Sunday, May 31, 2009
Saturday, May 30, 2009
Defining D-MER: What It IsI first read about D-MER a few months ago, maybe in January or February, and I recognized it immediately as something that I was experiencing, on the mildest end of the spectrum.
Dysphoric Milk Ejection Reflex is a newly recognized condition affecting lactating women that is characterized by an abrupt dysphoria, or negative emotions that occur just before milk release and continuing not more than a few minutes.
Preliminary testing tells us that D-MER is treatable and preliminary research tells us that inappropriate dopamine activity at the time of the milk ejection reflex is the cause of D-MER.
Clarifying D-MER: What It Is Not
How D-MER Presents: What Mothers Feel
- D-MER is not a psychological response to breastfeeding.
- D-MER is not nausea with letdown or any other isolated physical manifestation.
- D-MER is not postpartum depression or a postpartum mood disorder.
- Lastly, D-MER is not the "breastfeeding aversion" that can happen to some mothers when nursing while pregnant.
The negative emotions, or dysphoria, that a mother with D-MER experiences often manifest "in the mother's stomach" - a hollow feeling, a feeling like there is something in the pit of the stomach, or an emotional churning in the stomach. Mothers report varying types of emotions with D-MER ranging from dread to anxiety to anger, these emotions fall on the D-MER spectrum which has three different levels. The common thread between these levels, is the wave of negative emotions or dysphoria, prior to letdown, when nursing, expressing and with spontaneous letdowns, that then lifts within another 30-90 seconds, and then usually repeats with each letdown.
A key piece of D-MER is that a mother with D-MER feels absolutely fine except just
before her milk starts to flow. D-MER is a brief feeling, not more than 30 seconds to 2 minutes, only and always beginning before let-down. This is not postpartum depression and most of these mothers feel perfectly fine except for that pre-milk moment. A brief interval after the negative feelings appear, the milk begins to flow.
D-MER can easily go unrecognized since
- some mothers have so many closely spaced letdowns per feeding that the feelings do not have a chance to dissipate before the next D-MER is upon her, making her feel that she experiences on long D-MER through most of, if not all of, the feeding
- many mothers do not physically feel a letdown in their breasts and so does not connect the feeling as to being just prior to letdown and
- given the fact that D-MER happens with spontaneous letdowns as well, a mother may not immediately connect the way she is feeling to being a breastfeeding phenomenon.
This level is described on D-MER.org as: [italics mine]
A sensation of a pit/hollowness or sinking in the stomach
An urge to "get away"
General negative emotions
Feelings of being hopeless
Feelings of being apprehensive
There's a long list of other feelings that "level one" moms describe; below are the things from that list which sound like what I experience:
An inability to cope
Ill at Ease
A fear of having failed
(not any more, but very
much so before Peeper learned to nurse)
In fact, I had identified, with the first few weeks that Peeper was actually nursing (by our trip to Texas, at which point she'd been nursing for less than a month) that I quite often got what I can best describe as an "oh shit" or "I've fucked up" feeling in my gut, just as she started to nurse.
I had attributed it to leftover emotional baggage from the pumping. In retrospect, I'm sure I was feeling it each time I pumped, but since negative feelings were totally justifiable then, it never struck me as odd.
When I continued to feel it when Peeper actually nursed, it did strike me as out of place, but I figured I was just still associating letting down with the negative feelings I had about the pump.
When I read about D-MER, those feelings made sense, and it was helpful to have a reason for them, and to be able to say (usually), "Oh no! What's wrong?! Oh yeah, that's what it is, and . . . now it's gone. Whew."
I didn't really think too deeply into it, but I am now realizing that maybe I don't always recognize the negative feelings as D-MER and dismiss them as I shoud, and I've started to put together that perhaps this is, while certainly not the root of, at least exacerbating some issues that I've been having over the past, oh, I dunno, seven months or so.
The weird thing is that I've never had negative feelings about breastfeeding.
About the difficulties we had getting started, of course, but never about Peeper breastfeeding.
That, I love.
Even when it seemed like that's all she did all day, and even when I would think, "Are you kidding me? Again?!" I still couldn't say that I didn't love everything about it.
I love the connection that she and I have because of it, I love that until recently (and other than that bit of formula that, yes, I will always regret) I built her all by myself, and I love that, for all its imperfections, in both form and function, my body is doing exactly what it was designed to do, nurturing her both physically and emotionally.
So the breastfeeding itself, I do not feel negatively about one bit, but I do often have negative feelings that occur while I am breastfeeding.
(Of course, one could argue that there are many things that "often happen while I am breastfeeding" because I am breastfeeding so much of the time!)
It occurs to me that many of those times when I let myself get insecure about my parenting, and start fretting about whether we're doing things "right," or when I let comments from less-than-supportive people get to me, or when I just get scared about, well, everything, it's very likely that I'm actually experiencing D-MER and letting the feelings take me on that trip toward negativity, before I recognize that they are, in fact, false emotions.
When I'm not actually in the middle of it, it's pretty easy to recognize that if Peeper is sleeping in my lap, and starts to stir, and I offer her a breast, and she latches and settles back down, and I then immediately begin to worry about whether I'm nursing her "too much" (does such a thing exist?) or making her sleep "too much" (ditto) or just "making" her nurse (not possible - tried it for six fucking weeks, remember?) to make her go back to sleep, because I'm just too selfish to want to deal with entertaining her when she wakes up (and what kind of a mother does that make me?!) that, yeah, just maybe that's some crazy talk being inspired by the feelings of dread and guilt and anxiety that are produced by a dropping dopamine level when she latches and my milk starts to flow for her.
So, I'm trying to remind myself of that. When she's nursing and I get that feeling in the pit of my stomach, I tell myself, "Yep, there it is. Just ride it out. And, there it goes. Okay, we're all good now."
"Ride it out," is a good metaphor for me, because it reminds me of a rollercoaster or something like that. Literally, because the stomach feeling is similar to what you feel when the coaster drops, but also figuratively, because it is a false emotion.
A rollercoaster or a scary movie or a haunted house is "fun" (not for me, but I hear some people like them) because you get to experience the "rush" of fear without actually being in danger.
I try to think of it that way, and try to experience the "wooooo" in my belly and think of it as "ride" that I'm on that will be over in just a few seconds.
What's a bit trickier, though, are the D-MER episodes that come with "spontaneous" letdowns, when it's not so obvious what's going on, and therefore, I'm even more likely to "believe" the feeling and justify it.
