mental health.

So I gaze longingly at my Prozac. In only a few weeks, it will be building in my system, doing whatever it does to make me feel better. And I can do it. I can make it. I am like a runner with burning pain in her legs, a few inches from the finish line, or a dieter warding off desires for a piece of chocolate cake.

These metaphors are absurd, unhelpful, and demeaning. I am trying, in acting like a strong woman, in making my decision while consuming a shit sandwich, to reject this language and this way of thinking. My difficult doctors were right: There’s a big difference between suicidal and too sad, too sleepy, too pissed. Yet the mother and her body and her mind—especially her mind—are the center of the family; they are its source, its foundation. Mothers need to be energetic, positive, patient, loving, and as present as possible. If I need drugs to embody these adjectives, then I need to take them. My children need me to take them. The medical community should direct and inform my taking of them as much as it is able to, but for now I have to keep my expectations of their knowledge and especially their support fairly low.

Women often have to endure. To tolerate. They also have to negotiate, evaluate, assert, reassert, assess, deliberate, and wonder. And cry. Because as I make the decision to take drugs, to go on Prozac as soon as the last day of week twelve has passed, I cry.

Bullet #21 on 20 Ways To Be a Strong Woman: “Make your decisions. Then weep.”

 *   *   *

Author’s Note: My daughter, Adele, is now four months old. She’s a champion cooer, nurser, and puker, and she’s been doing beautifully since her birth. The rest of my pregnancy with her was very hard—I was chronically ill with colds and bronchitis, which affected my mood significantly. When I was about six months pregnant, I decided to go up on the Prozac—from twenty milligrams to thirty, and it helped get me through and be more present for my now three-year-old son. 

In retrospect, I notice how doctors, when they discussed anti-depressants and my pregnancy with me, emphasized the safety of the baby in my body but forgot entirely about the needs of the one already here. Mothers need to be functional all the time, pregnant or not; along with their gestating babies, they and their families also need to thrive.

Anna Blackmon Moore is a writer and writing instructor in California. Her blog is dearadele.wordpress.com/.

Brain, Child (Winter 2009)

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At The Pump

At The Pump

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By Alexandria Peary

winter2009_pearyI’m lying on my side on hospital sheets low on thread count and high on antiseptics. The nurse presents me with my baby, a big-nosed reddish sleeper, while the progressive-seeming lactation consultant with dangling goddess earrings looks on. I am supposed to model different positions, and we are to see how well the baby latches on.

I fumble around, one breast angled out of the hospital gown, trying to arrange the baby around my still-engorged belly. All the while, I’m thinking, When else is it expected that one go topless in front of total strangers? This pink asterisk of my nipple seldom sees so much air.  It’s just assumed that a woman can seamlessly make the transition from a society of keeping covered to a place where she’ll be told to pull out her breast so that others can assess how good she is at using it.

“I guess I need a refresher course,” I tell her after a half minute of moving my breast like a joystick. I explain that it’s been two years between babies.

As the lactation consultant reviews the “football hold” and side-style feeding, I pretend to go along with it and make the motions. I feel like someone attempting reform, promising to eat healthfully but just waiting for the expensive diet coach or hawk-eyed spouse to leave the room to heave myself into the Godiva chocolates.

My breast actually aches—but not for my baby. No, it aches for its first postpartum bonding with the pump.

I’m just waiting for the lactation consultant to leave the room so my husband can dig out my breast pump, hiding beneath a pile of clean underwear in one of my bags. I feel like I’ve snuck a lap dog into the hospital. Although this baby’s waters broke three weeks early and I was unprepared, my hospital bags unpacked, I still managed to instruct my harried husband to find the breast pump. After my insurance card and meditation CDs, my Purely Yours was next on the list of crucial items.

Why don’t I tell her the truth? I wonder. That I don’t plan on breastfeeding at all? That I’m a full-time pumper? By the time this baby is six months old, I’ll have pumped (a conservative estimate) for fifteen days straight, and when I say “days,” I mean fifteen twenty-four-hour-day days.

