Motherhood Blooms Lactation™

Breastfeeding With A Nipple Piercing

Can I breastfeed with a nipple piercing? What if I used to have one? Will a nipple piercing affect my milk supply or my baby?

You might not have previously considered breastfeeding at the time you got your nipple pierced. Maybe now you’re thinking about breastfeeding or you’re about to have a baby and wondering if you need to take out the piercing.

When a nipple piercing is placed, it’s important to consider the possible implications it could have for breastfeeding.

The short answer is yes, most people who have had nipple piercings can successfully breastfeed but their breastfeeding experience may look different than they planned. This is because a nipple piercing will affect different nipples in different ways.

Most people who have had nipple piercings can successfully breastfeed but their breastfeeding experience may look different than they planned

The possibility of nerve damage

There is a possibility of nerve damage that could interfere with milk let-down and may cause pain. Your body will still make milk because the breast tissue is healthy but when your nipple is stimulated (by a suckling baby or a pump) the nerves do not tell your brain to let-down milk. This can also interfere with the feedback required to sustain milk production. This means in the first few weeks you might have a strong supply but a times goes on, you may find your supply decreasing. Every body is different. You won’t know how it will affect your body until you start breastfeeding. Overtime and over multiple breastfeeding experiences, sometime the nerves regenerate. They are reports however of some people experiencing nipple pain at the site of the piercing possibly due to nerve damage.

Generally, the longer the amount of time between your piercing and breastfeeding, the better the outcomes.

The possibility of scar tissue

With a nipple piercing, there is a risk of scar tissue that could block some of the ducts. This could affect milk production over time. If your nipple piercing scars shut, it won’t affect your initial ability to make milk but rather how much milk comes out of the nipple. If the milk cannot exit the nipple, there is a higher risk for plugged ducts and mastitis. What happens in these conditions is the milk sits in the ducts and coagulates. It creates a lump or a firm spot. It can quickly become inflamed and lead to an infective condition known as mastitis. With recurrent plugged ducts and an inability to exit the nipple, the milk making cells in that part of the breast may stop producing milk overtime. Your body will adapt to producing all the milk that can be removed. Ultimately, this may affect supply on that side only. Your baby may be fussier on the side with less milk and may prefer the opposite side (if you had just one side pierced). Every body is different. You won’t know how it will affect your body until you start breastfeeding.

Do you have to remove a nipple piercing to breastfeed?

If you do currently have a piercing, it is recommended you remove the jewellery before breastfeeding. The jewellery could rub on the baby’s hard palate (roof of the mouth) and make breastfeeding uncomfortable for them. Not to mention it could damage the soft tissue. In addition, if the jewellery were to come loose, it’s a choking hazard. Removing the jewellery will leave holes that are no longer plugged. It is very common to leak milk from these holes.

The possibility of leaking through the extra holes

When you remove any piercing, a hole is left behind. With a nipple piercing, two holes are left behind in an area where milk exits the breast. It is not uncommon to leak milk through these additional holes. The nipple itself has an average of 9 pores milk exits through. This number varies per person and ranges from 4-18 per nipple. When you remove the nipple piercing, there is now one large hole on each side of the nipple. Depending on the gauge of your piercing the holes may be relatively small or possibly much larger. This means, when your body has a let-down there is a possibility milk will also come out the sides of the nipple. If this happens when you are not breastfeeding (because you heard your baby cry) just wear some breast pads inside your bra. When your baby is breastfeeding, ensure they have a deep latch and are actively swallowing milk. For some babies, the extra milk can be challenging to manage if they don’t have a deep, effective latch. Despite the extra milk leaking through your nipple(s), you shouldn’t see any milk pouring from your baby’s mouth.

Will a nipple piercing affect my milk supply?

It’s unknown if your nipple piercing is going to affect your supply or your breastfeeding experience until you actually begin lactating. It’s important to understand the implications it might have and to have realistic expectations of what it means for breastfeeding. Our bodies are intelligent and amazing and many people can feed a baby on one breast alone. Other times, there is no impact to supply. It’s truly individual. If you’re concerned about what it means for breastfeeding, meet with a lactation consultant during pregnancy to discuss your goals and options. They will also create a plan for you and makes adjustments after you begin breastfeeding.

Last updated March 30th 2021

References:

Garbin, C., Deacon, J., Rowan, M., Hartmann, P., & Geddes, D. (2009). Association of nipple piercing with abnormal milk production and breastfeeding. JAMA, 301(24), 2550-2551.

La Leche League International (LLLI). (n.d). Nipple Piercings. LLLI.org. Retrieved from: https://www.llli.org/breastfeeding-info/nipple-piercings/

Wilson-Clay, B., & Hoover, K. (2017). The breastfeeding atlas (6th ed.). Manchaca, Tex.: LactNews Press.

4 tips for plugged ducts

It can be common to hear about someone who experienced a plugged duct (sometimes called a clogged duct) while breastfeeding but what does that actually mean? And what do you do if you find yourself with a plugged duct?

Before jumping right to what to do, it’s important to understand a little more about breast anatomy. This helps you understand why what is happening in your body is happening and when I share the tips to helping relieve and prevent them, they will make more sense.

The (absolute) basics

To be able to understand what is happening when you have a plugged duct you should first understand basic breast anatomy. During the second trimester of pregnancy, your body is already preparing for breastfeeding by growing a network of milk ducts. In simplest terms, the milk ducts are tubes and they carry milk from the milk sacs (where milk is made) to the nipple. Milk then exits from multiple pores in the nipple. When milk cannot be removed (due to an obstruction) or sits in the duct for a long period of time it can coagulate. The milk ducts can start to narrow due to inflammation.