I suspect this is probably happening more than I realize.
Let's think it out. . . .
Quite often when she is nursing, I suddenly feel the "oh shit" in the pit of my stomach, and the next thing I know, she goes from barely sucking to gulping. I've felt no physical sensation of the letdown in my breasts themselves, but I felt D-MER and then there was more milk, so it's obviously happened.
And often, when she is not nursing, but she's crying, or I'm looking at photos of her, or thinking about her, or cats are yowling, and I do feel the letdown sensation, which was clearly triggered by some sort of non-physical stimulation.
D-MER.org also says:
Touching, feel good times and food raise oxytocin, as well as some kinds of stress. In these situations a D-MER mother's oxytocin may be raised, triggering a letdown. Part of the letdown includes the precursor of D-MER. This means it may feel like the situations are causing the feelings, which cause the letdown, but that is not the case. Instead it is the situation (of stress or family or food) which causes the oxytocin surge which triggers the milk ejection reflex, which starts with a drop in dopamine which is what causes the D-MER. This happens whether or whether not a mother feels the letdown physically in her breasts, as many mothers don't. So uncomfortable feelings/negative emotions do not result in a letdown. So if a mother is feeling D-MER type feelings on and off throughout her day, unconnected to nursing, the feelings are the sign that the milk ejection reflex has been triggered by either a conditioned reflex (sound of a baby crying) fullness of breast (oversupply or missed a feeding) or by emotion (stress or pleasure.) In these situations it is still D-MER and the feelings are not a valid emotional reaction.So, how often might I be having spontaneous letdowns that I don't feel physically, but with which I am experiencing D-MER and not identifying it?
How often does it happen that, say, someone other than me or Shrike is holding Peeper, and she's crying, and it's all I can do not to snatch her from their arms and "fix" her, and the longer it goes on, the more stressed and anxious and angry I get about the whole situation.
Or how often am I anxious about a stressful situation, related to Peeper - her medical adventures, for example, or an encounter with a less-than-supportive person - or not, and I get way more upset about it than I rationally feel like I "should."
No, I certainly don't think I can blame all my insecurity, anxiety, over-sensitivity to criticism and post-traumatic stress about our early breastfeeding experiences on D-MER, but I would imagine that it can't be helping matters a bit.
As much as I totally love breastfeeding Peeper, as thrilled as I am that it has worked out so well for us, as devastated (and there is no other word for it) as I would have been had it not worked out, as 100% certain as I am that it is absolutely the best thing for her and me and our family, and as strongly as I feel about continuing as long as she wants and needs to, it has, for many, many reasons, been just fraught with anxiety for us from day one.
I do not think that any of this anxiety was caused by D-MER (see My Breastfeeding Story), but it does occur to me now that it has probably been exacerbated by it, at many points along the way.
So, what to do about it?
D-MER.org lists three levels of management options, from lifestyle changes, to natural treatments, to prescription treatments.
I don't think that what I'm experiencing requires prescription-level treatment, but if I did decide at some point that it would be appropriate, the suggested medication is Welbutrin, which I've taken in the past and tolerated well, so that's good to know.
The natural treatments suggested include some herbal stuff, but also DHA which I've been taking since pregnancy, for Peeper's brain development, and tryptophan-containing foods which, ironically, include dairy. Great. Might I have actually increase the D-MER when I went dairy-free!?
The lifestyle changes include education about D-MER, which I think is definitely the most important thing - just knowing what's causing the negative emotions is a big help.
They also suggest distraction, including "surfing the internet" while nursing. Well, I'm always in front of my computer when I'm nursing, so that's obviously not helped, but I have noticed that I don't experience the D-MER as much if I'm in the middle of a conversation, or something like that.
I guess that's why it's never impacted my comfort level when nursing in public. I suppose I'm distracted enough by whatever else I'm doing that I don't notice it. In fact, now that Peeper can latch by herself, I can get a boob accessible, and get her intp position, latched and nursing while sitting in a restaurant, talking to Shrike, eating, or hell, ordering, without missing a beat.
It also seems that being well-rested, well-hydrated, and getting adequate exercise can be helpful. Well, I do drink lots of Kool-Aid.
And what to do with all this information?
I'm not really sure just yet. I know that it had helped to just recognize what's going on, and to remind myself what it really is that's making me feel the way I do, when I start getting freaked out about things.
Of course, I will also be talking more with Dr. T about it, especially as it relates to my interpretation of what might actually be D-MER episodes during spontaneous letdowns.
(This has been in the back of my mind for a while, but I finally remembered to mention it to her in like the last five minutes of our last session. It wasn't until afterwards that I really got to thinking about it and figuring out some of the bigger picture.)
And I guess we'll see how it goes from there.
As I was reading this post by Amalah the other day, I couldn't quite figure out what it was about the nothing-but-a-BumGenuis-diaper photos of baby Ezra that looked so right-but-not-quite-right to me.
At first, I thought it was just because it was a photo of a baby who is not Peeper in the same "outfit" that Peeper is usually wearing these days, but then I thought, "No, something is missing . . . ."
I am not used to seeing an infant's naked chest without a scar down the middle of it, and I guess my eyes had forgotten that they don't all have them.
I haven't quite decided how I feel about that.
This was actually taken a few days ago - Tuesday, maybe? - but my phone couldn't manage to get it here then. I found it in the outbox today, and here it is.
We were playing at Target and Peeper was trying on hats.
Well, Shrike was trying hats on Peeper.
And Peeper was trying to see.
Thursday, May 28, 2009
Wednesday, May 27, 2009
You are seven months old today.
It's been a big month for you, what with the eating of everything in sight and all.
When you began this month, it was all goody, all the time. Now it's still goody all the time, but also anything else we put in front of you.
I don't think there's been anything you've turned down, except that twice, you've not wanted the veggies at TGI Friday's, until I've washed off the butter at home.
I'm taking that as a sign that your dairy thing is still going on, and I'm probably going to wait a bit longer before adding it back to my diet, or introducing it to yours.
(Except that bit of butter, I supposed. The first time, I didn't realize it was there. The second time, I figured it hadn't hurt you the first time.)
It also seems like you've really matured alot in the past month. Maybe some of it is percetion, related to the fact that you eat like a big girl, but you are also suddenly seeming lots more communicative.
You are doing really well at finding another person's facial features, although you really can't care about your own yet.
