Thursday, November 27, 2014

Being Thankful, Being Inspired

lighting up my life and making
me cherish every second!
I am wishing everyone a happy Thanksgiving this year and hoping that among your many blessings, you are thankful also for good health and celebrating that health and your ability to be active to the best of your capability by doing some form of exercise with family and/or friends today! I am now 3 months into my 3rd go-round of knee rehab (my first beginning 20 years ago after my first knee surgery), and I can't help but think back to what a profound appreciation I had my first time back on the basketball court after rehab. I wouldn't wish an injury or a surgery or anything ill upon anyone, but it really does give you pause when you start to express frustration in your athletic and fitness accomplishments, if you can hold onto that sense you had before of the miracle of recovery and remember how far you've come and be thankful that you are physically able to do whatever it is that you did today- be that bending over to tie your own shoes or running or walking down the street. I almost feel that my postpartum knee issues have come along because now is a time for me to reflect on that first comeback and realize how much stronger and more appreciative of my health that made me, to be with my baby and family whenever possible, and to get stronger mentally and physically for whatever the next hurdle is.

Today I am thankful for my loving and patient husband and my amazing baby girl. I am thankful for our extended family that keeps us going and shows us nothing but love and support. I am thankful for caring friends, near and far. And I am thankful for health and fitness. I may often be disappointed that I am sick or not sleeping or not able to run or exercise for whatever reason, but I am able to do my job, and I am on my way to getting stronger, and I know this journey back is in front of me for a reason. Today I ran 2 miles to test things out (of course I would wait until the first snow fall of the year to get back on the pavement), and I'm in pain now, BUT, I am  thankful for the opportunity to try. And I am thankful for having a daughter and a husband and friends and family and patients who all daily inspire me to be a better mom, wife, friend, physician, and human being. This holiday season, I hope you will all be thankful for your own health and fitness and your own opportunity to try to get better. Good luck and good night.

Happy Thanksgiving everyone.

If you need more reasons to be thankful or more inspiration, look no further than this girl.

On deck:
-The Nursing Mother's Triathlon, Part III
-Foot health
-Spine health

Thursday, November 6, 2014

The Mommy-Baby Core Workout

Shoulder press with baby :)

My Favorite Mommy-Baby Core Workout 
More exercises to correct the anterior pelvic tilt and weakened hips and core strength that occurs during pregnancy. See last blog on pelvic floor syndrome, The Ultimate Core.

*warm-up - grab a kid-friendly playlist and dance/sing with your baby, you can throw in some shoulder presses with baby to increase your heart rate and work shoulders while dancing (Violet LOVES those) 

*pelvic tilts - not as much movement involved for baby, but talk to baby or sing while baby is held in a seated position on your abdomen while you are lying on your back with knees bent and feet flat on the floor, rock your pelvis to flatten out your back and push it into the floor. Hold 10 seconds, set of 10.

bridges with baby :)
*advanced pelvic tilts – if the other ones seem to easy, add these to your repertoire- after rocking your pelvis and pushing your lower back into the floor, lift one foot off the ground, lifting the knee toward the chest (thigh vertical). Return and repeat on the other side. x10.

*bridges - again with baby held in seated position on abdomen, lift butt/pelvis off floor; if with baby, hold 2 counts, lower, repeat, for set of 10. Without baby, hold 10 seconds, set of 10.

*modified bridge – do them without baby, build up to holding for 10 seconds, set of 10. You can also do them against a wall if you need more modification.

Figure 1.
Photo credit:
*advanced bridge – without baby (bouncer or gym for him or her while you do these), bridge up, then while keeping pelvis level, lift one leg and straighten it out, holding it even with other thigh, hold for 10 seconds, set of 10 on each leg. Alternatively, you can hold the leg bent as in figure 1. An even more advanced exercise is to bridge up with one leg, but be sure to build up to this and use the correct muscles, so as not to strain the back or hamstrings.

*floor press - to give baby something a little more interactive, throw in some floor push-ups. Start by holding baby on your tummy in a seated position while you are lying on your back with knees flexed. Do a pelvic tilt to make sure you engage your core muscles. Then bring baby overhead with your arms straight up in the air, next bring baby down toward you, keeping your elbows in to recruit triceps and chest muscles, push baby back up toward the ceiling in a press. Violet also loves this one.
floor press with baby

*"bird dog" pose - this is core, this is balance, and it has many variations for even more fun! On all four's with baby beneath you, lift your opposite arm and leg parallel to the floor (see figure). If too difficult, do just one arm or just one leg. If not difficult enough, do the unilateral arm and leg. If still not difficult enough (What are you, Superwoman?), do this while closing eyes (not so recommended if doing with baby, but makes exercise more difficult). Hold 10 seconds, set of 10 on each side.
Figure 2. Bird Dog Exercise.
Photo credit:

*"kissing" push-ups – with baby on the floor - do a push-up over your baby and smile and count. When I go down, I give Violet a kiss on the forehead or cheek, and then when I push back up, I smile and count the number of the push-up. She pretty much thinks this is the best game ever, and she is basically learning all her numbers at the age of 5 months as well as the importance of exercise and strength training. She is going to be such a prodigy. ;)
I love that Violet loves these push-ups so much.
She could probably do them all day...Mommy, however,
cannot, at this point, anyway! ;)

*make more core - make any standing arm exercise or lift with your baby into a core exercise by re-training your body to use your lower abdominal muscles (and Kegel while you're doing it, too, if you can neuromuscularly multitask that much). Give yourself a gentle bend to your knees, tilt your pelvis backward slightly and contract your lower abdominal muscles- then do your lift.

*cool-down/dance more with baby :)

Remember, happy and healthy mommy = happy and healthy baby!