So what is a plugged duct/clogged duct?

In short, a plugged duct is a palpable lump in the breast due to inflammation. “Plugged” ducts is technically a misleading term. They should however be promptly looked after. If they’re not, there’s an increased risk of mastitis which is an inflammatory condition that can quickly become infective. If you notice a red, shiny streak on your breast paired with a fever, chills or body aches, these are signs mastitis which as mentioned, is a more serious concern because it can become infective.

Why did I get a plugged duct/clogged duct?

Plugged ducts can occur when milk flow is obstructed or milk is not being removed. They can happen for a number of reasons. Plugged ducts can happen:

If you miss a feeding or a pumping session
If you space out the time between feedings (whether intentionally or unintentionally)
If your baby isn’t effectively removing milk at the breast. This could be due to their latch or poor positioning at the breast
If you are using the wrong flange size when pumping
If you have an abundant milk supply
If there’s lots of pressure against your breast such as with a tight fitting bra

How do I know if I have a plugged duct/clogged duct?

Get familiar with your breasts. Regularly feeling your breasts after a feeding or in the shower will help you become familiar with their normal landscape and quickly allow you to recognize changes. You will be able to feel a firm lump or knot in your breast. The lump should be palpable which means you should be able to located the edges of it. A lack of symptoms is also helpful when thinking about plugged ducts. If you do not have a fever, redness on the breast, chills or body aches, that’s a good sign it’s more likely to be a plugged duct. When locating a plugged duct use the pads of your fingers to feel for the border of the plug so you know where it begins and ends. This will be important when you begin some of the massage techniques.

How can I remove a plugged duct/clogged duct?

There are several ways you can care for a plugged duct. With any of the methods, it’s always about reducing inflammation. My four personal favourites that I use with families are the following. These are not meant to all be used. Start with one method first. Using all of these at once can created unwanted inflammation in the breast and quickly escalate to something worse. If you have a plug that you would describe as stubborn, always reach out to a lactation consultant to they can get to the bottom of the issue with you.

BREASTFEED/REMOVE MILK

Breastfeed and remove milk as usual. The newest guidelines from The Academy of Breastfeeding Medicine suggest there’s no need to try and “empty” the breast. Excess pumping can increase inflammation further.

GENTLE MASSAGE AND COLD

Gentle breast massage to move the excess fluid towards the arm pits to the lymphatic system can help. Use cold after milk removals. If you’re pumping, ensure the flanges fit correctly. You can also use a little bit of coconut oil to lubricate the flanges.

A great video about breast massage

https://www.mayabolman.com/videos/v/breastgymnastics

REDUCE INFLAMMATION

Reducing inflammation can include anti inflammatory foods as well as over the counter medications like Advil and Tylenol

How do I prevent a plugged duct/clogged duct?⠀

Frequent and effective milk removal are the keys to preventing plugged ducts from reoccurring. If you are frequently experiencing plugged ducts, go back to the list at the beginning. Can make any changes to your baby’s latch and/or positioning, the frequency of feedings, your bra type or pump flanges? If you have and you are still always experiencing plugged ducts, get in touch with a lactation consultant. You can connect with me HERE.

4 Signs Your Baby is Getting Enough Milk

How do I know if my baby is getting enough milk?

This is probably one of the top questions I get from new parents. It makes sense. You can’t see the milk going into their body so how do you really know? The good news is, there are definitely a few signs to watch for that will tell you if your baby is getting enough milk.

1. Looking or listening for swallowing

When a baby is taking in milk, they have to swallow it. 4-5 swallows per feeding of colostrum is what we’re looking for. When milk transitions, and the volume goes up, we’re looking for a 1:1 ratio of suck:swallow after let-down has been initiated. But what are you actually looking for? When a baby swallows milk, you will see their jaw drop slightly lower and pause momentarily. You can also have a look at your baby’s ears or the side of their face as you may notice the bottom of the ears move when the jaw drops down. This is a swallow. You can also listen for a swallow. A baby’s swallow sounds like a soft “kah” sound.

2. Generally content after feeding

Your baby should be alert prior to feeding and generally more sleepy and content after a feeding. Every baby is different and not all babies experience a milk coma right after feeding which is why we pay attention to their behaviour. If they are no longer showing those early hunger cues and seem relaxed, you can take it as a sign that they are content after the feeding. Many babies will also have their hands in fists prior to feeding and then relax to a more open hand afterwards. Sometimes their arms get really floppy after feedings too. This is just another sign they are full and relaxed after a feeding.

3. Diaper output is age appropriate

Newborns produce a lot of wet and dirty diapers. During the first week, we look for 1 wet and 1 dirty diaper for each day of life. On day 1, or within the first 24 hours we are looking for 1 wet diaper and 1 dirty diaper. Baby’s first poop is called meconium and is very dark, sticky and tarry. After this, on day 2, we are looking for 2 wet diapers and 2 dirty diapers. The poop will still be dark but may resemble a darker green than brown. As the days progress, by day 5 your baby’s poop should have transitioned to a mustard yellow in colour and you should be seeing 5+ wet diapers and 3-4 yellow dirty diapers. If there’s so many that you’ve lost track, chances are your baby’s diaper output is appropriate. It’s always important to track during that first week because it’s a question all lactation consultants will have for you. The first couple of poops your baby has should be about the size of a toonie or larger.

4. Your baby is gaining weight

This is a clear sign that milk intake is enough. What is most important though is that your baby is sticking to their own growth curve. The growth percentiles are not report cards. A baby in the 50th percentile is not doing poorly nor is a baby in the 95th doing better than others. This is just simply comparing their size and weight to other babies of that age. Humans are different sizes. It’s normal! We’re not all supposed to be the same size so the same goes for babies. Your doctor/pediatrician should be using the World Health Organization growth velocity charts. These charts take into account infant growth and development from all over the world and use the growth of a breastfed baby as the norm.