Except your head. You don't usually point to it when asked, but you do this thing where you bonk yourself in the side of the head repeatedly, and you've always got your thumb and forefinger out, in kind of an "L" shape.
Mommy says you're calling us losers. She's probably right.
We wondered for a while if your cradle cap (which you have, and it's gross) was itchy, and maybe you were trying to scratch it, but we've been told that it doesn't itch. (How do grown-ups know that?)
You're not really petting your hair like you used to do, just bopping your thumb into the side of your head. I'd love to know why.
We've been signing to you, and are trying to be more consistent about it as you get older, and I (over) analyze every little move you make (including the one I just described) lest an attempted sign slip past us.
You've not signed back to us yet (that we know of) but, in your own way, you're making it much more clear what you want, and there's not so much guesswork involved these days.
For example, when you want to nurse, you've started reached toward the goodies, or grabbing at my shirt, or throwing your body into nursing position.
A few mornings ago, I realized that I'd known you were awake and wanting to nurse, not because you were fussing or rooting, but because you were patting around on the bed, looking for me. (I'm right there, but your arms aren't very long.)
Yesterday, we were in Target and Mommy was wearing you, and I was standing in front of you both, when you started groping me.
Mommy said, "Hmmm, subtle."
I'm sure it won't be nearly as cute when you do that in the middle of Target in a year or two, but for now, it's kind of nice that you're being so clear about it.
You've also, just in the past few days, gotten more consistent and more obvious about raising your hands to be picked up. It's still pretty subtle (actually subtle, not ironically subtle like the goody grabbing), but I can see it.
And, despite my repeated attempts to teach you the sign for "all done," you've found your own way to tell us that you are finished eating and ready to get out of your high chair.
You start trying to unbuckle the seat belt!
Now, I'm not at all concerned that you will actually get it open, because it's hard for me to do, and by "trying to unbuckle," I mean "slapping at," but you definitely understand that piece of plastic is what's keeping you in there.
I just noticed that today, so I'm thinking that we will emphasize the "all done" sign when I see you doing that, and see if we can't get you to do that instead.
One problem I've noticed with the signs, though, is that I almost always have to sign one-handed, because if I'm not holding you, I'm holding a piece of food, or wiping you up after a meal, or something. So, I'm not sure how you're going to learn any two-handed signs from me!
Speaking of holding a piece of food, we usually have to hand things to you, because you're not quite coordinated enough yet to pick them up on your own. And your little arms can only reach about a inch or two onto your placemat, so the food tends to run away from you, too.
I've gotten some tips on ways to prepare things that are easier to pick up and hold on to, and I hope that will help, but mostly, it will just take time and practice.
You're practicing your gross motor skills a lot these days, too.
You are making real progress toward sitting up on your own with no propping, and can often stay upright for several seconds at a time. Other times, you keel right over. So, there's still some work to be done, there.
You still aren't rolling from back to front but I swear, everytime you play on your back, it looks like you're going to. You have been thiiiiiis close forever!
I'm sure you can still roll from front to back, but you've not done it very recently, mostly because I give in and take you off your tummy first.
You still hate being on your tummy, but I am trying to "encourage" you to do at least some tummy time each day. You can do some pretty impressive push-ups when you want to, and you think about rolling, then you lay your face down, nose-first, on the
freshly laundered and disinfected designer baby blanket pet fur covered carpet and whine pathetically.
I have started putting a toy in front of you, just out of reach, to lure you into attempting some sort of forward movement. Today, I think you scooted an inch or so to get your monkey!
When on your back, you scoot around quite a bit, but I don't think it's particularly intentional, or goal-oriented.
You're squealing and laughing and "talking," but we're still waiting for you to start imitating sounds, or to repeat specific sounds. Expecially ones that start with M.
You squeal and laugh the most when you are playing with Mommy. Because she is a nut.
You love it when she sings to you (favorite song: Chantilly Lace) and reads to you (favorite book: Are You My Mother?).
Or, you're just as happy with a recitation of Are You My Mother? from memory. Which Mommy and I can both do, complete with voices.
(When you are older, you will realize that the voice of the cow who is not the baby bird's mother comes from the snooty-attitude cow in Babe, who says, "The way things aaare, is the way things aaare." This cow is pretty snooty herself, actually: "Hoooow could I be you mother? IIIII am a cooooow.")
When you are fussy or whiney, all we have to say is, "A mother bird sat on her egg. . . ." and we've got your attention.
You've also learned the "guess what/why/when/how/where/who?" game. I'm looking forward to you being able to point to the answers (Peeper's butt/thigh/chin/brow/hair/-ooo!") but already, you know what's coming and when I say "Guuuesss what?" you start to smile a bit, and by the time I get to "Guess when," you are grinning in anticipation of the chin-tickle.
And, speaking of your butt, you are also pretty good about raising your legs waaay up to give us access to it for diaper changes, which is very helpful. (Except when you are trying to roll over while we're trying to fasten up your diaper; that's less helpful.) Sometimes you even do it when I ask you to.
More and more (but certainly not all the time) in fact, you seem to be responding appropriately to instructions or requests, which is really cool, but also kind of freaky.
(If you can understand these things, how much else of what we are saying do you understand? I suppose we should start assuming you understand everything, huh? I'm really sorry if we're screwing you up by saying things you don't need to be hearing. Oh, hell, I'm just really sorry we're screwing you up, in whatever way it is that we're screwing you up, because I'm sure there's something.)
Everyday, you are becoming more and more of a person, with opinions of your own, that you can express, and that we can more and more often actually understand.
It is fascinating to watch as you learn about the world, discovering how things work, and how to interact with them.
Sometimes you get so frustrated, because you know what you want to do - like picking up a piece of food, or getting a toy that's out of reach - but your body just can't make it happen yet.
But it will soon, and then you'll be on to new challenges and new things to learn.
Tonight, I was watching you on your playmat, as you reached out and touched one of the toys gently, with one finger, then batted at it, and then grabbed it and pulled on it.
It seems like just yesterday that you'd accidentally hit the toys every now and then, but we weren't even sure you even realized it!
It is just amazing how much you grow and learn and change so quickly, not just from month to month but even week to week, and sometimes day to day.
I can't wait to see what you're working on for your next trick.
One thing that will never change, though, is how much I love you, my little Roo-Roo.
Tuesday, May 26, 2009
I noticed some ground turkey in the freezer a few days ago and figured I ought to do something with it.