For my first child, I pumped for seven months, and I’ll probably pump for nine months for this baby, which means I’ll have spent about 576 hours at the breast pump between November 2007 and August 2008. Like T.S. Eliot’s Prufrock, who could measure out his life in teaspoons, I can measure my time by the books on tape I’ve listened to while at the pump.

For my first daughter, I splattered many a tome with breast milk, including War and Peace. For this daughter, I’ll have listened to the thirty-six tapes of Gone with the Wind in less than a week and a half. And I’ll also have listened to so many John Grisham and suspense books that the plotlines will become as obvious to me as the pattern on a plaid shirt. For Christmas this year, my husband and I will treat ourselves to a deep freezer, the type people use for spare apple pies and sale-flyer pot roasts, which I will completely fill with tubes and storage bags of milk by the beginning of February.

My milk will spilleth over, filling this huge upright freezer, plus a waist-high freezer, plus the one in the fridge. The milk will come in a variety of shades of yellow, like paint samples chosen by someone who wants to redo her living room but can’t decide which shade she likes best. The sunflower yellow-orange of early days nearest to colostrum, the flat yellow after carb-laden meals, and the pale skim milk when I had salad for lunch.

*     *     *

I became a mother who loves pumping more than breastfeeding when Sophia was born two and a half months premature and had to be tube fed during her lengthy hospitalization.

The medical community expects that a mother will stop breast pumping once her preemie leaves the neonatal intensive care unit. After all, it’s the baby accustomed to the bottle who is supposedly prone to “nipple confusion,” not the mother. You’re not supposed to fall in love with your breast pump, to mourn the end of your relationship with the machine, as I did when I had to return my hospital rental. You’re not supposed to feel that the last time you turn the knobs is as sweetly sad as the last time another mother nurses her baby.

The first time around, breast pumping meant I was able to do something constructive for my severely premature baby. Pumping was something that I alone could do, not the extensive staff of expert doctors, nurses, or therapists. It was a continuation of my pregnancy—it had that same privacy, that same power to help someone grow. Every time during that confusing summer that I pumped at two in the morning and again at four, I was reminded that I could do something right to counter the irrational guilt I felt about my pregnancy’s early end. I could fill the freezer in the NICU ward as well as the one in her second hospital; I could inundate them with my milk until they told me to hold off. Pumping was a symbol of hope—of the future when Sophia would be freed from the hospital.

With this second child, Simone, born healthy, it’s different. Pumping will become a way to increase the thickness of the rolls of fat on her stubby legs, to build on her natural good health. Like my mother covering the dining room table with an excess of food, pumping will allow me to see the abundance of yellow gold that my body produces, the food that will be Simone’s sole source of nourishment. I filled the NICU freezers, and now I can fill the freezers at my own home. Pumping will also allow me to continue pursuing my doctorate, to be away from home for extended periods of time, and to share with greater equity parenting a newborn with my husband. If it weren’t for the circumstances of Sophia’s premature birth, I would not have known the benefits of full-time breast pumping.

Given all these rock-solid reasons for pumping, why don’t I tell the truth in my hospital room? Well, even with the amount of supportive cheer pumped into the air by the maternity floor staff, I can sense that my preference for pumping will be challenged. I’m the anti-poster child for the La Leche League—or at least that’s how I feel around other mothers. (My three-year-old daughter will have watched so many pumping sessions that she will point to my chest and ask where mommy’s “breast pump parts are,” referring to my breasts.)

A belief in full-time breast pumping is not popular among the mothering circles I travel in—the liberal, critical thinkers, rather than the commercialized versions of parenting seen in most magazines. While it’s true that no one has ever said to me outright that I’m wrong to feed my breast milk to my baby from a bottle rather than directly from my body, the message is in the air. It’s present when another woman tells me how disgusting frozen breast milk looks or tastes. This strikes me in the gut, as though someone had unplugged the huge freezer holding the evidence of all the hours I’ve pumped.