The Ultimate Core

At long last, the route of all postpartum and even pregnancy problems when it comes to maintaining fitness and health- pelvic floor syndrome/dysfunction! All the fellas out there, read no further if you can't stomach it, but wouldn't it be nice to know what your mom went through for you and what your wife or sister or friend is going through, so you can be more supportive when she is a little cranky postpartum (or any other time in life, for that matter!)?

What is the pelvic floor?

Pelvic floor is the term for the muscles, ligaments, and connective tissue that support the female abdominal contents like the uterus, bladder, vagina, and bowel. My favorite thing about the pelvic floor (as if I have so many things that I like about it) is that people describe the muscles themselves by saying, "the muscles you use to Kegel," and they describe Kegel-ing by saying, "You know, contract your pelvic floor muscles, the muscles you use to stop and start your flow of urine." Well, now that that is all perfectly clear to those who haven't done an anatomy class or who aren't OBGYN's. Honestly, I have seen and dissected the muscles in anatomy class and also done my fare share of pelvic exams during medical school and residency, and you still need to train yourself how to use them and Kegel properly, especially after pregnancy when everything is a wee bit different down there.

What is pelvic floor dysfunction?

Pelvic floor dysfunction encompasses a wide range of issues that result from weakened pelvic floor muscles that ranges from urinary or fecal incontinence to uterine or other pelvic organ prolapse. There can be impairment of the sacroiliac joint, lumbar spine, coccyx, or hip joints. The surrounding tissues can have increased or decreased neurosensitivity leading to pelvic pain. Pelvic floor syndrome is more of a pain syndrome that could mean that you have pain with intercourse or experience pelvic pain even after 6 months postpartum. This is all so uplifting, isn't it? Don't worry, I am writing this blog to help!

What causes it?

The major known causes of pelvic floor dysfunction are obesity, menopause, pregnancy, and childbirth. There may be an inherited deficiency in collagen in some women that makes them more prone to developing these problems. They have researched whether pelvic floor syndrome results more from traumatic births or methods of delivery, but the percentages are the same if women had vaginal births vs. C-section, so it's really about all that time your body and your collagen adapted to carry your baby in your uterus during pregnancy. At least 1/3 of women will have one of the conditions that make up pelvic floor syndrome during their lifetime.

Why core training is important
Photo credit:

Everyone thinks that "core" is just your abdominal muscles, but the pelvis (sacrum and ileum) has to stabilize itself during gait to absorb the forces that are distributed from the trunk and upper extremities to the lower extremities. The SI joint is at a pivotal place on the pelvis, where the hips and spine intersect. There is increased joint laxity during pregnancy, particularly in the SI joint, which causes a lot of women to have SI joint pain or even neurological symptoms in their legs. Unfortunately, the increased joint laxity experienced during pregnancy can continue postpartum, and the entire pelvic floor can remain weak and lax. Moreover, the positioning that occurs during pregnancy, the increased lordosis (sway back) and anterior tilt of the pelvis that occurs during pregnancy takes time to undo with neuromuscular re-training. All of this means that the muscles that help stabilize your CORE, your whole skeletal system, and allow you to absorb the increased forces that occur when you are walking, running, and jumping, need extra training. These muscles include muscles in the hip, pelvis, and trunk. It's not just about abs anymore, ladies.

Tips for Kegel-ing

1. Find the right muscles.
You can find those elusive muscles used for Kegel exercises by stopping your flow of urine. The muscles you contracted to do this are the same muscles you will need to contract for a Kegel. If you are still having trouble, if you aren't sure if you are Kegel-ing properly, or if you think  you are Kegel-ing properly but you still have urinary incontinence, ask your OBGYN for pelvic floor physical therapy (Yes, it exists).

2. Find the time.
Some women do them at traffic lights!

3. Use Type I and Type II muscle fibers…
Contrary to popular belief, doing 10-second contractions for multiple repetitions isn’t always the way to go. Your pelvic floor needs strengthening of both Type I and Type II muscle fibers; you need endurance to hold urine at all times, and you need fast-twitch fibers to make a forceful contraction during Valsalva (sneezing, coughing, laughing, and other actions that increase intraabdominal pressure) to prevent sudden leakage of urine.

4. Build up to 80 to 100 contractions per day.
Begin as early as 1-2 weeks postpartum with five repetitions of five-second contractions, with five seconds of rest in between, while lying on your back. At 4 weeks postpartum, try these in various positions, lying on your side, sitting, standing. Do two or three sets. Then switch to doing 2-second contractions (Type II) with four seconds rest. Then gradually progress to doing Kegels while walking or lifting things. Build up to 10 repetitions of 10-second contractions. Then add multiple sets per day of both 10-second contractions and 2-second contractions. The goal is 80-100 of both types by 2 months postpartum...

5. Pace yourself, be consistent.
I was definitely not there at 2 months postpartum! Don’t feel behind; pick up where you can and do what you can do. The goal is 80-100 contractions daily, doing them during activities, even while running. Do not despair. It takes time to progress, but before you know it, you’ll be running and coughing (valsalva!) at the same time without peeing on yourself! (It could take 6 months postpartum to get there.) 

6. Seek help.
If you are having urinary incontinence at 6 weeks postpartum, you should be asking your OBGYN for a referral for pelvic floor physical therapy. Some women are still experiencing these issues 6 months to a year after childbirth, and some women experience it again during menopause or never seem to get better. There are surgeries, there are inserts, and there are a variety of over-the-counter pad options. One new option is Under There Solutions, a group that seeks to help the 1/3 of women who experience urinary incontinence. They have fashionable absorbent panties, so you don't have to wear smelly and uncomfortable liners or pads. They are also starting to work on biofeedback intriguing does that sound? I know, you'd rather your pelvic floor PT work right away...but, in the meantime, why not? You can learn more by going to their website,

Guidelines for Core Conditioning:

The more I progress through the postpartum period, the more I really wish I had (1) done more strength training during pregnancy and (2) that I had done more core strength training prior to initiating running postpartum. After going through it myself and after seeing many women returning to exercise post childbirth and presenting with injuries to Sports Medicine clinic, I have a few guidelines:

1. FMS prior to return to sport/exercise
I would really recommend that all women get a functional movement screening after pregnancy by a trainer, physical therapist, or Sports physician. This way the problem areas can be targeted before too much stress is applied to the joints and to the anatomic positioning that has taken 9 months of pregnancy and however long postpartum to develop.