We finally bought some pasta that Peeper might be able to pick up (eh, it's still a bit short and doesn't stick out of her hand very far) and needed something to go on it, and I also thought it might be good to give her sticks of meat that are not of the sausage or weiner variety, so I used the turkey for both.
The photo was taken when they first went in the oven. Cooked, they look about the same but all brown and crispity and a little smaller.
Ground turkey - 1/2 lb
Veggie chips, enough to fill the
mini-chopper twice (see photo)
Pepper and sage
- Buzz veggie chips in chopper or blender or whatever until they are crumbs.
- Mix chip crumbs and ground turkey thoroughly.
- Add a tiny bit of pepper and sage.
- Form into "fingers" (I made them literally about the size of my fingers, and
- Coat lightly with olive oil, and cook at 400 F for about 15 minutes, turning
a couple of times during cooking.
- Drain on paper towels. I froze most of them for later.
Barbecue Turkey Rotini
Shrike won't touch this, but Peeper and I love barbecue anything!
Ground turkey, 1/2 lb
Carrot, grated (added this to trick me into eating vegetable)
- Heat onion and carrot until softish, then add turkey and brown.
- Add barbeque sauce and some water and cook a little while.
- Add rotini and cook a bit more.
- That's it.
Monday, May 25, 2009
. . . then started to get a little bored . . .
We'd just finished up our midnight snack (me: reheated spaghetti, Shrike: mixed nuts, Peeper: sweet potato, greenbean, waxbean) and Shrike walked past the sunroom and said, "Oh my gosh! [Yes, that's really what she said.) There's a toad!"
As I've mentioned before, when the weather is nice (and sometimes when it's not), we often leave the sunroom door open for the dogs to come and go as they please.
This evening, they pleased to invite a friend over to play.
Shrike chased him down and released him back into the wilds of our backyard.
While Peeper and I "helped" by taking photos and saying "Oh no! Is he coming over here? Eek!"
Okay, so it was mostly me saying those things.
While I ran for the camera, Mr. Toad hid behind the couch.
Turns out he was the least frightening thing back there.
She then herded him across the room, picked him up and put him outside.
Sunday, May 24, 2009
This post was written for submission to the May Carnival of Breastfeeding, the theme of which is "Share a Story," but like the big dumbass that I am, I'd made note of the carnival date, not the submission deadline, and missed my chance to participate!
So, I will go ahead and post it now, and if there's another appropriate carnival topic down the road, maybe I'll resubmit it.
Perhaps "Overcoming Breastfeeding Challenges" or "If I Knew Then . . ." or "Breastfeeding Support and Lack Thereof."
Much of this story is old news for my regular readers, but there are also some things that I didn't blog about as they were happening, because it was just too painful at the time.
It still is, but it's part of what I need to do before I can let it go and move on.
For as long as I can remember, I have wanted to be a mother.
When I became pregnant at the age of thirty-nine, by in vitro fertilization using my partner Shrike’s eggs and anonymous donor sperm, one of the things I looked forward to most was breastfeeding.
It was something I've always found fascinating, so I’d done a good bit of reading and I had also learned a lot about it from my older sister, LadyKay, whose children were breastfeeding when I was in my late teens and early twenties, so I went into it thinking I knew pretty much all I needed to know, and expecting that we would have no problems.
Boy, was I wrong.
Our daughter, Peeper, was born four weeks early. I delivered her vaginally, with no pain medication. Shortly after her birth, we were told that she weighed five pounds, four ounces, and that she was doing very well, especially considering her size and age.
I gave her an opportunity to nurse fairly soon after birth, with the help of my doula and La Leche League leader, DoulaK.
She latched a bit, and DoulaK said that her technique looked good, and her suck looked strong, but she wasn't especially interested. DoulaK told me not to worry, because she had twenty-four hours before the doctors really expected her to do much nursing.
That night, and the next day, I gave her several opportunities to nurse, often with the help of one of the midwives or labor and delivery nurses. She had a couple of pretty good sessions, but was still very sleepy and not especially motivated.
Her mouth was so tiny that it was difficult to get around my nipple, let alone to get the good, deep latch that she really needed.
Another problem she was having with latching was that my areolas were swollen, making the nipples stand out less, so there wasn't much for her to grab on to. One of the nurses commented that, "Oh there's often some swelling after delivery, that will go away."
I learned later that the swelling was probably exacerbated by the IV fluids I'd received during labor, and a couple of days later, from engorgement as my milk came in, but that a simple reverse pressure technique would have temporarily relieved it, and made my nipples more accessible to her.
One of the lactation consultants stopped by to see us the morning after she was born, but Peeper had just finished nursing, so we didn't put her to the breast for the LC to observe.
One of the first things she told me when she walked into the room was that, "Most of our preemies need to be supplemented. I recommend a breast pump and a nipple shield and she may need some formula."
A while later, both devices were delivered to my room, with little or no explanation of how to use them.
When Peeper was about twenty-four hours old, she was weighed again, and was now four pounds, four ounces.
The pediatrician who saw her that night said that he didn't believe she had really lost almost 20% of her birth weight, because she “looked too good.”
I also later read that babies whose mothers have received IV fluids during labor are often born retaining quite a bit of fluid, and can easily lose 20% with no ill effects because they started out ahead of the game.
The doctor told us that he suspected Peeper's birth weight wasn't accurate, but that we'd have to assume she had lost a full pound, and go from there.
I agree that the birth weight wasn't accurate - or, possibly, was elevated because of the fluids. I'd had very frequent ultrasounds during my pregnancy, and we'd known since 17 weeks that she was small, about 2 - 3 weeks behind her gestational age.
Based on the 10% of birth weight that babies are "allowed" to lose, combined with extrapolating from my ultrasounds, we suspect that she actually weighed about 4 lb 12 oz. That's the weight that we put on the birth announcements, and it's what we tell strangers in the grocery store, who are surprised to hear how old she is, because she is still quite small for her age.
But, assuming she had lost 20% of her birth weight, the doctor said that we would have to start supplementing her, with breast milk if possible, or formula if "necessary."
I was adamant that she not get any artificial nipples, so we were told we could finger feed her using a supplemental nursing system, and could also try using the SNS at the breast, when she was willing to latch.
I was also adamant that she not have any formula, but the pediatrician insisted that she must take in X amount of food (the amount per feeding increased over the next few days) and if I couldn't pump enough, we would have to give her formula as well.