No one ever says how beautiful—how maternal—the image of the woman at the breast pump is.  On the box of the pump I own, a woman in a business suit sits at her desk looking robotic, as though she could just as easily be hooked up to her adding machine or laptop as to her breast pump. She’s certainly no goddess-like woman cradling humanity.

And no poster celebrating breast pumping will be seen above the OB/GYN examination table. And yet I fantasize about such a poster, a Madonna-like figure in blue robes sitting with a breast pump (you pick the brand) attached lovingly to her chest, beaming and beatific. For I am just as dedicated to pumping as another mother would be to nursing. I, too, become irritated when someone impedes me (with a class held longer, with a lingering conversation, with bad city traffic) from feeding my baby—that is, from pumping every three hours.

No one will come into the hospital room after I give birth and ask me about my pumping plans. I won’t readily find an extensive support group or service for the breast pumping, so if the pump suddenly fails because of a microscopic slit in valve, I may think it’s a problem in my milk supply and give up.

After giving birth, a woman is frequently asked whether she intends to nurse. The seemingly benign question hangs in the air. Once the desired response is supplied—Yes, of course!—it’s as though a curtain is parted from around the patient’s bed. The beaded chains rattle, and the patient is allowed entrance into the land of golden good mothering. Until the moment the question is answered, however, there’s the distinct possibility that the woman will end up on the other side, that of not-so-good-mothers, a landscape of pollution, television, and cheese-flavored snacks.

Breast pumping gets only half of that good-mother equation right. You’re making the milk, but you’re denying your child of the psychological benefit of your closeness, a benefit provided, the true believers insist, only through nursing.

My baby daughter seems not to have received that message. She’s oblivious to any concerns about her way of dining and happily “tops” bottle after bottle of my breast milk with a little smile on her face. And although our way of feeding the baby means my husband is frequently the one who is up at two in the morning, he feels he’s had more opportunity to bond with his daughters than most dads whose partners breastfeed exclusively.

And when he asks why I worry so much what the lactation consultant, my relatives, or the nurses think of my pumping, I have an unexpected answer. It’s not that I particularly care what people think of me. It’s that I’m protecting my pumping from them. I don’t want my breast milk to be contaminated by their conservative attitude—an unacknowledged contributor to centuries of others telling women exactly how to be women.

If I can just get out of the hospital with some pumping initiated, I will be free to do as much pumping at home, at the office, and in the car as I like, with no one to judge me except the occasional female acquaintance or relative. I won’t have to answer the phone when the nice lactation consultant makes her several follow-up calls in the week after I return home. I can sit at the kitchen table with two-year-old in high chair, a two-day-old in her bassinet, and a breast pump churning at my chest as the consultant’s voice fills the answering machine. I can surround myself with the maternal trinity of child, baby, and breast pump.

Author’s Note: While writing this piece, I discovered at iVillage.com a whole online community of mothers who exclusively breast pump. Like me, these women have experienced personal and professional blessings from exclusively pumping. I’m still pumping, several months after I had expected to be done (in fact, I’m pumping while I type this sentence), but I’m at the tail end of it. I’m trying to deal with the sweet sadness that comes from the prospect of ending.

Brain, Child (Winter 2009)

Alexandria Peary is an Associate Professor and the First-Year Writing Coordinator in the English Department at Salem State University. She is the author of two books of poetry, Fall Foliage Called Bathers & Dancers (2008) and Lid to the Shadow (2010). The latter was selected for the 2010 Slope Editions Book Prize. Her work has appeared in The Denver Quarterly, New American Writing, The Gettysburg Review, jubilat, Massachusetts Review, Fence, Crazyhorse, Spoon River Review, Verse, Literary Imagination, and Pleiades. 

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Bad Medicine and Good

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By Karen Dempsey

fall2008_dempseyMy breasts ached with the need to nurse Liddy as I stood at the pharmacy counter, gripping the prescription bottle of omeprazole the pharmacist had neglected to flavor. I knew that if I gave Liddy the vile-tasting acid suppressor unsweetened she would screw up her tiny face and cry, and when the liquid hit her tender stomach it would come straight back up. I had already delayed her ten a.m. feeding to pick up the prescription; she needed to take it on an empty stomach, before she nursed. I had left her at home with my mother and my eighteen-month-old son, Brennan. She was waiting for me, crying, I imagined, from hunger, and refluxing because of the crying.