2. Be patient
What? You mean being patient as a mom extends past just motherhood and relates to all of your life now? Know that it takes time to retrain all of the neuromuscular adaptations that brought you that amazing baby of yours. 

3. Be consistent and persistent
Sometimes this means that you miss some days and have some setbacks because we all know that mothers have other things to do besides exercise. BUT, remind yourself how important this is for your health, mentally and physically, as your baby grows. Your baby gets heavier and more active, and you need to have good strength and core stability so you don't injure yourself picking your baby up from a low level or running after your toddler later on. And you know that since you have become a mom, you have forfeited any right to get that extra 15 minutes of sleep that everyone else seems to get, so, just get up out of bed when that first alarm goes off and have your time to yourself to do some core strengthening exercises and clear your head before the day becomes busy. Every day makes a world of difference, but even just 4-5 days a week, if you are consistent, will show you results if you stick with it.  
Preview of the next blog - look how much fun this girl is having!

4. Have fun with your baby!
I have been doing my PT exercises (knee rehab + core strengthening) with Violet. This makes me much more likely to get it done (since I don't have 2-3 times per day to spend 30 minutes doing something without Violet), and it also makes them way more fun! I do as much as I can of my exercises with her in her bouncer, or I play with her while she's in her "gym" (Fisher Price activity gym; she LOVES it and it is a total lifesaver if you don't have one). Then when she gets bored or fussy, she gets to come with Mommy to do more exercises. Stay tuned for my next post on the Mommy-Baby Core Workout. 

Dr. Eliza Myers (A.K.A. Superwoman) fitting
in exercises with her daughter during pregnancy! She
used the DIA Method to help with diastasis recti.

5. Start early?
I can't find anything evidence-based that shows that pelvic and core strengthening during pregnancy improves postpartum outcomes, but it can't hurt, right? And, anecdotally, I have the story of one amazing lady who did do exercises to train core muscles during pregnancy, and she reports that it made a huge difference. Think you don't have the time or the energy during pregnancy? Just take a look at this amazing wonder-woman-mom who is not only a hospital attending, a mother of 2 (now 3, actually), doing her exercises with her kids while pregnant! How is that for the ultimate motivation?

References/More Info:

Geraci MC, et al. Evidence-based treatment of hip and pelvic injuries in runners. Phys Med Rehabil Clin N Am. 2005 Aug;16(3):711-47.

Saturday, October 4, 2014

Jogging Strollers: Safety and Changes in Running Biomechanics

Running Stroller Safety
Violet is 4 months going on 5, and her head control, torso
strength, and motor skills have been exceptional since birth,
and I really feel like this kid will be crawling any day now, no
joke, BUT I am still not taking her out in a jogging stroller
any time soon. She has her walking stroller and loves it! :)
Is your baby ready?
Before 6 months of age, babies just do not have the head and neck control and neuromuscular tone required to stabilize themselves while you jostle them around to get your running chi on. Yes, there are infant car seat adapters for popular jogging strollers like the Bob, but I would recommend against these. We pediatricians discourage anything that can rattle a baby’s brain since we don’t like shaken baby syndrome and retinal hemorrhages. If you think it’s fine for your baby, just take a look at how much your baby’s head moves around when you try to sit him or her up. Some babies aren’t even ready for jogging strollers at 6 months, but this age is the minimum as far as I’m concerned. Just my professional opinion.

Are you ready? Altered Biomechanics –

Being ready to run postpartum is a little different than being ready to run with a jogging stroller postpartum. Pushing the jogger requires additional abdominal strength to stabilize your torso and pelvis while you are pushing with your upper body. You need increased gluteal and hamstring activity to push the weight of the jogger because you lose forward momentum generated by shoulder drive. People often compensate for this by increasing foot turnover, i.e. shortening running stride. Unfortunately, this has a potential to stress the sacroiliac (SI) joint and can be especially problematic for women who already experienced SI joint pain during pregnancy. The remedy is to try to maintain as much space as possible between you and the stroller to give yourself a more regular stride. Some physical therapists recommend pushing the stroller out in front and maintaining regular stride while using the safety strap to maintain control of the stroller, only in safe flat areas. This is not a good idea for your child, though, as this is NOT SAFE, no matter where you choose to do it. Try running with a partner and taking turns pushing the stroller, or keep your jogging stroller runs short, so that you aren’t altering biomechanics for hours on end. If you are having SI joint pain or dealing with different nagging injuries, you may need to find a different way to get in those runs (i.e. don’t use a jogging stroller) or consult a PT or Sports Physician to see how you can alter your stride. Women are particularly weak in the hips, core, and pelvic floor musculature after having a baby (next blog: pelvic floor syndrome!!!), and even running without a stroller can lead to injuries if you don’t strengthen these muscles and correct your mechanics prior to hitting the road. More on this next blog.

Do you have the right stroller?
There are so many out there and choices can be overwhelming! Even picking one brand often still leaves you with many options of different models. In general, you shouldn’t be running with a regular stroller. A stroller specific for jogging is preferred, usually with a single front wheel that provides better steering for running. Check out some of these top brands:
Top-of-the line stroller maker for dedicated running parents.
Baby Jogger F.I.T.
A mid-price range brand stroller, it offers your child a wide seat and folds nicely. The fixed wheel can be challenging for maneuvering.
The classic bike company has branched out into the stroller market. It offers a simple and affordable stroller.