I had received essentially no instruction on how to use the pump, so I just stuck it on me and turned it on for about ten minutes.
The insides of the bottles were foggy when I finished, but not even a drop of colostrum could be collected to give to her from that first session. It was incredibly disheartening.
I knew that I was producing some, because I was able to express a few drops when trying to get her to latch, but there wasn't enough to pump yet.
I don't remember the exact amounts, but the next time I pumped, I think I got about five or six milliliters, and the doctor wanted Peeper to have fifteen, so we mixed it with about ten milliliters of formula.
I was crushed.
By the next feeding, I was able to pump enough to match the amount that she was required to take, so we didn't have to add any formula, but the pressure to produce enough for her was unbelievable.
Each time I pumped I could see that what I was producing was slowly changing over from colostrum to true milk, and I was getting a bit more each time, but the amounts were still tiny, and I was absolutely obsessive about capturing every tiny bit.
I wasn't at all confident that I could make as much as she needed, but I knew that I wanted her to get every drop that I made, and if we had to "top her off" with formula after that, I could live with it.
That is a lie.
I actually hated the idea of her getting any formula at all, but I told myself I could live with it, because I was being told that Peeper couldn't live without it, so I felt I had no choice.
Peeper was born on a Monday afternoon, and on Wednesday afternoon, I was discharged and she was transferred to the Pediatric ward, where Shrike and I were able to room in with her.
The routine at that point was that, every three hours, I would put her to the breast and attempt to get her to latch, usually using the SNS.
She sometimes nursed a tiny bit, but more often, she refused. She would sometimes fall asleep at the breast; other times, she actively fought it.
These attempts usually involved at least three people - not counting Peeper. I would hold her body with one arm and support my breast with the other hand, a nurse would grab her head and shove it onto my breast (very counterproductive, in retrospect) and Shrike would try to thread the SNS tube into her mouth at just the right moment.
She absolutely hated the SNS tube, and it would fall out or she'd let go or she wouldn't latch at all.
This would go on for about fifteen minutes - later, I was actually given a time limit for how long we were allowed to work on getting her to latch before supplementing - and then we would give up, and Shrike would finger feed her expressed breast milk while I would pump for the next feeding.
This process generally took about an hour. Then we'd rest or, if we were lucky, sleep for a couple of hours until it was time to do it all again.
At some point on Wednesday, it was determined that Peeper was jaundiced (as is to be expected with a 36-weeker) and she was put under bililights, which meant that she had to stay in her bassinet, and we could only hold her during feedings.
That evening, the doctors were worried that she was "working too hard" to eat, and expending more calories than she could afford.
They checked her blood sugar and it was a low. After being fed some breast milk, it had not come up enough so they gave her some glucose water (also finger fed with the SNS) and it came right up, but they were now more concerned and started testing her blood sugar at the beginning of each feeding routine (three hours after the last meal).
This continued through the night, and in the morning, Shrike's mother called to check in on us. I don't remember her exact words, but she essentially told me to not be "so hung up about the breastfeeding" and that "it's just important that she eats, and at least she's getting the milk," but "if it doesn't work, it's not the end of the world."
I know that she was speaking out of concern for Peeper, and I'm sure that she genuinely thought that she was being reassuring and comforting to me about “not being able to breastfeed,” (which I’m sure she assumed was going to be the case) but the effect was the exact opposite.
What I heard was that I was putting Peeper’s health at risk by depriving her of the food she needed, in order to satisfy my own whims; that it really didn't matter whether she breastfed, and I was being silly to be so upset about it; and that I should just stop this and do what was best for Peeper.
But I knew damn well that what was best for Peeper was to breastfeed, and I knew that to me, it would be the end of the world if she weren't able to, and I'd be damned if I was going to give up on her – and myself - this soon.
All day Thursday, I asked for a visit from the lactation consultant, but she was tied up on the labor and delivery floor, so it was evening before she made it over, and she'd not been there very long when the pediatrician came in to talk to us.
At this point, Peeper had been having trouble keeping her temperature up, while laying under the bililights in just a diaper, so the heat in the room had been turned up to about eighty degrees. I was sitting on a chair in the corner of the room, right under the ceiling heat lamp, Peeper was in her bassinet, and Shrike was somewhere on the other side of the room. In the tiny room with us were the lactation consultant, the pediatrician, Shrike's mother and sister, and one or two nurses.
I will forever think of this conversation as "The Nipple Intervention."
The pediatrician started by saying that "I know that breastfeeding is important to you, and it is the best thing for Peeper, so we definitely want her to do it, but . . . ."
Both breastfeeding and finger feeding were too much work for Peeper, and she still wasn't keeping her blood sugar up like she should, and we had to get milk into her more quickly, so we were going to have to give her bottles.
I think I asked if there were any other options, but I was told that no, she must take bottles, or she was not going to be able to get enough food.
I probably express a concern about using artificial nipples, because the lactation consultant said that we could use Nuk nipples which "are much less likely to cause nipple confusion."
I'm not at all certain, though, what I actually asked about or what concerns I expressed, because I did not feel as though I was in a position to do or say much of anything other than agreeing with the pediatrician's plan.
What I believe I said was, "Of course, I want to do whatever she needs. It’s not ideal, because I was hoping to avoid bottles, but I have no problem with them if that's what she needs at this point. If we can use the Nuks, that's fine with me. But of course, we'll do whatever you think is best for her."
What I know I was feeling was that I was being completely ganged up on and intimidated and bullied into doing what the doctor wanted.
I felt very much like I was being told that it was time to stop my silliness and selfishness, and listen to the grown ups, and get serious about actually taking care of my child.
I felt like I was being judged by everyone in the room for my hesitance to agree to bottles before that point.
I felt like I had to agree, without any argument, in order to convince them all that I really did care about Peeper and I really did want her to be okay.
I felt like all of this was about them – the doctors, my in laws, even the lactation consultant – telling me what we were going to do.
And I felt like Shrike was neither being consulted by them, nor was I even allowed to consult with her about it, because she was on the opposite side of the room the whole time.
I also felt, very strongly, that this was not the right thing to do, for me or especially for Peeper.
I made myself be okay with it at the time, because I had no choice, but I knew there had to be another answer.
I knew there had to be other, better ways to get the milk in her without introducing artificial nipples.
I knew I hated everything about the idea of giving her bottles, and I was terrified that they were going to be the beginning of the end of any hope I had of her ever breastfeeding.