The pharmacist’s voice and expression were passive as he stared at a computer screen and clicked the keyboard. “There’s no note here about flavoring.”

I leaned onto the counter, fighting the urge to scream or throw something. This pharmacy—a huge urban pharmacy in a national chain—had already failed to refill the prescription the first time I’d called. This was my third trip here in a week, and I still didn’t have what I needed. “She has to have the flavoring,” I said. “She can’t keep it down like this. I called last night, and they said it would be ready by ten.”

“I can mix it again, but it needs to sit for twelve hours. We can have it for you tomorrow.”

The week before, Liddy had stopped breathing after a feeding. She had just been diagnosed with gastroesophageal reflux disease. At the time, I didn’t fully understand the mechanisms of reflux, and I’d thought she was choking, gagging on spit-up. I had been sitting on the couch, her warm little newborn body curled on my shoulder, when she spit up and then spit up again. Milk surged up out of her mouth and nose, and she suddenly tensed and arched away from me, her face puckered and red. “Okay okay okay,” I said, and turned her over my forearm and vigorously rubbed her back as I’d seen a nurse do at the hospital, when she’d stopped breathing after birth.

Liddy’s face was scrunched closed, and she’d turned a deep purple. John was downstairs, out of earshot. My heart raced as I searched the bassinet for a bulb syringe to suction her mouth. Suddenly she gasped, and breathed, and relaxed into my arms. The incident was over in a moment, so quickly that I had a hard time believing it had happened at all. The next morning, I learned from her doctor that these episodes occur in reflux babies when the esophagus closes off to protect itself against the burning of stomach acid. The closed esophagus prevents the child from breathing. “That scares the heck out of me,” the doctor said. “Next time, don’t hesitate to call 911.”

I thought about saying all of this to the pharmacist as he stood before me, so dispassionate, in his crisp white coat. I could feel other customers watching me, and I knew that I must look like a mad woman—my tearful, red-rimmed eyes framed by the dark hollows of sleep deprivation. Like Liddy, I’d been sleeping for only forty-five minutes or an hour at a time. When I finally spoke, my voice was low and even, though I forced the words through what felt like a knot in my own throat, a swallowed scream or sob. “She is three weeks old.”

He took the bottle from my hand and walked away.

For a moment, I thought the conversation was over, but then I saw that he was mixing something. He came back out with another bottle and said that though my insurance would only pay for the generic version of the medication he had refilled it with the brand-name, Prilosec, because it mixes faster, and had added the cherry flavoring. He said to shake the bottle, then remove the cap and let it sit for ten minutes before giving it to her, to help the medication break down.

The gastroenterologist had warned me not to expect Liddy’s condition to improve until the medication had been in her system for a couple of weeks. Omeprazole does not actually prevent reflux from occurring. It simply reduces the acid content in the spit-up, allowing the damaged esophagus to heal over time. Still, I carried the bottle home flooded with relief that we could at least begin Liddy’s treatment.

The first few days, Liddy swallowed the medication easily, but something looked off. I held the dark brown prescription bottle up to the light in the kitchen, swirling the contents and studying the bottom of the bottle, where I could see little beads floating in the liquid. John called the pharmacy again to ask about it, and he received the same advice I’d been given: Shake the bottle, remove the cap, and let it sit for ten minutes before filling the tiny oral syringe. I kept looking at the bottle, though, and at the liquid in the syringe each time I filled it. A few nights later, I called the pharmacy again.

“Oh,” said the woman who finally picked up the phone, when I described what I was seeing. “Oh, no … that doesn’t sound right.” I heard distress in her voice. She told me she needed to hang up and check something, and then she would call me back.