The new growth curves are expected to provide a single international standard that represents the best description of physiological growth for all children from birth to five years of age and to establish the breastfed infant as the normative model for growth and development
The World Health Organization

If you can see or hear your baby swallowing for a few minutes each feed, they seem content afterwards and are producing lots of wet and dirty diapers while gaining weight, your baby is getting enough milk.

If all the above are happening BUT you’re in pain or breastfeeding is not enjoyable or doesn’t feel sustainable, always reach out for support. Lactation consultants are detectives; always working to get to the bottom of every feeding issue. They are trained specifically in the area of human lactation and are the specialists when it comes to infant feeding.

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Last updated March 5th 2021

References:

Campbell, S.H., Lauwers, J., Mannel, R., & Spencer, B. (2019). Core Curriculum for interdisciplinary lactation care. Jones & Bartlett Learning.

Newman, J. & Pitman, T. (2014). Dr. Jack Newman’s Guide to Breastfeeding. HarperCollins Publishers Ltd.

3 tips to get a better latch, NOW!

Updated February 20th 2023

I’ll start by saying there is tons of information online that references “a good latch”.

The hospital staff might have said to you “he has a good latch”. The new parent blog you read said “Be sure to get a good latch”. You see posts on Instagram that say “A good latch shouldn’t hurt”.

Before I tell you how to get a good latch, let’s talk a little about how to know if it’s not a good latch or rather, not an optimal latch.

What if it doesn’t really hurt but you’re still not sure if it’s a good latch? How do you know?

So first, if there’s pain the latch needs to be checked. If you’re tensing up, curling your toes or holding your breath as you latch your baby because of pain, it’s not a good latch. You should get help for that, asap.

If breastfeeding is comfortable and you’re pretty sure your baby is drinking milk but your nipples are coming out flat or misshapen (meaning they are not round anymore) there’s room for improvement.

When your nipples come out of your baby’s mouth as a different shape, this means the nipple is not reaching to where it should. The nipple is being compressed against the hard palate.

If your baby’s chin is not touching your breast or if their nose is ending up buried in breast tissue and the only way for them to breathe is for you to hold down your breast tissue with your finger for the whole time…it’s not a good latch. That one is usually a quick position adjustment.

Lastly, if milk is leaking out of the sides of your baby’s mouth while they are drinking or if they are making slurping or smacking sounds, it’s a poor latch. There’s an issue with the seal they are creating on the breast and this also means you should get support.

Ok, so how do I get a good latch?

A good latch can mean the difference between a comfortable breastfeeding experience or a painful one. While pain can be common during breastfeeding, it indicates your baby’s latch can be improved as I mentioned above.

There are a few adjustments you can make to help relieve the pain and reposition your baby for a more effective latch. Especially if you’re waiting to see a lactation consultant, hours feel like days when the latch is wrong. I know because I was there too.

So here are 3 things you can do right now to get a better latch.

1. Relax and Get Comfy

Make sure you are relaxed and in a comfortable position. I often work with parents who breastfeed in very uncomfortable positions putting unnecessary tension on their neck, shoulders and back. If you’re doing this you’re not alone!

If you ever feel awkward holding your baby to breastfeed, switch it up and try a new position. Use as many or as little pillows as you need. Sometimes larger breasts need pillows or rolled towels for support. Do whatever works to make yourself comfortable. I often recommend the laid back position for a comfortable latch.

Whatever position you’re in, there’s no real right or wrong if you’re comfortable and your baby is able to drink well. Our bodies are different shapes and sizes so are our chests, adjustments are what tailor a position to you and your baby.

2. Watch Your Baby

It’s easy (especially in the very early days) to want to scroll through your phone, place a few online orders or watch a movie when you are breastfeeding. Breastfeeding has a learning curve for both you and your baby. While you’re working to perfect your latch, tune into the feed and watch your baby.

Your baby’s tummy should be facing yours and their ears, shoulders and hips should be in alignment. An easy way to remember this is “nose and toes” should be pointing in the same direction. They should also be very close to your body, touching actually. Any gaps can make getting a comfortable latch more difficult.

You also want to watch them so you can latch your baby when they open wide like a yawn. This will ensure the entire nipple gets into their mouth and all the way back to the soft palate. You can always tickle their lip with your nipple to encourage the wide gape.

When your baby gets ready to take in the nipple, they should lead with their chin. More of their bottom lip should be covering the areola than the top. This is known as an asymmetrical latch. It encourages the nipple to point to the roof of the mouth which assists with getting a deep, pain free latch.

3. Bring Your Baby to The Breast

Bring your baby to the breast, NOT the other way around! Please, do not stretch and pull your breasts towards your baby. Bring your baby to your breast. If you’ve followed tips 1 and 2, you should already be in a position where your baby is at your breast. If you are still finding yourself stretching or pulling yourself towards your baby, adjust your body again, and then attempt latching.

I hope this provides you with some more clarity.

If you’re still struggling with latching, join my community of other breastfeeding parents, going through the same things you are.

This is a safe space to ask questions and support each other. We talk about all things postpartum, breastfeeding and babies!

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References:

La Leche League International. (n.d). Positioning. La Leche League International. https://www.llli.org/breastfeeding-info/positioning/

Newman, J. & Pitman, T. (2014). Dr. Jack Newman’s Guide to Breastfeeding. HarperCollins Publishers Ltd.