After the doctor left, Shrike and I went down the hall with the lactation consultant, and talked with her about it, away from the crowd, out of the heat, just the three of us. She made me feel somewhat better about the decision, but I still was very uncomfortable with it.
DoulaK stopped by that evening to visit, and we talked with her for a long time. She was very reassuring, but also suggested some other possible feeding options, which the lactation consultant dismissed as not being appropriate in our situation.
While DoulaK was there, Peeper nursed for quite a while - probably the best session we'd had since the first day.
Over the next day, Peeper's blood sugar stabilized, and her weight continued to go up, and we were discharged on Saturday.
The bottles had done the trick, I suppose, in getting the milk into her more quickly and easily, but they'd also done their damage, and she was almost completely refusing the breast by that point.
For weeks, I pumped and Shrike bottle fed Peeper, and we slept in two and three hour bits in between.
My nipples got incredibly sore, and I was in constant pain, not only when I was pumping.
I'd started with pump flanges that were too small, and used too high a suction setting on the pump (because of a lack of training) and that started the damage, which just got progressively worse.
Feeding wasn't Peeper's only health concern. She was born with a congenital heart defect (two holes in her heart, which were surgically repaired when she was twenty weeks old) and she had some questionable results on her metabolic tests, so there were weekly trips to the cardiologist an hour away, and one train trip to a Children's Hospital four hours away.
For every trip, we took the breast pump along, and I pumped in the hospital lactation room, and parking lots, and riding down the interstate.
When we were at home, I still offered the breast at almost every feeding, but it became harder and harder to deal with her refusal to latch.
It was impossible to not take it personally, to not feel like she was rejecting me.
The worst part was that not only would she not latch, but she would fight against it, and would wrap her tiny little hand around my very sore nipple and push it away, saying what sounded all the world like, "Uh-uh! Uh-uh!"
I don't know how many times I handed her to Shrike for a bottle, crying, and asking, over and over, "Why won't she do this? Why doesn't she like me?"
I can't even begin to count the number of times I talked to DoulaK on the phone during that time, and she always had a recommendation for something I could try to ease my nipple pain, or to encourage Peeper to latch, or just to help us to bond, in the absence of an actual breastfeeding relationship.
Most importantly, she always listened to my concerns and my feelings and validated them, she always encouraged me to keep trying and she always assured me that Peeper would eventually get it.
She reminded me that Peeper still wasn't even supposed to be outside of me yet, so of course, she was having trouble. Many full term babies take a couple of weeks to learn to nurse well; I just had to be patient and give her time to mature.
She also told me, over and over, that she had faith in Peeper and that it might take a while, but that she knew she would be breastfeeding eventually.
Her confidence in our ability to work through this was invaluable at a time when I had none of my own.
I also can't tell you how many hours I spent on the computer researching nipple confusion, and breast refusal, and nipple pain, and everything else I could find.
In my research, I found very little information on how to solve nipple confusion, only information about how to prevent it - warning after warning to avoid introducing artificial nipples.
This is when I learned that syringe feeding or cup feeding would have been viable options for us, had our doctors and our hospital been willing to do either.
Both techniques are used in NICUs with babies much younger, much smaller and much sicker than Peeper, and I am still very angry that neither was made available.
We were very lucky that Shrike was able to take a month off work when Peeper was born, because as hard as things were those first few weeks, at least she was there the whole time, doing all of the bottle feedings, and most of the diaper changes, and a lot more of the hands-on baby care than I was.
I felt at times like actually parenting Peeper was Shrike's responsibility, and my job was to pump and hand them milk.
Shrike was incredibly supportive through it all, and never once suggested that I give up on trying to get Peeper to breastfeed.
In fact, there were many, many feedings when I just wanted to have Shrike give her the bottle and get it over with, but she encouraged me to "give her a try" first.
I know that, even though she usually turned me down, if I'd ever let myself get away from offering Peeper frequent opportunities to nurse, we'd have had no hope of getting her back to it.
And, as much as I was missing the opportunity to feed Peeper, and as much as I was not bonding with her, she and Shrike were able to bond in a way that would not have been possible if she had been breastfeeding from the beginning.
That, I suppose, was the silver lining in the very dark cloud that I was living in at the time.
It doesn’t make sense, but as jealous as I was of their relationship at the time, there was also nothing that made me happier than to see them together, and to see Shrike holding her, and talking to her and caring for her.
When Shrike returned to work, though, things got much more difficult for me. Now, for ten hours of the day, I had to do it all myself.
When I'd try to put Peeper down long enough to pump, she would cry. Then I could cry, telling her, "I am doing this for you!"
Several times, I pumped while holding the bottles to both breasts with one hand and elbow, as she lay on my lap, taking a bottle from my other hand.
"You know," I'd tell her, "There's really a much simpler way to do this. How about we cut just out the middle man, huh, Kiddo?"
I was using a Medela Pump In Style, and anyone who's used one will tell you that it "talks." The noises that it makes are incredibly voice-like and when you add in a dollop of hormones and a heaping helping of sleep deprivation, it becomes something of an auditory Rorschach test.
I'd heard the pump say all kinds of crazy things, from "Loser McCain, Loser McCain," in the days following after the presidential election, to “We're losing control, we're losing control," after failing for a third time to catch a urine sample for some metabolic testing that Peeper needed, but now, the bastard really turned on me.
On the first or second day that I was home alone with Peeper all day, I was pumping while she lay in her bassinet and we both cried, and the pump was saying, "It's such a pain, it's such a pain."
Well, yes, I couldn't argue with that.
Then it changed to, "It doesn't pay, it doesn't pay."
And, for a moment, I started to believe it, and that is the closest that I ever came to giving up.
I knew I needed help to get past that, so I picked up the phone and called DoulaK, and told her, through my tears that, "We're having really rough day, here. Do you have a minute?"
We talked for hours, and she told me that I sounded much like every mother of a newborn that she talked to.
Not necessarily a mother of a one-month old, mind you, but a newborn, because that's what Peeper really was at that point.
She was just starting to "wake up" and realize that she was no longer a fetus but an actual baby.
She'd learned how to cry. She wanted to eat all the time. I was pumping as often as I could, and barely staying ahead of her.
I was exhausted, I was discouraged and I was devastated.
All my life, I’d looked forward to having a baby, and now that I had one, nothing was going the way that it should.