My phone rang again within minutes. The flavoring they had used, she said, was incompatible with the medication. The omeprazole had failed to break down. It had stayed in the bottle, in tiny, silvery beads, as I fed Liddy cherry syrup twice a day for a week. “I am so, so sorry,” she said, assuring me that she would have the prescription refilled again, this time with a compatible flavoring.

The next morning, I took the kids on a major outing by myself for the first time. We went to the Museum of Science, Brennan’s favorite place on earth, and I managed to time Liddy’s feedings right and keep her straight and still for the requisite thirty minutes afterwards while Brennan rearranged the pieces of an enormous Lite-Brite and built a fragile wall with spongy, yellow blocks. The outing exhausted but also energized me because I had made it through the morning alone, in public, with two very young children.

When Brennan fell asleep in his car seat on the drive home, I took advantage of the relative quiet to call the pharmacy again. Yet another pharmacist answered the phone. At first, he could find no record of another refill. Stunned that anyone in the store could be unaware of the terrible mistake they had made, I retold the story, no longer feeling the need to hide my fury. He put me on hold and came back on to say that the medication had been prepared overnight, and the store had identified the correct flavoring, but they didn’t carry it, and they had not yet been able to arrange for a delivery.

“This is the eighth phone call I have made to your store about this prescription,” I told him. “I have been in to talk to a pharmacist three times. Someone has to take responsibility here. My daughter needs this medication, and you need to get it for me. Someone has to figure this out, right now, and that someone cannot be me.”

He promised to call me back.

I drove home, slipped Liddy out of her car seat and into the special sling-like seat that held her body straight and upright, then carried a sleeping Brennan to his crib. I sat at the kitchen table and dialed John at work; the moment I heard his voice I knew that my reserves of strength had dissolved. I wept as I described my latest, fruitless phone call. I had remembered another pharmacy, one that specialized in compounds, and I wanted to know if they could take the omeprazole already prepared by CVS and flavor it into a form Liddy could tolerate. I just couldn’t pull myself together to make that final phone call. I spelled “Skendarian” out for John, and he hung up to look for the listing.

Skenderian Apothecary is an independent, family-run store about a fifteen-minute drive from our house. I had been there only once, after Brennan’s birth, when, in the process of sterilizing the tubes for my breast pump, I had somehow melted them into a rubbery lump. I’d spent that desperate afternoon calling around for replacement tubes and posting a message to my local new mom support group listserv. Another mom had e-mailed to recommend Skenderian. I called the pharmacy, and the woman who answered told me to come right over. She kept the store open for me past closing time and showed me how to cut the ends of the tubes so they would fit my machine.

John called me back just minutes after we talked to say that Skenderian, which specialized in compounds, could take the omeprazole we already had and flavor it on a form Liddy could tolerate.

I called the big-chain pharmacy for the last time, and the young guy I’d spoken with on the drive home from the museum told me they had located the flavoring and he would spend his own time, after his shift ended, driving to the other store to pick it up so that they could have it ready for me that evening. He also suggested that, after this refill, I transfer my prescription elsewhere. His pharmacy—with one of the highest volumes of prescriptions in the area—was not equipped to do it.

I let him finish and then told him I would be in to pick up the prescription, unflavored, and that I would be transferring everything over to Skenderian. And then I hung up, and waited for my new babysitter to come and care for Brennan so that he could run his toy trucks through the back yard instead of accompanying me on the frantic drive to two separate pharmacies.

After fetching the bottle from the original pharmacy (along with the address for the complaint department of its national headquarters), I drove over to Skenderian and carried Liddy inside. A man who I would come to know as Robert, the pharmacy manager, met my glance from behind the counter.

“My husband called—”

Robert nodded and reached out to take the brown plastic prescription bottle I held in my hand. “I talked to him,” he said. “Let’s see what we’ve got.” He examined the label, then held the bottle up to the light just as I had a few minutes before. “Bubblegum or grape?” he asked.