How to Hand Express

How to perform this Press, Compress and Release method to collect milk

Updated March 27th 2023

Hand expression is a valuable skill for all lactating parents to have. It is not cost prohibitive because all you need is your hands! It’s been shown that hand expression increases breastfeeding rates when compared to pumping at 2 months postpartum.

Hand expression is useful in the first 24 hours after birth as it can help assist with the transition from colostrum to copious milk production (aka milk “coming in”) and assist with colostrum collection. Hand expression is a valuable collection method even for someone with a pump because colostrum can get stuck in the tubing of a pump due to the small volume that is produced and it’s thick consistency.

Hand expression can also be used prior to the birth of your baby. Provided your midwife or OB/GYN has cleared you, hand expression can be used as early as 37 weeks gestation to collect colostrum in advance of baby’s arrival. The reason you need to be cleared to do this is because the nipple stimulation can lead to early labour for some (thanks to oxytocin) and so, it’s not recommended for everyone. Always consult with your care provider. You can grab a video download below that includes a video on this topic.

Why would you want to collect colostrum prior to your baby’s birth?

Collecting colostrum while pregnant can be very helpful if you’ve previously struggled with breastfeeding or milk production. This ensures you have some additional nutritional support if your baby is having troubles effectively latching.

This is also a supportive technique if you have gestational diabetes as your baby can become hypoglycemic at delivery and having the extra colostrum on hand will support their blood sugar. If you’re expecting multiples it can be helpful as well. If you’ve had prior breast surgeries and are unsure how it might impact milk production, collecting beforehand can be invaluable.

Colostrum collecting before birth requires collecting and saving the colostrum in feeding syringes that are 1mL – 5mL. You can freeze the syringes. They should then be placed in a container or bag labelled with the date and your name. It might also be helpful to add your health card number to them. You can then bring the frozen colostrum to your birth.

Whether you are collecting colostrum prior to delivery or expressing milk after your baby’s birth, the method is the same.

The Method of Hand Expression

With clean hands find a comfortable position, ideally resting with your back and body supported and massage the breasts in circles, working towards the areola. This will help stimulate the flow of milk.
Either doing this yourself, or with a partner, the milk collection container should be placed underneath the nipple. A small cup, spoon or syringe will work to collect the colostrum.
Your thumb and index finger should be placed on the breast about one inch above and one inch below the nipple. Your hand will create a “C” shape or a “U” shape. It’s important to measure from the nipple because areolar size varies significantly.
Press your fingers back towards the chest wall (your rib cage), gently compress the breast tissue (squeezing, bringing your fingers together) and then release the compression. Repeat this over until you begin to see colostrum* or mature milk depending on which stage of milk production you are at. Go back and forth between sides. *if you’re expressing colostrum, hold the compression for about 3 seconds before releasing
It’s important you always remain relaxed as it can take a few compressions before you see milk. In addition, you should always feel comfortable. If there is any pain or discomfort, you should adjust what you are doing until you are comfortable. It may also be helpful to have your baby nearby this will increase the release of oxytocin which stimulates milk let-down. The entire process may take 20-30 minutes.

If you are collecting colostrum PRIOR to your baby’s birth, you would perform hand expression twice a day for about 10-15 minutes and you would save the colostrum in feeding syringes which you can freeze and take to your birth.

This technique should not damage your skin and delicate breast tissue. Always be gentle. Your breasts are not like the muscle tissue of your body, you do not want to be using a lot of force on them.

Grab my free colostrum collection guide

and set yourself up for breastfeeding success! This free guide includes access to a FAQs video as well as a video demo of hand expression.

CLICK HERE

Hand expression is just one of the topics covered in my prenatal breastfeeding course The Breastfeeding Before Baby Program. This program is designed specifically for pregnancy. Investing in a prenatal breastfeeding class before your baby is born helps get breastfeeding off to a strong start and can save you time spent online in the long run.

If you’re looking for some support to help you breastfeed your baby whether you’re nursing or pumping, you can work with me here.

Alex Wachelka is an International Board Certified Lactation Consultant passionate about helping you to confidently feed your baby. She owns her private practice Motherhood Blooms Lactation and sees clients virtually and in person.

References:

Campbell, S.H., Lauwers, J., Mannel, R., & Spencer, B. (2019). Core Curriculum for interdisciplinary lactation care. Jones & Bartlett Learning.

La Leche League International. (2020). Hand expressing. La Leche League International. https://www.llli.org/breastfeeding-info/hand-expressing/

Newman, J. & Pitman, T. (2014). Dr. Jack Newman’s Guide to Breastfeeding. HarperCollins Publishers Ltd.

4 Ways to Help Your Distracted Baby Feed Better

mother using phone while breastfeeding her child

updated March 7th 2023

Your baby has been nursing well for the past 12-15 weeks when suddenly, you notice your baby becoming more distracted when they are nursing. Every sound seems to catch their attention, the dog walks by or someone new comes into the room. All of these events will cause your baby to stop nursing and have a look around. If you previously nursed in public, you may notice your baby is having a very difficult time now.

Latch on, pull off, latch on, pull off…

It can be very frustrating nursing a distracted baby. Around 3-4 months babies become much more aware of the world around them. Suddenly they are paying more attention to the room they are in, the sounds they are hearing in and outside the home. They may latch on and pull off only to latch on again, maybe feed for a minute and then pull and become frustrated because they are no longer drinking milk. This makes feedings difficult and may be misinterpreted as weaning when it’s not. Babies younger than 18 months typically do not self wean.

When distracted feedings happen, your baby will nurse for a shorter period and may nurse more frequently at night to make up for the calories. This is completely normal and the night nursing is beneficial for your milk supply. It’s also a quiet, calm, distraction free environment.