Additional Tips:

◊ Pack and schedule runs wisely.
Bring hydration and snacks for the both of you. You are working harder and need the fluids and nutrition and kids need snacks, let’s just face it. Try to schedule a run pre-naptime or another time when your child is likely to enjoy the ride without getting fussy or cranky. You may have to go for shorter runs than anticipated. You can also run to a park and let your child play and run around, then run home. Having a short break mid-run makes for a happier child in the stroller.

◊ Protect your child from the environment
This means proper clothing, a shield for colder wind, dressing your child appropriately (in general, one more layer than what you would be comfortable wearing if you were just sitting out in the weather and not running), and also avoiding running near cars or other dangers whenever possible. Control your environment as much as you can. You’re not running alone anymore!

Use the full harness and consider a helmet.
I know it sounds nutty, and I guess it depends on how safe your environment is and how fast you are going, but think about what would happen if a crash were to occur. The harness is a must because it will prevent your child from falling out or getting shaken around. Depending on the age, you also don’t want your child to get fingers caught in the wheels. Yikes!

Don’t run hands-free.
We mentioned this before, but, although this is a great way to preserve some of your running form and give your SI joints a break, it’s not safe for your child or others who may be on your running path. Yes, there’s a safety strap, but it’s just not worth it. A better idea is to have a running buddy and take turns for who pushes the stroller, so each of you get a break for full regular strides. You can also alternate pushing with one hand on the stroller to help give your legs a break, so that you get at least one arm with your natural arm swing that helps you drive through your stride.

Don’t look to PR. It’s a “jogging” stroller, not a sprinting stroller.
Consider stroller runs resistance workouts and alter your goals accordingly. Expect one minute per mile slower than your normal pace. Speed and other form runs really should be done alone or on the treadmill. Sorry folks, but feel good about the fact that the jogging stroller workout is improving your core and back strength. You may even notice that running sans stroller makes you feel light and effortless with improved PRs!

Father-daughter duo: Iram Leon, who has brain cancer, crosses
the finish line with daughter Kiana 
at the Gusher Marathon in Texas.
Okay, so this guy isn't the best example of not PR-ing, BUT,
isn't he basically your hero now?
Build up gradually.
Mix in jogging awhile doing your regular stroller walk, then work up to running only with an empty stroller, then try with your child.

Follow race rules (some don’t allow jogging strollers), start in the back, safety first, and remember that when running with your child, it’s about the journey, not the destination. Run slower and enjoy the ride.

References and More Info:

Gregory, et al. Physiologic responses to running with a jogging stroller. Int J Sports Med. 2012 Sep;33(9):711-5.

Smith, et al. Physiological and biomechanical responses while running with and without a stroller. J Sports Med Phys Fitness. 2005 Sep;45(3):270-6.

Looking for a fun way to get your child involved in your workout? Check out Stroller Strides! 1,112 classes in 47 states!!!

On deck: Pelvic Floor Syndrome! (I promise, it’s really happening. Been doing some more research!)

Wednesday, August 27, 2014

The Nursing Mother's Triathlon, Part 2: Got Milk?

Finding time can be the most difficult logistic thing to overcome when trying to get back to your normal fitness routine as a nursing mother, but once you have that part figured out, chances are you have stumbled onto the next hurdle- keeping up your milk supply while staying active.

The Science:
Pathophysiology of lactation
Our bodies have very low estrogen and progesterone while nursing and high levels of oxytocin and prolactin for lactation. I did finally find some studies on nursing mothers who exercise, but don’t be overjoyed just yet. The most recent studies I can find are from the year 2000, and they were on lactating cows!! So please email or message me if you are a nursing mother who exercises, a formula-feeding mother who exercises, or a mother who does either but does not exercise (we need controls) and are interested in being part of a study on all of this stuff! What we know so far based on what studies have shown:

1.       Oxytocin blunts the stress response that is normally produced during exercise.
This has been shown by studies on lactating and non-lactating women and measurements of cortisol and ACTH post-exercise. Pretty neat stuff.
2.       Exercise may attenuate lactation.
Rat studies only, so we obviously need more research on this to fully understand what is going on in the human body of a lactating and exercising woman. Theoretically speaking, extreme exercise could throw off the balance of the hypothalamic-pituitary-adrenal axis that controls all of this and cause a decrease in milk supply. I'm sure it's not true for every woman, since there are women out there doing Ironman races as nursing moms...not too many, but they're out there.
3.       Nursing mothers take longer to lose pregnancy weight than formula-feeding mothers.
Studies have shown that nursing mothers eat more calories than formula-feeding moms, and it is postulated that this is why nursing mothers take longer to lose baby weight than formula-feeding moms (6-9 months as opposed to 2-4 months). However, no studies have looked at weight gain in the baby as a measure of whether lactating mothers are or are not taking in adequate calories. 

Showing that lactating women retain pregnancy weight gain longer than formula-feeding mothers due to increased calorie intake is only the first step since this does not tell us if milk content is sufficiently caloric or nutrient-dense for the babies and whether they are gaining weight. It also doesn't help us know what calorie goals we should have as nursing and exercising moms to ensure that our babies are still getting the calories they need. I really want to study this, folks, but, moving on…

GOT MILK? What to do when you have problems with supply
If you have noticed a drop in supply following returning to workouts or after increasing workout intensity, here are some things to consider:

1. Are you well-hydrated?
You probably aren't. You know that hydration is always rule #1 with me, and until you are urinating a very light yellow color (almost clear), you could always use more fluids. See tips on hydration from last blog post here.