I paced Skenderian’s immaculate waiting area. We deliver for any reason, read a sign posted over the registers. I looked around and saw, tucked into the corner, a basket of brightly colored toys and books. Several therapeutic chairs rested nearby, including one that bore a sign beckoning, Try this seat.

Robert came out with the uncapped bottle of omeprazole, and held it out for me to taste. “Sweet enough?” he asked.

Skenderian became a regular outing for the three of us, as Liddy’s dosages changed frequently and her medication regimen soon expanded to three separate prescriptions. On my second or third trip there, I parked outside and entered into a long negotiation with Brennan over how many matchbox cars he could bring in with him. When I finally got both kids into the store, Robert’s younger brother Joe was waiting behind the counter, holding a pen out to me. He had already located Liddy’s prescription, set it on the counter and flipped to the page in his notebook where I needed to sign for it.  My face must have given away my astonishment. He laughed and said, “I saw you getting out of the car. I know from experience that it takes a while with two.”

Most of the staff, in fact, knew me by sight once I had been in a couple of times. “How is Liddy today?” they would ask, reaching up to the shelf or into the refrigerator for whatever prescription I had called in.

We visited the store once or twice a week, and it soon began to rival the Museum of Science for Brennan’s favorite place on earth. He ran straight to the toy basket each time we walked in, digging for the red plastic van and the tiny dinosaur that had quickly become his favorites

I began to think of Joe as my personal pharmacist. He conducted a great deal of research after the shelf-life of omeprazole compounds came into question, and helped me determine when the time was right to switch Liddy from the liquid compound to solutabs, little tablets that break down instantly in water, which were easier to store and dispense. Joe would compliment me on a new haircut, and say things like, “You’re a good mother,” unsolicited, with utter sincerity. He told me anecdotes about his own two children, and said Saturdays were his favorite day to work because it is a slower day and he can chat with people.

The sense of ease and familiarity I felt with the staff took on new meaning as summer approached, when I finally admitted—to John, to my doctor, and to myself—that I was sliding into the depths of post-partum depression. When I spoke to my doctor about anti-depressants, I had a fleeting but intense desire to have her call the prescription in to some other pharmacy where I could remain anonymous. My cheeks burned when I went into Skenderian, alone this time, to pick up the medication. But Robert saw me walk in and sailed right over, asking gently, “We haven’t done these for you, before, have we?” And then he spent ten minutes advising me on easing into the medication. My eyes welled as he spoke, but he never looked away as he talked about beginning with half-doses the first few days and trying different times of day if the drowsiness was too intense. He cautioned me against taking cold medications, which would keep me awake when we both knew that I couldn’t afford a sleepless night. And he smiled when he said that a glass of wine, once in a while, would be okay.

Liddy suffered through eight or nine ear infections in her first eighteen months.  The pain increased her refluxing and fussiness and marked the periods of our most sleepless nights. With each new round of antibiotics, her pediatrician prescribed numbing ear drops to soothe the pain while we waited for the infection to subside. On New Year’s Eve, I checked our supply to see that we were nearly out, and desperately dialed Skenderian, hoping they had some on the shelf so that I could get it before the holiday.

The answering machine picked up and a prerecorded message told me the store was not only closed for the holiday but would close early for New Year’s Eve, at two p.m. I stared at my bedroom clock, which told me it was after three, as I listened to the message and the beep that followed.

“Oh, we’re fucked,” I said—into the pharmacy answering machine.

When I had confessed to John my reluctance, months before, to fill the antidepressant prescription with Skenderian, he had made me laugh by assuring me they already thought I was crazy.

So when I told him now about the message I had inadvertently left, he burst out laughing, then quickly composed himself. “I’m sure it happens all the time,” he said. Though I was sure I’d feel sheepish the next time I went into the store, I knew that they knew me and that they’d be laughing, too.

Author’s Note: The bad bottle of omeprazole sat on a shelf in my refrigerator for months. I kept it as a reminder of what we had gone through, Liddy and I, a reminder that I had held the pieces of the puzzle and that I had to fit them together, even when it was hard and I was tired. John took the bottle out one day when he was cleaning the fridge. “Why are we keeping this?” he asked. The stubborn silvery beads that had not broken down after all those months. I knew what it held and represented, and I didn’t need it anymore. I told him he could toss it, and I heard it disappear into the trash.

