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.