So what can you do about those distracted daytime feedings?

1. Offer the breast frequently

This may mean prior to your baby cueing especially if they are alert as they are staying awake for longer periods at this age. You want to provide many opportunities for them to latch and drink milk especially when the feedings are interrupted by their own curiosity. ⠀

2. Minimize distractions

A common piece of advice is to head into a room, preferably one where you can darken the environment by pulling a shade or drawing the blinds. This will shut out the distractions and help create an environment where your baby will effectively nurse.

While this might be effective, if you have an older child, this is not something you can do without another adult present. Chances are, it’s just you and your kids so this is why I like to suggest you take advantage of the nighttime feedings.

Nighttime nursing is still very much needed (and normal!) by this age group and often, they will do some of their best feeding because they are sleepy. Side lying position is wonderful for night time nursing, especially if you safely co sleep. A semi reclined breastfeeding position is also great for night time. Practise to see what feels most comfortable and works best for you.

3. Try motion

Using motion such as rocking or swaying your baby while nursing them might help to reduce the distractions. You can use a baby carrier/wrap or a sling and walk around and nurse them while they are in it. It takes a little while to get the hang of but it.

4. Skin to Skin

Skin to skin acts like an amazing re-set button. It is so helpful when feeding a distracted baby. This will not only help calm your baby but help encourage your baby to latch. Skin to skin also releases oxytocin which helps your milk let down. Not all older babies will respond well to this so experiment and do what works best for your baby.

Bonus tip

Here’s another option your baby may respond well to. Clipping a toy or a pacifier clip to your bra strap to keep them distracted but at the breast so they continue to feed.

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References:

Bonyata, K. (2018, Jan 1). The distractable baby. Kellymom.com. https://kellymom.com/ages/older-infant/distractible-baby/

Campbell, S.H., Lauwers, J., Mannel, R., & Spencer, B. (2019). Core Curriculum for interdisciplinary lactation care. Jones & Bartlett Learning.

La Leche League Canada. (2015, Dec 17). Thursday’s tip: Breastfeeding the distracted baby (6-12 months). La Leche League Canada. https://www.lllc.ca/thursdays-tip-breastfeeding-distracted-baby-6-12-months

Newman, J. & Pitman, T. (2014). Dr. Jack Newman’s Guide to Breastfeeding. HarperCollins Publishers Ltd.

Lactogenic Breakfast Cookies

Updated March 29th 2023

Who doesn’t love cookies for breakfast? Or snack, or anytime really? The reason these cookies are great for anytime is that they are full of nutrient dense ingredients and free of refined sugars. They are made with oats and flax to help nourish your body and support milk supply but can be enjoyed as an after day-care snack as they are great for kids too.

When I was making these cookies I wanted to keep them egg-free so that the recipe could be made vegan. The cookies overall are very allergen friendly as they are:

Egg free
Gluten free
Nut free
Dairy free* (if strictly coconut oil is used)
Sesame free
Peanut free
Soy free

They remain soft and chewy after baking and will keep this texture once they are refrigerated. They can also be frozen and thawed out the day prior to eating.

They’re not your typical cookie. They’re sort of like a granola bar combined with a cookie because of the texture and the type of ingredients.

You don’t usually think of chia seeds or pumpkin seeds when you think of cookies. These cookies are made with ingredients that will help give you a calorie and nutrient boost which is essential when you’re recovering from birth and making milk for your baby.

Not the prettiest picture but this is what the dough will look like once everything is mixed

Some of the nutrient dense ingredients used in these cookies include:

Chia seeds: very good source of omega 3s, iron and fibre. Essential nutrients when you are recovering postpartum and lactating.

Pumpkin seeds: source of magnesium, protein and other trace minerals.

Oats: oats are a source of fibre called beta-glucans that can help support healthy cholesterol levels. They are also thought to boost milk production; acting as a galactagogue (increasing milk supply)

Banana: rich in potassium, fibre and a source of vitamins and minerals. The banana also helps naturally sweeten the cookies while boosting the nutrition

How to make them:

Ingredients:

1/4 cup water
2 tbsp ground flax seeds (also known as flaxmeal)
1/2 cup ghee (ghee is lactose free but not vegan as it is derived from butter. You can use coconut oil in place of this to keep it dairy free)
1/2 cup coconut sugar
1 tsp vanilla extract
2 cups gluten free oats
1 banana
1/3 cup pumpkin seeds, unsalted
2 tsp cinnamon
1/4 tsp salt
2 tbsp chia seeds
1/2 cup dairy free chocolate chips

Directions:

Preheat oven to 350°F. Line two baking sheets with parchment paper.
Combine water and ground flax. Set aside for 5 minutes. This will create a flax egg.
In a larger bowl mash the banana (using a fork is fine). Add the ghee (or coconut oil) coconut sugar and vanilla. Whisk together. Add in the flax egg. Whisk until combined.
Combine oats, cinnamon, salt, pumpkin seeds and chia seeds. Stir. Add to wet ingredients. Fold everything together. Add in chocolate chips. Fold again just until combined.
Use a 1/8 cup measuring cup to scoop cookies. Alternatively you can use a small ice cream scoop or place 2 tbsp of dough at a time into your hands and manually form the cookies. Place on lined baking sheets and flatten slightly.
Cookies will not expand or spread out so don’t worry too much if they are close together.
Bake 12 mins. Allow to cool on pans and refrigerate after they are cool.
Yields 16-17 cookies.