Brain, Child (Fall 2008)

About the Author: Karen Dempsey’s writing has appeared in The New York Times, Babble and other publications. She lives in Massachusetts with her family. Follow her on Twitter @KarenEDempsey or read more of her work at kdempseycreative.com.

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Don’t Speak

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By Liam Callanan

My youngest daughter, almost two, won’t speak.

It’s a problem, but not much of one, the pediatrician tells us—or rather, that’s what her mouth tells us. Her eyes betray a little more—I’m not worried now, but will be the next time we meet.

I don’t have to wait. I’m worried now. Maybe it’s perfectly normal for one’s child not to be a fluent communicator by eighteen months, but in our house it’s not. She has two older sisters who said more sooner, and worse yet, my baby girl’s father—me—is a fiction writer. If she makes it age two or twenty or beyond unable to catch a fly ball, fine. But she has to speak.

Right now, though, only the doctor’s speaking, and she says: Be patient.

***

Patience is a precious commodity in our house—Jane is the fourth of four girls. It may be that she’s not spoken yet because she’s not been able to get a word in edgewise.

And if the math is tripping you up at this point (1 baby + 2 older sisters = 4?), don’t worry—arithmetic is another problem area for us. Jane is our fourth child, but only the third we brought home from the hospital. She was born in 2007, her sister Honor in 2002, and Mary in 2000. Lucy was born February 19, 1998, and by the time I got to hold her in the hospital, she was already still and quiet. You have no idea how beautiful she was—or how quiet that room was. Up and down the hall, babies cried, mothers shouted, doctors and nurses called to each other. Anyone entering our room quickly fell quiet as soon as they saw the yellow rose a cautious nurse had taped to our door: hospital code for what had happened within.

We couldn’t be so oblique with our daughters. Instead, we followed the advice of experts and told them about Lucy directly. Just the minimum, we were told: Don’t overwhelm them. So we didn’t. But our girls occasionally overwhelm us. Every February, Mary, our oldest, reminds us that it’s time to buy the crib we purchase and donate each year on Lucy’s birthday. Honor, who inspires her teachers to ever-more elaborate euphemisms—”spirited,” “lively,” and, my favorite, “capable of extreme leadership”—will sometimes tell strangers in line at the grocery store about her “stone sister” (as in gravestone?) “who doesn’t speak.”

On the other hand, Honor will sometimes try to egg Jane into speaking in various public situations—which Jane never does. She smiles shyly, giggles or points, but she doesn’t otherwise greet the cashier or, say, the person behind her at church, or the other child on the playground.

***

At home, Jane’s a bit more loquacious. We’ve assured the doctor that we do hear “Mommy” and “Daddy,” and for a while, we were quite certain that her first official word would be “cheese,” which was fine with me. A word’s a word, and Jane was our first child to be born in Wisconsin. It would make a good story. But then cheese retreated, and Daddy melted into “Diddy” and then I started noticing that both I and Dora the Explorer went by “Diddy.” Then Dora’s friend Boots the Monkey, too. That’s not a good sign, I thought, but couldn’t think of a way to share that with the pediatrician: My daughter confuses me for a small lavender monkey.

***

Be patient, the doctor says, and we are, even though these are the months of the “language explosion” when other children—especially, it seems, the children of parents who blog—are learning a hundred words a day, and in multiple languages. That our doctor isn’t concerned yet is frustrating, but also reassuring. One of the things I like about her is her slowness to panic. When she asked Honor at age five to draw a self-portrait on her clipboard (I confess I don’t remember this diagnostic test from when I was a kid), and Honor instead drew a thigh-high stiletto boot and went to the other side of the form and marked “yes” beside all the “Abnormal Mental Health Symptoms” before we could get the pen away from her, our doctor did not commit Honor—or her parents—to an asylum. She smiled and said Honor was precocious and that she’d see her next year. She did, and Honor brought her a beautiful, full-length self-portrait—ponytail, crown, stiletto boots and all.