My baby was early, and she was tiny, and she had a hole in her heart, and she might have a metabolic disorder (she doesn’t) and I couldn’t even feed her.
For four weeks, I'd been holding on to the lactation consultant’s prediction that Peeper would pull it together and learn to nurse by her due date. Now that date had come and gone and she was no closer than she was at a week old.
Yes, she'd had a few days here and there when she'd suddenly decided to latch, and a couple of times she'd even nursed several times in a day.
But each time I thought she'd turned a corner, the next day, we'd be right back where we'd started.
That was almost worse than if she'd never latched, because I would get my hopes up repeatedly, only to be disappointed time and again.
But, I did have that glimmer of hope that she was not completely refusing the breast, she did still know how to latch, and she was still willing to do it on occasion.
In the hospital, I'd been given a couple of different nipple shields, but Peeper wasn't able to latch with either of them, because they were so much bigger than her mouth was at the time.
LadyKay had told me that a nipple shield had done the trick in getting her son over his nipple confusion (after having been given bottles in the hospital, when he was jaundiced), and suggested I might think about giving one a try.
I was hesitant, though, because it hadn’t worked before, and I also knew that they can often cause more problems than they solve, so DoulaK had been hesitant to recommend that I use one just yet.
This day, though, she suggested that I consider it.
The main concerns with a nipple shield are nipple confusion - a moot point, since we were already there, and nursing with a shield was better than no nursing at all, and that the nipple doesn't receive as much stimulation as it would if the baby were latched directly, so it can cause a reduction in milk supply. However, my supply was well-established at this point, and I would still be pumping, so I wasn't too concerned about that
I thought about it for a few days, and when Peeper was just over five weeks old, I tried the nipple shield.
She latched immediately.
I was very careful not to get my hopes up, because she'd tricked me before, but I kept offering the breast, with the shield, and she kept taking it.
I believe it was a Wednesday that we first used the shield, and from Thursday afternoon through the day Friday, she did nothing but nurse, nap, poop, and nurse the other side.
For about thirty-six hours straight.
Her tummy was full enough that she didn’t fuss for a bottle, and my breasts were empty enough that I felt no need to pump.
I called DoulaK on Friday and said, "You told me to call you with some good new for a change, so I am!"
This time, we really had turned the corner.
We gave her a couple of supplemental bottles over the weekend, mostly because I was freaking out each morning that "She's not eaten in five hours! If she won't wake up and nurse, make her take a bottle!"
Of course she was sleeping longer, she'd been cluster feeding like crazy, and if I'd waited thirty minutes or an hour, she'd have been awake and asking to nurse again, I'm sure.
On Sunday, Shrike's parents watched her for an hour or so while we went out to get a Christmas tree, and gave her a bottle while we were gone.
She turned six weeks old the next day, and (with the exception of the day after her surgery, before we were allowed to pick her up) she's not had a bottle since.
Within two or three weeks, I had weaned her off of the nipple shield, and we were home free.
It's hard to believe, as I sit here typing, while Peeper naps and nurses in my lap, that this is the same kid who refused to latch for six weeks.
Now, she refuses to unlatch!
She is still small for her age, but all her doctors have been thrilled with her growth - especially considering her heart defect, which often causes babies to grow slowly.
Her growth has been a huge thing for me.
Especially in the early days, I was so worried that if Peeper wasn't growing as fast as her doctors wanted her to on breast milk, they would insist that we give her formula.
Even now, every single time I put her on a scale, I hold my breath, as I wait for its verdict, as I wait to see whether it will say that I am doing my job, that I am a fit mother for her.
In those first days and weeks, all we were asking of her - all they were asking of me - was that she eat and that she grow.
If she couldn't do that - I couldn't do that - I felt like I would be failing her.
As it turns out, she could. And I could. And we have.
She is almost seven months old, and she is thriving.
With the exception of about two ounces of formula in her first eight days (the 10 cc I mentioned above, and a couple of times that I was away from her briefly and she ran out of the pumped milk available) she was exclusively breastfed until she was six months, six days old.
Now almost seven months old, she continues to breastfeed on demand, but we've also started offering her finger foods, taking a baby-led approach to the introduction of solids. She's loving her "chewin' food," but is still nursing just as much.
I know that it's only a matter of weeks before she's getting enough nutrition from the solids that she starts cutting back on her nursing, and I'm a little sad about that, but I’m also proud of what a “big girl” she's getting to be.
Of course, our nursing relationship will be changing significantly over the next several weeks and months, as she eats more and more solid foods, and will continue to evolve as she matures, but I'm looking forward to breastfeed as long as Peeper wants and needs to.
Peeper and I got off to an incredibly rough start with nursing. We were dealt some bad cards, and, I now realize, we were given some bad advice from the pediatricians and some other people at the hospital.
I also now realize that we encountered some people who claimed to be, or perhaps even truly thought they were being supportive of our efforts, but were, in reality, sabotaging us.
I am still very angry about that, and am still very, for lack of a better word, traumatized, by the whole situation, especially the "nipple intervention."
But, more importantly, we also had some very, very good advice and support and encouragement all along the way.
We got great technical advice from DoulaK, LadyKay, MidwifeK and LeaderH, and incredible emotional support from all of those people, as well as Shrike, of course, and Anonymama, Dr. T, and many friends.
Without their help, we never would have made it through those first six weeks, and I would have been absolutely devastated if Peeper had not learned to breastfeed.
I went into it probably knowing a lot more about breastfeeding than most people who've never done it, I was absolutely committed to making it work, and I had a great support system.
And I still doubted, everyday, whether we would be able to do it.
I totally understand, now, why women give up on breastfeeding, especially if they are not lucky enough to have that kind of support.
But there is no excuse for them not having that support. There's no excuse for hospitals pushing formula when a baby doesn't need it. There's no excuse for them not offering alternative feeding methods to avoid the introduction of artificial nipples and there's no excuse for women not being told where they can turn for help.
Shrike tells me that Peeper wouldn't be nursing today if I weren't so damn hard-headed, and I like to think she’s right.
I've done a lot of things in my forty-one years, some of which I'm pretty proud of, but there is nothing that I'm prouder of than sticking it out and having enough faith in Peeper, and in myself, to give her the time to mature and trying one thing after another until we finally hit on the answer, and doing what it took to get us through those first six weeks to bring us to the point where we are today.