The cookies will look very similar to this after baking as their shape will not change

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Navigating the Holidays with a Newborn

How to manage a newborn and breastfeeding during the holidays

Updated November 12th 2021

I’m going to start with a little story. I had a 4 week old at Christmas back in 2019. I was a first time mom, newly postpartum and I was having a very difficult time breastfeeding. I was exhausted and stressed.

I reluctantly agreed to have some family over for Christmas. Because we live far away from family, they were also ALL staying in my home. Making the decision to have multiple people staying in my home for Christmas added to the stress I was experiencing. It didn’t help that I asked half of them to book a hotel and they flat out refused. You can bet I’ll be taking about boundaries later on.

There is SO MUCH going on when you have a brand new baby and the holidays can bring added stress and challenges. I’m going to provide you some tips for making your life easier and still focusing on yourself and your baby during this time.

How do you manage newborn life during the holidays

Watch Your Baby

What I mean by this is actually look at your baby to see what’s happening and how they are feeling. It’s important to know babies can become overstimulated. Newborns do not have the ability to shut out external stimuli and can easily become overwhelmed. They will express this overwhelm by crying, fussing and becoming irritable. Bringing them to a quiet, dark space will help. This helps to shut out the distractions and will be very helpful when nursing them. You may also find they want to nurse more. This is because the act of suckling helps regulate their nervous system.

Watch them for feeding cues as well. Catching those early hunger cues which include stirring, their mouth opening, turning their head side-to-side and rooting around can be missed if your baby is with another family member. When a baby escalates those hunger cues to stretching, bringing their hands to mouth and moving around more, a family member may try to shush them in the hopes of soothing them or pop a pacifier into their mouth. This will then start to spread out feedings which can put you at an increased risk of plugged ducts.

When these early cues and escalations are missed, babies start to cry, turn red and get very agitated. This may be the point that Aunt Doris says “let’s get you to mommy” for a feeding but at this point, your baby is going to need to be calmed by you before they will feed.

When a baby is crying because they are hungry, this is more of a distress signal than a true hunger cue so rocking, bouncing, singing, cuddling – any number of these things may need to happen before your baby is in a calm enough space to latch on and feed.

>> For more tips around breastfeeding a newborn in the first two weeks, check out my post ’14 tips for breastfeeding in the first 14 days’

person covering infant with swaddling blanket — Photo by Isaac Taylor on Pexels.com

Take a Time Out

The holidays bring their own special kind of stress. Stress hormones can interfere with oxytocin and your let-down. They can also impact your overall production (noticing a dip in your supply).This can make breastfeeding feel more stressful. Supporting milk production by reducing stress is about reducing your stress hormones and increasing oxytocin.

Taking time away in a quiet dark room with your baby can help. Watching videos or looking at pictures of your baby while you’re pumping can help support your let-down. Smelling something of your baby’s can also help.

It’s about finding ways to calm and relax yourself. When your stress hormones are low, your body can optimize oxytocin and prolactin. Maybe this means listening to music you enjoy while feeding your baby. Or maybe it’s using an essential oil you love while in the shower. Maybe you can find 5 minutes to sit still and deep breathe. All of these activities can naturally reduce stress hormones in your body and help to increase your milk production.

If it’s feeling like it’s too much, tell your company you need to feed the baby and take a time out. Go into the bedroom or nursery and spend 30-45 minutes alone with your baby skin to skin. Skin to skin releases oxytocin which is a feel-good hormone that relaxes both of you. Your baby should be in just a diaper and you undressed from the waist up. Your baby can breastfeed during this time if they want to but they can also just rest or sleep. This will help calm the both of you and give you much needed time alone.

>> if you’re wondering what else might be affecting your supply, grab my free video here

Set Boundaries

You are in charge of who is allowed to come over and for how long. It can be very difficult as a new parent to tell family you don’t want them over for an extended period of time but if the people visiting are close enough to be spending time with your new baby, you should be able to set some rules with them.

Set boundaries and stick to them and say NO whenever you need to. They don’t have to hold your baby. You do not have to justify your decisions, whatever they may be. You are the expert of your own baby.

When you’re navigating questions from family like “why don’t you use a bottle?” or “why are you giving him a pacifier?” or unsolicited advice like “just let her cry” you can simply respond with “because this is what works for us”.

Put Your Guests to Work

Having someone else hold your baby is not what you need. Ask them to:

Rake leaves
Shovel the driveway
Take out the garbage
Pick up groceries
Do some of the cooking or bring some food
Do a load of laundry
Fold laundry
Vacuum
Set the table

You get the idea…you are not there to wait on them. You just brought another person into this world and your body needs time to rest and recover. Tell your guests ahead of time if they intend to come, you’ll expect them to help support you.

Your body will tell you if you’re doing too much. Your bleeding (called lochia) can increase the more you’re physically doing. So be sure to take time to rest.

Make Sure You Eat

When you are lactating your energy needs are higher than when you were pregnant. Make sure you’re eating enough. Don’t worry so much about what you’re eating but that you’re eating. It’s so busy being a new mom and if you have company over, even moreso.

The holidays are filled with foods that will support your postpartum recovery and milk supply. Protein is very important when it comes to your body healing and your energy levels. It also has a role in milk production because it helps balance your blood sugar. Turkey and ham are great holiday sources of protein. So is roast beef which is also a great source of iron, a mineral needed for milk production. Nuts are also a great snack filled with protein, fat and fibre to support you postpartum.

Other holiday themed foods that can support milk production include oats, dates, molasses, apricots, fennel, sweet potato, almonds and dark leafy greens to name a few.

Your breastmilk will always be the most nutritious milk for your baby no matter what you’re consuming. Your body will always prioritize the milk and your baby. No one’s diet is perfect.