2. Are you sleeping enough?
Of course not. You are a nursing mother! But, are you sleeping enough to make the milk supply that your baby needs and to have enough energy to be the mom you want to be? These are the important questions. No one can tell you how much sleep you need, but most adults need 7-8 hours of sleep a night. Very few of us are getting that, but that's what studies show is healthy. To be honest, during Ironman training, I need 9-10 hours of sleep a night. That's just what my body needs to recover adequately from heavy endurance workouts. Hence, I'm not Iron-training with a newborn. Since my daughter's birth, I can count on one hand the times I have gotten the 7-8 hours recommended for adults even in the form of cumulative sleep in 24 hours. (A lot of that has to do with being a pediatric resident in addition to a mom, but some of it is just motherhood.) What I have found helpful is getting a larger chunk of sleep at night, up to 4-5 hours, and then trying to nap during the day. I don't really get to nap during the day when I am working or when I am off and taking care of Vi by myself because now she really doesn't nap during the day, so this doesn't happen often, but, if your baby and your schedule give you the opportunity to nap or sleep longer, then you take it! I know this sometimes means missing out on your one opportunity to work out that day or your one opportunity to clean up the wreck that is your house, but sometimes sleep is more important, especially if you are noticing a decrease in milk supply.

3. Are you eating enough?
Although nursing mothers are encouraged to eat an additional 300-500 calories per day, it is hard to know for each mother/infant combo how many calories are needed for nursing. Oxytocin, the hormone that helps your body produce milk, also works in digestion, and different women respond differently to this hormone. For some women, nursing may use many calories and make them lose all of their baby weight, and for others, it may make them more efficient at digesting food and getting calories from it, thus more efficient at making milk on less calorie intake. All I can say is that this goes along with what we learned about exercising during pregnancy- you have to listen to your body. In this case, listen to your body, to your baby, and to your milk supply! In general, try to maintain a healthy, varied diet rich in fruits/vegetables, high in fiber (That’s for you so you are not constipated!), and include some omega-3 fats. Remember you should be having liquids throughout the day and frequent snacks with lean protein. I have tried everywhere from 1700 to 2500 calories per day, sometimes with additional calories on harder workout days, and I have to tell you that what gives me the most energy and the best milk supply is eating a snack every 3 hours…which makes sense because it goes along with how frequently I am pumping while away from my baby. When I am with her and nursing her all day, she is my cute little milk monster and eats every 2 hours and I just try frantically to keep up :-P (Disclosure: not every baby eats like Violet does at her age; she is just sleeping a ton at night and has to get in calories when she is awake. Don’t hate me for having a baby that sleeps- I rarely see her. I also don’t anticipate this lasting long!)

On a more superficial note, I often wish my body was smart enough to take the fat that still lingers on my hips, belly, and thighs for Violet's milk, but it's just not; apparently oxytocin makes my body even more efficient at extracting calories from food than endurance training does! I have come to the conclusion that while nursing, you have to decide that yes, you probably could get in excellent shape and be super fit, but, milk supply and your baby's health are more important. If you don't come to that conclusion, then that's also fine, but you might need to supplement more with formula. Ask your pediatrician when you are making that decision.

4. Are you taking time to relieve stress?
If you have been reading this blog for very long, you know how I feel about stress and cortisol. They can help your body overcome amazing things, but when you are trying to lose weight or you are trying to pump milk, they can be real downers. If you are extremely stressed out, your milk production and your letdown reflex are going to suffer. Postpartum anxiety is a real thing, too, just like postpartum depression. If you are having trouble dealing with emotions or dealing with any of this (It's okay to have trouble. Parenting is a tough job, and so is nursing.), then make sure you tell your doctor. I can't tell you how to find balance for yourself any more than the next person can, but when you feel like it is all too much, chances are you need a break, even if it is a short walk without the baby, a light workout, or getting your nails done. Remember that a happy mommy means a happy baby. They pick up on our stress often before anyone else does, including ourselves! And stress does affect you physically, including your milk! Take care of yourself, so you can take care of your baby. It's really ok to do something for yourself regularly; I give you permission.

5. Avoid hormonal birth controls and medicines that can interfere with lactation.
Always ask your doctor if you are not sure if a medication you must take falls under this list.

6. Cluster feeding...
Sometimes babies feed every hour in the evening hours to store up on calories and fill up before going to bed. This does not mean you are losing milk supply, and it does not mean your baby is starving and not getting enough milk. Try not to supplement during this time because your baby is doing a great job of stimulating your body to produce more milk with this frequent feedings.

7. Growth spurts!
Maybe it seems like you are not pumping as much or your baby needs to nurse constantly, and you worry that you are having a drop in supply, but really it could just be that your baby is growing more and increasing his or her nursing frequency or milk intake over a few days to a week in order to take that next step up. It's hard to know for sure until the growth spurt is over, and it's more complicated when you are exercising, but this is something to consider. Major growth spurts generally occur at 7-10 days, 2-3 weeks, 4-6 weeks, 3 months, 4 months, 6 months, and 9 months. But, as a pediatrician, I have to tell you, they are just growing all the time that first year. It is a period of major growth. Nurse as frequently as you can to stimulate milk production and make sure #1-5 are taken of. After that, we can move on to ways to increase supply...

Methods to Increase Milk Supply

1. Mindful pumping
Violet watching Mommy doing her PT 
exercises. Looking at a cute picture like 
this, of course you will pump more milk!
 Make sure when you are pumping that you are giving your body the opportunity to get the most milk out of that time spent on the pump. Work can be stressful. It's important that when you go wherever you are going to pump that you make a mental separation for yourself. Grab a snack and some water, go to your pumping place, take a deep breath, and RELAX. Look at pictures of your baby or have a video of your baby to watch. If you continue to do your desk work while you are pumping, the amount you pump won't be nearly as much as it would be if you were thinking of your baby. Recorded cries from your baby are also helpful because our bodies are physiologically wired to respond to that.