As awful as those early weeks were, and as hard as some of the other things we've been through with Peeper have been, from worries during my pregnancy about a possible neural tube defect, to her open-heart surgery, I think that I am a stronger person for it, and I am a better mother for it, and Peeper, Shrike and I are a stronger family for it.
I spend a good portion of my day (and night) with Peeper at my breast, and sometimes I get tired, and sometimes I need a break, but I never, ever take it for granted.
And I never will.
Saturday, May 23, 2009
Evidently, when Shrike wakes up before we do, she watches us sleep. Or, she watches Peeper sleep, and I'm there, too.
The other day, I was mostly asleep, when Shrike said (to whom, I don't know - because I was asleep), "Aw, look, she's laughing in her sleep."
Which made perfect sense to me, because I'd been dreaming that I was tickling her belly button.
A couple of days ago, Shrike reported that Peeper poked herself in the eye with her thumb - and then gave it a dirty look.
On Tuesday, the three of us went to vote. When we got to the check-in table, the
I told her our last name and as she started looking for it in the book, I said, "There are two of us, and we're both here. Actually, there are three of us, but this one isn't old enough to vote yet."
When she found us in the book, she said, "I'll hold the baby, and you sign your name right here."
Um yeah, no.
So, I said, "Oh, I'm fine," and reached for the pen. Believe me, I can do much more complex things with a baby in my arms than signing my name. Hell, she wasn't even nursing at the time!
Shrike said, "I'll hold her while you sign," so I handed her off.
The election judge said, "Ok, Grandma can hold her."
Whozat: 3 / Shrike: 1
Whozat: 1 / Shrike: 1
I have been told three times in the past two weeks how much Peeper looks like me.
A couple of days ago, we were asked, by someone whom I really thought would have already known the answer to this question, "So, are you doing any attachment parenting stuff? You know, like Dr. Sears?"
I'm gonna go with a "yes" on that one.
"Talk To Me" baby sign language DVD:
"This is the sign for milk. You can use it to mean real milk, breast milk, or even formula. "What the fuck?!?
". . . real milk, breast milk . . . ."Oh no. She. Didn't.
I am already on the Peeper Can't Eat It Diet, regarding her dairy sensitivity, but I may have to also go on the Peeper Shouldn't Eat It Diet, regarding her, um, babiness.
More than once, I've snagged an Oreo on my way through the kitchen, while carrying her in one arm, and she's started gumming at my cheek while I was eating it.
As though she planned to chew through the side of my face, and into my mouth, so she could have some.
Remember a while back, when I blogged about Peeper hating the carseat?
Well, I forgot to mention that she got over it shortly after that.
When we moved the straps up to the next setting.
All together now, class: Worst. Mothers. Ever.
Friday, May 22, 2009
Elita, at Blacktating, is giving away several breastfeeding and baby items to celebrate her one-year blogiversary.
Visit her blog to learn how to enter, and you could be a lucky winner of one of these great prizes:
- The Black Woman's Guide to Breastfeeding, the only breastfeeding book written specifically for African-American women, by Kathi Barber.
- A 2-Pack of Organic Velour Flat diapers and pins courtesy of sustainablebabyishSloomb. Bamboo velour is ridiculously soft...perfect for baby's skin!
- A $50 gift certificate to One Hot Mama. You can get yourself a nursing tank, bra, Mama Spanx, maternity gear...the options are endless! One Hot Mama has stylish options for every mom or mama-to-be.
- A MilkBank breast milk storage system. I reviewed this product and thought it was great. And don't tell anyone, but sometimes I still let my son have his milk in a MilkBank bottle.
- A copy of the 3rd edition of The Complete Book of Breastfeeding by Sally Wendkos Olds, a classic breastfeeding book.
- The Wonders of Mother's Milk, a gorgeous hardcover multicultural children's book about breastfeeding, by Mishawn Purnell O'Neal.
- 25 Things Every Nursing Mother Needs to Know. A compact, beautifully illustrated breastfeeding book. A perfect shower gift!
Thursday, May 21, 2009
Shrike's Pappy (her maternal grandfather) is a World War II veteran, and for the past twenty years, he's been in charge of putting Memorial Day flags on the veterans' graves for his American Legion post.
He used to handle several cemeteries personally, but in recent years, he's gotten down to one, and the whole family helps.
Because the flags are put out on a weekday, this is the first time that I've been able to join them, and it couldn't have been a more perfect day to spend outside.
We lucked out and by the time we arrived at the cemetery, most of the flags were already set, and everyone was taking a break for a picnic under a tree.
After lunch, Shrike went back out with them to finish up, while Peeper and I guarded the cars, took a short walk (within view of the unlocked cars), and had a bit of goody and a nap under the tree.
This is a churchyard cemetery. The church has been rebuilt a few times, but according to the cornerstone, the original building was erected in 1747.
The oldest grave I saw today (in the very small area that I covered) was from 1781, belonging to a man who came to America in 1746, at the age of 18, and "established the family in this country."
At least one of the flags that was placed today was on the grave of a soldier from the Revolutionary War.
Another was on the grave of Shrike's paternal grandfather, who also fought in World War II. He and her grandmother attended this church for several years, and they are buried there.
Wednesday, May 20, 2009
I've realized that if I don't want Peeper to eat something, I probably shouldn't eat it in front of her, because she wants some of whatever I've got, and she usually gets it.
Today, she had sweet and sour rice/chicken/onions/peppers and Sante Fe style rice, with beans and corn. (I believe corn is the defining characteristic of "Sante Fe style," isn't it?)
She seemed to really like both, but they also frustrated her, because they were not very finger-feeding-friendly.
At lunch, with the sweet and sour, she was in my lap and I held the spoon out, to see if she'd take some off of it. She grabbed it with two hands, right at the "neck," put it in her mouth and ate it.
Okay, that'll work.
At dinner, I put some Sante Fe rice on her placemat (it's stickier, with no sauce) but she couldn't really handle it alone, because she can't open her fist on command to get the food out of it - let alone having any sort of pincer grasp yet.
I suppose I ought to try to take some photos of Peeper doing something - anything - besides eating, huh?
But not today.
Here's her new set-up. I adjusted the height on the highchair and removed both trays and moved her to the end of the table (with more of an overhang) so she can just sit at the table.
She was having a lot of trouble reaching over the lip of her highchair tray to get to the food, so this gets her better access.
Also, her placemat has a great trough to catch dropped food, and is easier to clean, because it actually fits in the sink and dishwasher. We need to buy ten more of them.