***

But the girls have always been good with doctors. Once, when the pediatrician finally did hit the panic button and send us to the Children’s Hospital emergency room—it was midnight, and Mary, seven, had been throwing up for twenty-four hours straight—we found ourselves in an exam room with a nurse practitioner who was going through her triage sheet. Midnight, and my daughter hadn’t kept anything down for more than a day, and had never been up this late in her life: “Would you say she’s acting … playful?” the NPT said. Mary’s head lolled against my chest. I didn’t answer. Two hours later, when the IV saline solution drip had miraculously restored her, the NPT returned to check on us. She whispered to me over the tubes and beeping: “How’s she feeling?” Before I could answer, Mary opened her eyes from her two a.m. nap and said just one word: “playful.”

***

In short, Mary and Honor are not shy—nor ever at a loss for words. When I told them I was reading at a local bookstore, they both asked what their role would be—they couldn’t imagine not having one. Since I’m still learning what it is to be a writer, and parent, and writer-parent, I said they could do whatever they wanted. Honor spun like a ballerina, fell, rose, and then curtsied to broad applause. Mary read a story that consisted of two lines: “I like chocolate. If you like chocolate, raise your hand.” When the entire audience did, she smiled and both girls gave me a look that very clearly said, Top that, Dad.

Of course, I’ve learned there is no topping them. What do you say when your six-year-old wakes you just before dawn, whispering at your bedside in the cold dark, Dad, I need a stapler? Or, when you’re invited to your daughter’s third-grade class to talk about “what writers do,” and after answering polite questions like Do you have a limousine? and Do you think of the words or pictures first?, Mary asks, “Dad, why are you so wild at home, and normal here?”
Speechless.

***

What could I say? That at home, I like plugging my iPod into the stereo and blasting whatever comes out so my girls and I can dance like popcorn in a kettle, because I spend all day very, very quietly sitting at a desk and talking to no one? That I’m wild with them—talking, tickling, tackling—because they’re so funny and so fun? That I will, and have, taken them to New York or Chicago or a random city some Saturday because life is short, and I’ve never been patient enough to wait for the adventures to come to me?

Or that I love talking a wild blue streak with them, dancing until we drop, because there was a day—a lonely cold one in February—that I thought I would never know a noisy life, that I thought my first daughter, so pretty, so silent, would also be my last.

Jane is our last.

Every milestone of hers that passes—smiling, sitting up, crawling, walking—is bittersweet. I already dread the day I dismantle the crib—the one we bought for Lucy, the one we’ve used for each girl since—and take it to Goodwill instead of storage.

And maybe Jane senses this in me. I wouldn’t be surprised if she understands everything we say. Maybe Jane knows that that first word will also be a last hallmark. Maybe she’s waiting.

Her sisters aren’t, of course. Honor has decided we’re aiming too low—she sits Jane down with chapter books, tries to get her to repeat words like “conversation” and “tiara.” Mary, meanwhile, recently completed a worksheet that asked her to predict the future. She came up with a list that included “boys will like Barbies,” “people will drive plastic cars,” and—”your first word will be fiction.”

Fiction?

Author’s Note: Jane loves fiction, loves cuddling with a book any time of day. And sometimes afterward, she will speak—low, steady, earnest, but absolutely unintelligible whispers that she sometimes punctuates by patting my cheek or nose. I want to ask Mary what she’s saying. Or, for that matter, Honor. I want to ask Jane. I want to ask Lucy. I want to ask all my girls if what I do all day as a writer is so different from what I do as a parent—imagine what might be, what could have been, and patiently, quietly, wait for the words to come.

Brain, Child (Winter 2010)

About the Author: Liam Callanan’s novels include All Saints and The Cloud Atlas. He coordinates the Ph.D. program in creative writing at the University of Wisconsin-Milwaukee. He’s on the web at liamcallanan.com.