2. Pumping frequency
When away from your baby, try to pump at least every 3 hours. You can get away with every 4 hours, and you should never go longer than 5-6 hours without pumping, but if you are trying to keep up with a baby in a growth spurt, or if you are noticing a drop in milk supply, then aim for every 3 hours. This also goes for night time- sorry folks, but you shouldn't go longer than 5-6 hours without pumping even at night. You get a better pump output and letdown if you pump when you wake up naturally, so try not to set an alarm to pump. I usually wake naturally at 3-4am, so that is when I pump and sometimes even workout because it gets trickier to fit that in later in the day.

3. Pumping technique and hand expression
Try changing the setting on your pump to increased frequency when your letdown slows on the pump and then go back to the slower frequency once letdown happens again; try to stay on the pump for a full 30 minutes if you have the time to ensure that you get multiple letdowns during the pump. (I have a really slow letdown at times, so I always get more if I stay on for 35-40 minutes, but I only do this during my morning pump when I have gone 5 hours between feeds/pumps.) Hand expression is also clinically proven to increase milk supply. You can hand express while pumping, and this has been shown to increase the amount you pump. However, it also helps get your baby to feed better on the breast for babies that are slow feeders. Go here for instructions on how to do breast compression while baby is feeding: There are also YouTube videos out there on this stuff, and your lactation consultant can also work with you to teach you how if you are having trouble.

4. Let your baby do the work
Pump on your way home and have whoever is watching your baby not feed in the hour or so before you are coming home, so that when you get home, your baby will be very hungry and stimulate milk production. If that sounds mean to you, just remember that your breasts should make milk while your baby is nursing. Another thing to try is a whole weekend or 2-3 days of high intensity nursing. Nothing stimulates increased milk supply like your baby! Spend a couple days with your baby and nurse for every feed (no bottles), so your baby can ramp up your supply. This works. Whenever I have a weekend off to be with Violet, I go back to work on Monday, and my boobs ache all day and I always look forward to when I get to pump because I am making so much extra milk.

5. Galactogogues
Galactogogues are substances that have been shown to increase milk supply in some studies. There are natural ones- almonds, oatmeal, fenugreek, milk thistle, etc. There is mostly anecdotal evidence to support these. Fenugreek has the most evidence, but anecdotally, it doesn't work for everyone. There are medicines that can be prescribed by your doctor, such as metoclopamide (available in U.S.) and domperidone (Canada only) that may also help. These work by blocking dopamine receptors and increasing prolactin levels. It doesn't hurt to ask your doctor if you have tried everything else.

Good luck, ladies!

On deck:
-Part 3
-pelvic floor syndrome and athletes
-running stroller safety


Altermus et al. Suppression of hypothalamic-pituitary-adrenal axis responses to stress in lactating women. J Clin Endocrinol Metab. 1995 Oct;80(10): 2954-9.

Brewer et al. Postpartum changes in maternal weight and body fat depots in lactating vs nonlactating women. Am J Clin Nutr 1989 Feb;49(2):259-65.

Noble et al. Oxytocin in the Ventromedial Hypothalamic Nucleus Reduces Feeding and Acutely Increases Energy Expenditure. J Anim Sci. 2000 Oct;78(10):2696-705.

Laatikainen TJ. Corticotropin-releasing hormone and opioid peptides in reproduction and stress. Ann Med. 1991;23(5):489-96.

Sadurskis et al. Energy metabolism, body composition and milk production in healthy Swedish women during lactation. Am J Clin Nutr 1988 Jul;48(1): 44-9.

Sohlström A, Forsum E. Changes in adipose tissue volume and distribution during reproduction in Swedish women as assessed by magnetic resonance imaging. Am J Clin Nutr 1995 (2):287-95.

More Info:

Saturday, August 16, 2014

The Nursing Mother's Triathlon: Pump-Run-Breastfeed

All nursing mothers who exercise are getting the triathlete stamp of approval from me. Working out while continuing to breastfeed my little angel has proved to be one of the more challenging but also rewarding aspects of motherhood. Men may not want to continue to read this blog, but if you know a nursing mom, I suggest you continue reading, so that you can understand just a little bit about what it is like for her and how you can be supportive of her endeavors and help her be a happier, healthier mom. If you don't want to read all the other stuff, skip to my blog post on Tips for Supporting an Exercising Nursing Mom.

Go run, Mommy, and have fun-
I'll be here when you get back! :-)
I haven't jumped back into triathlon in the traditional form yet since I'm focusing more on the mental health benefits of short workouts while learning how to be a new mom and being Ironsherpa to my husband as he develops his Irondad skills. But, I will say that fitting in some short workouts while being a nursing mother, although challenging, is very rewarding and rejuvenating, during a time when you need all the help you can get to stay upbeat and energetic.

It's not easy, though, and it gets very tricky to maintain your milk supply and feed your baby while exercising. The first step to being a mom, especially one who is breastfeeding, is to take care of yourself. But there's something in the set of 2 x-chromosomes that makes us want to do exactly the opposite--forget ourselves and take care of others. Everyone sites the airplane analogy--in a crash, put the oxygen mask on yourself first because if you pass out, you can't help your kids. Comparing parenthood to a plane crash doesn't feel too far off sometimes, but you get the idea. Your nutrition, your hydration, your ability to relax and allow your letdown reflex to happen--all of these things come together to help ensure your baby gets the nutrition, growth, and development he or she needs. I have my best milk supply and letdown when I am getting both sleep and exercise. It's a difficult balance to find both while working and being a mom to Violet, but when we are finding a way to make it happen, it seems to make a difference for both of us- we both just thrive by getting all of our needs met. She grows, plays, smiles, and is just the happiest baby, and I am happier and more energetic and able to be the upbeat mommy that I want to be for her. 