>> You can learn more about foods that support milk supply and other ways to help your body maximize your milk production inside the Milk Supply Masterclass.

sliced orange fruit in clear drinking glass — Photo by Olenka Sergienko on Pexels.com

What About Alcohol?

Of course I had to include this one as it’s a question on the mind of many. I’ll start by saying, no you do not need to pump and dump. You can consume alcohol while breastfeeding.

When you drink alcohol, the alcohol level of your breastmilk matches the alcohol level in your blood. Because of this, the general rule is if you’re sober enough to drive (or parent) you’re sober enough to breastfeed.

How much can I enjoy?

For most women, 1-2 drinks at a time can safely be enjoyed. This means you do not have to worry about the glass of wine you enjoyed with dinner, provided it was around 4oz. The general rule for alcohol consumption is a 4oz glass of wine, 1 oz of hard liquor or 8 oz of beer.

Remember to also drink water as alcohol is dehydrating and preferably enjoy the alcohol with a nutrient dense meal.

What if I’ve had too much?

There’s a few things to keep in mind.

If you are not sober, you should have someone else care for your baby.
It’s dangerous to care for an infant while intoxicated.
You may also want to wait until you are sober to breastfeed.
This could be several hours, if you find your breasts starting to feel very full, I would pump and discard that milk (since you were intoxicated)

Helpful info:

If you’ve only had 1-2 drinks and you are feeding your baby, you may find your breasts feel very full. This could actually be due to reduced transfer of milk.
The feeling of full breasts after drinking alcohol is because the baby is inefficiently transferring milk because it’s been found that alcohol blocks the release of oxytocin which is the hormone responsible for milk let down.
Hand express after your baby feeds to ensure the breast is empty and offer your baby the breast frequently.
>> here’s a link to how to hand express

To summarize this for you, you are allowed to set boundaries and say no. Continue to feed your baby when they cue they are hungry and take a time out if you need it. Don’t forget to enjoy all the delicious foods and cocktails that come with the season. Being a parent is hard. We’re all just taking it one day at a time.

Have questions? Join my private Facebook Community and connect with other new moms.

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References

Campbell, S.H., Lauwers, J., Mannel, R., & Spencer, B. (2019). Core Curriculum for interdisciplinary lactation care. Jones & Bartlett Learning.

Newman, J. & Pitman, T. (2014). Dr. Jack Newman’s Guide to Breastfeeding. HarperCollins Publishers Ltd.

Wilson-Clay, B., & Hoover, K. (2017). The breastfeeding atlas (6th ed.). Manchaca, Tex.: LactNews Press.

Natural Ways to Support Your Immune System

So it seems everyone is trying to avoid getting sick by buying all the hand sanitizer (and toilet paper?). The problem with that is, effective hand washing with plain ol’ soap and water is actually MORE effective at removing surface bacteria than hand sanitizer. Using an all purpose castille soap such as Dr. Bronner’s will do the trick.

In addition to practicing proper hand washing, you need to support your immune system to be able to prevent yourself from getting sick. Whether it’s you or your children, someone in your household is likely sick during cold and flu season. How do we prevent getting sick? and if we do get sick, how can we manage the symptoms naturally? I have your answers.

Prevention is key. We want to support our immune system to be strong all year so we don’t catch a cold (or the flu or another virus). Our immune system lies within our gut. This means we can support our immune system from the inside by supporting our gut with probiotic supplements and fermented foods. Fermented foods include kefir, kimchi, sauerkraut and brine fermented pickles (not ones soaked in vinegar and sugar). You might be most familiar with yogurt as a probiotic. While it’s true yogurt is fermented with good bacteria, ultimately there’s just not enough bacteria in the final product to support our gut. In fact:

“you would need to consume dozens of canisters of yogurt daily to obtain the amount of beneficial probiotics in a single high-potency probiotic supplement”
Caroline Farquhar, RHN http://www.renewlife.ca/blog/probiotics-yogurt/

In addition, many yogurts contain unnecessary added sugars and sugar actually reduces immune function. Now, most children may not appreciate the tang associated with naturally fermented foods. Good news is, there’s plenty of effective, safe children’s probiotics on the market. Genuine Health and Genestra make high quality supplements kids love.

There are also safe probiotic supplements for moms-to be. Genestra maternity pro is specifically for expectant mothers. For everyone else, I love this brand.

When taking a probiotic it’s important to have enough food for the probitoics so they can flourish. This “food” is referred to as prebiotics and consists of resistant starches (a.k.a fibre) from plant foods. This would include vegetables, legumes and high-fibre fruits (like berries). So you can already see how beneficial eating a variety of foods can be when it comes to your immune system.

Vitamins for Support

Another way to support your immune system is with Vitamin D. Research supports that a vitamin D deficiency is associated with reduced immune function. The very breif description is that vitamin D works with the cells of your immune system to strengthen it. The safe upper limit for vitamin D consumption is considered to be 4,000IU however, more is recommended to correct deficiency. A simple, inexpensive blood test can determine your vitamin D levels and you can work with your naturopath, RHN, or FMD to determine appropriate supplementation. I personally take 6000-8000 IU during cold and flu season and 3000-4000 during the summer months when I have more sun exposure. Here is the link to Health Canada’s recommendations for all ages. Unless otherwise discussed with your primary care provider, you can use these guidelines for babies and small children.

Vitamin C is another vitamin important for immune function because vitamin C helps create white blood cells which fight infection. You can take vitamin C in a supplement form but there are a variety of foods rich in vitamin C such as:

Bell peppers
Strawberries
Papaya
Kiwi
Oranges
Sweet Potato

I would focus on whole food sources especially for children. If you do take a supplement, it’s important to point out that vitamin C is water soluble. This means you pee out the extra your body doesn’t need so it is considered safer for that reason. You can however take too much (just like anything else) and diarrhea is typically a symptom. I take 3000-4000mg of vitamin C (while I was pregnant and while breastfeeding) to support my immune system.

