Dear all:

There are many downsides to private practice that those who work for institutions may not realize.  If we do not have a partner who works for a company that provides health insurance, those of us who work in the US are at the mercy of paying the highest rates for health insurance because we cannot compete with the large businesses and we also compensate in paying higher taxes on our private insurance to cover those who don't have health insurance that use the hospital emergency rooms.  We have to set aside time for paperwork for insurance and billing and the IRS that is usually done by an institution if you receive a salary.  In New York City we have even more complicated rules and decisions about such things as "unincorporated business tax" and now -- the "commuter tax".  Employees get to travel for free.  The self-employed pay a $300 per quarter tax for being their own employee and using the subway.  And of course if we go to a conference during the week, no one is paying our salary to go -- we are losing business.

Yet there are upsides. One of the upsides is we have more flexibility to put our suggestions into terms mothers can understand.  I actually don't use any sort of hourly rule for babies at all.  Keep in mind that I don't see babies when they are in the NICU or when they are under 4 pounds because those babies are in the hospital.  Nevertheless I do see mostly babies who have been given a bottle and many of whom were assessed by their ability to survive bottle feeding and discharged with little assessment of their ability to remove milk from the breast.  So, I do see my fair share of babies who snooze and need nudging.

Instead of timing rules, I tell mothers to pick a time to start their 24 hour clock.  Make a simple tally of the number of feeds for that 24 hours and if the baby is not getting to 8 feeds as they enter the second half of the 24 hour cycle, start nudging.  I teach them to look for signs of light sleep and try arousing their baby based on those cues.  I usually find it is a waste of time to try to arouse a baby out of deep sleep.  And if the baby really needs lots of nudging, I have the mother drink lots of water before bed (so she will wake up sooner needing to pee) -- adjusting the quantity of water to her perception of how long she can go without peeing after drinking a lot of water.  This usually wakes women up in light sleep and most women do wake up.  If she has been on an alarm system from the hospital and is nervous about waking, I have her try the water trick and if she wakes up before the alarm, then I tell her to stop setting the alarm.  The problem with alarms is that they can wake women in deep sleep, rather than light sleep, and are more disruptive to their sleep rhythms.  

I think that half the reason that women are so tired in hospitals at least here in Manhattan is that you have lots of noise and bright lights and people interrupting you day and night and very little of it has to do with the newborn at all.  I remember a couple of lactation consultants used to quote some figure that there are 80 + interruptions a day for postpartum women in the hospital.  The few times I've been coerced into seeing a mom in the hospital (and from my own experience) I've found that to be pretty accurate.

Best, Susan Burger

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