Why It's So Ridiculously Complicated

Being a nursing mother and finding a window for exercise is really challenging, even when you have someone supporting you and willing to watch your baby. The fact that I need to find a window of time that is good for Violet (i.e. when she is asleep or has just fed and will be happy for a while, ideally asleep so my husband can continue to sleep and doesn't have to get up and give her a bottle), a time that is good for my boobs (ideally pump for at least 30 minutes to empty the breasts entirely so my sports bra fits, for one, but also so that I am comfortable while running), a time that is good for me (preferably after getting 4 or more hours' sleep,  although sometimes I do it anyway on less, and after hydration and a snack), and a time that isn't a time when my husband has a planned workout since he is our family's main Ironman right now. This all amounts to me setting an alarm to pump at 330am and then exercising/running around 430-5...if Violet is still asleep and if Curtis is not doing an opening shift. The kicker is--babies change! A few times I was able to wake up and nurse Vi at 3 or 4am, put her back to sleep, pump, and then run, all before work. Now I have to get up and pump instead because she is sleeping longer in the morning...but today she didn't. You never know what these kids are going to do, so it's hard to plan around them and you may lose sleep trying being flexible is key. Whenever you feel like you are getting on a good schedule and have things figured out, chances are your baby will decide otherwise by entering a new phase of development or teething or getting sick.
Sometimes bike trainer is just easier than running! Out on
 our balcony I get fresh air but don't have to leave my baby,
and she loves watching Mommy and Daddy ride!

Just an example, the other day I ran at 6 after I pumped at 5, which seemed like it was working until later in the day I realized I'd only slept 2.5 hours and it was no wonder that I was feeling awful later. Sometimes your brain doesn't work as a new mom. More still, just so that all of that could work, my mother-in-law had to come over an hour earlier to watch Violet before I left for work. Then the saga of ridiculousness continues as I leave myself extra time to get to work so that I have time for all the mishaps that happen after fitting in a morning workout and showering and rushing out the door to go put on my pump in the car and pump on the way to work and get there early enough to discreetly take off my pump in the JMC parking lot (without being seen-HA) and have enough time to do it cautiously enough not to spill milk all over the place and start my morning crying over spilled milk. (That's a crazy run-on sentence, but motherhood is one long, run-on sentence, folks.) TRUST ME, fellas who are reading this, breast milk is totally worth crying over if you spill it. After all the trouble women go through to have enough milk for their babies, to keep up their supply even with the stresses of balancing childcare and work and whatever else in a woman's life, and to get that stuff out and store it properly and remember to bring all the pumping essentials wherever you are going--it's totally worth crying over. I have been livid coming home after a long day and realizing that instead of milk going into my collection bottle it is instead all over my scrubs. I guess that would be worse on the way to work, but it's pretty devastating either way. AND, lastly, there are all the bags--my work bag, my on-call/food bag, my gym bag if not working out at home, and my pump bag. I look like I'm going on vacation every day. Too bad it doesn't feel like a vacation very often.

So working out after work must be easier right? Ehhh...not really. I have always been a morning exerciser except when being on the inpatient service and winter force me to choose between working out at 4am in the dark or working out after 8-9pm after work. The problem with the after-work gym plans for a nursing mom is that by the time you finish work (for me, this timing is about as consistent as my baby's schedule), pump, get to the gym, change, exercise, shower, get back in the car and put on your pump for the ride home...congratulations! -another day of not seeing your baby, ever. And sometimes even if you choose the no sleep option and do a morning workout, who's to say you make it home in time to see baby then? But, you might see your husband. Remember that guy?

Without even throwing work into the mix, I think finding time for exercise as a nursing mom is pretty tricky. There is the childcare issue- yes, you can do stationary bike while your child is in a bouncer or pack n play, and we did talk about going for walks with your babies, but what if mom needs a little dedicated me time with some focused lifting or some find-your-zen-dont-hear-anyone-crying running? Not to make it more complicated for you, ladies, but you should not be running with your babies in a stroller until after 6 months at least because they just don't have the head control, but more on that in our stroller safety blog.

SO, the fact that exercising, nursing moms are making all this work--medal of honor, ladies...medal of honor.

Some Guidelines for the Nursing Athlete

Rule #1: HYDRATE.
Sometimes I drink 10 liters of water a day, no joke. Especially during the hotter summer months, I really don't think this is over doing it when you are working out and nursing. I also have more total body water percentage than most women because I am 6'2" and weigh...well, chances are, I weigh more than you do. But, still, 5-8 liters is not excessive for most nursing and exercising moms. I tell my patients to drink a tall glass of water every time they breastfeed their babies, and this is for women who aren't even exercising on top of that. Breastfeeding requires a ton of fluids. You are going to be constipated and vasovagal (fainting) if you don't drink enough water, and your milk supply may be affected as well. I can definitely tell a difference in how I feel and in my milk supply when I hydrate and sleep. But one out of two isn't bad, right? 

2. Nurse or pump prior to exercise.
This is especially for running (may not be necessary for swimming or biking depending on your workout clothes and how uncomfortable you feel when your breasts are full). It feels different, but I can bike and swim without pumping beforehand. However, by the end of the workout, I am looking for my baby or breast pump because it does become quite uncomfortable.

3. Choose workout gear appropriately and don't forget the BODY GLIDE.
All kinds of things are rubbing together that maybe didn't rub together before, so use Body Glide or Chamois butter, just sayin'. Please check out this blog on maternity workout gear that may be helpful for thinking about postpartum workout gear. This is my favorite sports bra super comfy for the nursing mom's boobies and great for coming in and nursing right after exercise thanks to the handy front zipper.

4. Empty your bladder prior to exercise.
Right before you run out the door, go back and pee. Trust me. Especially if you are already having a few pesky pelvic floor issues, the amount of Kegel-ing you are going to have to do (especially while running but really any kind of weight-bearing exercise) is really intense. My pelvic floor was sore after my first run back postpartum, and I only ran 30 minutes. Every step is an impact with the ground that your core and pelvic floor need to sustain and tighten to keep things were they need to be. (Sorry if that's TMI, fellas.) Help yourself out by having less urine in your bladder. If you did rule#1 appropriately, you'll need to urinate prior to exercise...and sometimes even during. I know, you thought you were done with that after pregnancy ended, but more on this in the pelvic floor syndrome blog.

5. Post-exercise nutrition.
You may need a snack depending on the time of day and how long you exercised. If you are doing endurance, for sure, you need a snack. You should be eating small and frequent nutritious meals with high protein while nursing anyway, so, chances are, it is time for one of those by the time you get back from working out, anyway, especially if your baby is ready to feed again. I know it seems to defeat the purpose of working out to lose baby weight, but think about it in terms of how endurance athletes train- you always need something after your workout with carbohydrates and protein to help your body recover. And those slackers aren't even nursing! Just think, you did whatever run/bike/swim you just did, and that whole time, you were also making milk for your baby. Amazing. Isn't the human body amazing?
Happy and fed baby, icing-knee mommy :)

7. Feed or pump post-exercise.
Your baby may be ready to eat again when you get back. If not, you don't have to pump again unless it is time for you to do so. You might not have made very much milk during your workout, so now is the time to replenish fluids and nutrition and rest, so you can fuel up for the next feed. That being said, I have definitely come back from running and fed Violet while still sweaty. She seems a little confused at first but doesn't care when she's hungry. Some women say that babies like that taste of salt. There's no medical reason not to go ahead and feed if your baby wants to eat, and there's no greater motivation to get home from your run/workout than knowing your baby is waiting for you. If you are trying to increase supply, it might help to have whoever is watching the baby wait to feed until you are back, so baby is hungry and you can stimulate more milk production...but more on that in Part 2.

It's worth mentioning again. Hydrate with every feed, hydrate when you first wake up in the morning, hydrate pre- and post-workout. Depending on how long you are going for, you may need to bring fluids with you, but let your thirst be the judge of that. If you are a nursing mom, and you are doing something at any point in the day that does not involve a cup of fluids, think again- and grab something to drink.

The Evidence

I put this at the end rather than at the beginning like I normally do because it's kind of a letdown. HAHA! Letdown... ;-)

Physicians these days are really big on evidence-based medicine. And I hate to say it, but after searching the literature comprehensively on this subject, I can't really find any good studies! There aren't any good ones at all! So any advice your obstetrician, your pediatrician, or your lactation consultant is giving you is mostly based on theory and scientific knowledge rather than clinical evidence. What a bummer, right? Didn't you think this blog post was going to provide you with all the answers?

1. Calorie restriction may play a role in weight loss for breastfeeding mothers.
Really? Amazing stuff. The one study* I did find was a literature review citing 6 other studies (who knows where they are because I didn't come across them) concluding that "weight management interventions which include an energy-restricted diet may play a key role in successful postpartum weight loss for breastfeeding mothers." Well, zippidy-doo-da. Obviously this is the case, but no one knows the specifics of how many calories lactating mothers need and it's even more complicated throwing exercise into the mix, and there are no studies on this AT ALL. Bummer. But more on that in our next blog post.

2. There is some anecdotal evidence out there that endurance exercise increases lactation.
I don't know about this, ladies. It's not a real study, so this is just women saying that they felt that their lactation improved with endurance training and some lactation consultants saying that they have noticed this in their practice with their patients. So really just take it with a grain of salt. My personal opinion (I can do this because this is my blog yay!) is that these endurance athletes who continued to train heavily while they were nursing were 1- doing so when they're children were already eating solids and therefore not needing as much breast milk or as frequent feeds, and 2- women who already had an abnormally high supply of milk to begin with. Some women just have a ton of milk. Yay for them. Can you tell I'm bitter? Moving on to our next segment on staying fit as a nursing mom, we'll talk about the challenges with maintaining milk supply while staying fit.

Going the Extra Mile

My conclusion to all this is:  we should study this! Who wants to be part of my study? To study it well, we would need women who are about to give birth and plan to nurse and exercise. To study it semi-well, we need women who did nurse their children and exercise and can remember a bit about what it was like...even better if you recorded your calorie intake and exercise each day...what, you don't do that? Am I asking too much? If you use a calorie app, I'd be very interested!!!

Need a Pep-Talk?

You can do it! 
How was that? ;-) Honestly, after writing all of this, I kind of need a pep-talk myself. It's important to realize that it's all worth it. It's worth it to feed your baby and help your baby fight infections and give him/her something that is very easy to digest and to have that mother-infant bond that everyone goes gah-gah about (It's actually really beautiful and amazing. I love nursing, which is why I'm writing 3 blogs on ways to continue to do it while you stay active). It's worth it to be healthy and exercise and to do something to take care of yourself when you aren't otherwise doing so these days. But, on the days that it's not worth it, when you haven't slept and you can't calm down and you've had an awful day, just go home and hold, walk, or play with your baby...
or, just sleep. Sleep is golden.

Stay Tuned...

Parts 2 and 3 in this series on staying fit as a nursing mom are coming up!
-Part 2: Got Milk? Maintaining Milk Supply 
-Part 3: So You Wanna do an Ironman? The Ultimate Motivation  

*Neville et al. The Effectiveness of Weight Management Intervention in Breastfeeding Women-A Systematic Review and Criticial Evaluation. Birth. 2014 Apr 21.