Zinc is a mineral that also plays a role when it comes to immunity. Organ meats are an excellent source of zinc as are oysters. I’ll bet you’re not a huge fan of consuming these foods. Good news is, you can find it in other foods and zinc is available as a supplement. Things get delicate though, when it comes to supplementing with minerals as too much of one can inhibit the absorption of another. I wouldn’t take additional zinc (beyond what’s found in your multi vitamin or a lozenge) unless you’ve discussed this with your naturopath or functional medicine doctor. Additional food sources of zinc include:

Black beans
Chickpeas
Lentils
Fortified whole grains
Almonds
Pumpkin seeds
Hemp seeds
Eggs

Again, demonstrating the benefits of varied diet.

Stress and Immune Function

Did you know stress is a key factor in how strong our immune systems are? When our bodies are under stress, our immune system becomes weakened making us more susceptible to illness. The reason for this is cortisol. Cortisol is one of the hormones released when we are stressed. One of it’s functions is to temporarily supress the immune system. This means over time, chronic stress leads to reduced immune function. So, keeping our stress levels low is important for strong immunity. We can support our body’s response to stress with the use of adaptogens which are herbs that help balance our immune system by nourishing the adrenal glands (small glands that sit above our kidneys and produce stress hormones). Some of these herbs include Rhodiola, Ashwagandha, Siberian Ginseng and Maca. While there are herbs that are considered safe during pregnancy and breastfeeding, there are many herbs that are unsafe during pregnancy and breastfeeding. Discuss with a trained herbalist or naturopath prior to consumption. I would follow this for children as well. It’s naive to assume children don’t experience stress. We know they do. This product helps children with nervousness and anxiety.

A lack of sleep is also a stressor on the body and will weaken your immune system. It’s important to do what you can to get a good night’s rest. This might mean shutting off electronics an hour before bed and finding a different way to wind-down. A note for new moms: trying to get a good night’s rest is an outlandish request, I know. I have been there (and still am). Just sleep when you can and keep reading to find out what you can safely take if you do get sick.

Supporting with Food

In addition to the foods already listed with respect to vitamin C and zinc, you can help support your immune system with other foods you might already be eating. Garlic is an excellent anti-bacterial and great for immune health. Raw honey is full of enzymes and immune supporting compounds (though typically should not be given to children under 2 years).

Reducing the amount of sugar you are eating will benefit your immune system as well. I am referring to refined sugar such as cookies, pastries, pop and packaged foods not the natural sugars found in fruits. Refined sugar weakens the immune system so leaving it out of your diet is helpful. Reducing or eliminating the amount of alcohol you are consuming will also support your immune system. This is because just like sugar, alcohol dampens the immune system.

Natural Health Products to Reduce Symptoms

So what happens if we do get sick? Well, you can help manage the symptoms with the below natural health products. I have used all of these in the past so they are some of my favourites. There are products appropriate for adults, children and even pregnant and lactating women!

Echinacea (A. vogel) is a herb that’s long been used to fight infection. I love this brand because it works! It’s anti-bacterial and anti-viral. This brand is also safe for pregnancy and lactation and their research supports safety and efficacy for preventative use for 4 months. This means you can take it as a preventative but if you do get sick, you can take it to manage symptoms. Just follow the dose on the bottle.
Elderberry Syrup (Suro) is available for children and adults and is wonderful when it comes to reducing the symptoms of colds and flu. This one is not recommended if you’re pregnant and breastfeeding however.
Medicinal Mushrooms such as Shiitake, Maitake, Chaga and Reishi are incredible immune modulators which means they help boost the immune system (Purica, Four Sigmatic) They help fight off bacteria and viruses. These should not be consumed by pregnant and breastfeeding women or young children without first consulting a naturopathic or functional medicine doctor.
Oregano oil is an incredible force when it comes to fighting bacteria and viruses. (not for pregnancy or breastfeeding or kiddos) St. Francis Herb Farm offers an excellent oregano product. You can take this at the first sign of infection. A couple drops under the tongue is all you need. Word to the wise, it’s spicy! And quite potent.
Deep Immune by St. Francis Herb Farm is a fantastic product that can be used to keep the immune system strong all season. This is safe for adults and there’s a kiddos version. It is not safe for pregnancy and breastfeeding.

If you’ve made it this far, thank you. I hope you found a little comfort in knowing you ARE in control of your immune system and there are other measures that can be taken to support the health of you and your family.

If you found this informative, please share so we can spread the word about natural immune support
#livevibrantly

Disclaimer: This information is for educational purposes. We do not yet know what cures/treats COVID-19. We do know we need to properly wash our hands and stay away from infected individuals to prevent the spread. If you believe you have the symptoms of COVID-19 do not hesitate to get yourself checked out.

Could you be iron deficient?

Updated May 19th 2021

Are you constantly tired? Do you feel weak? Do you have brittle nails and hair? What about shortness of breath or weak concentration? If you answered yes to any of these, you might be iron deficient (or anemic, just keep reading) and not even know it. Did you know iron deficiency is one of the most common nutrient deficiencies in the world? Iron is a vital mineral and here’s a few reasons why.

Carries oxygen in our blood

Two thirds of our bodies iron is found in red blood cells and is referred to as hemoglobin. In muscle cells, it’s referred to as myoglobin. (Naka Herbs, Web. 2008). Hemoglobin is a protein that transports oxygen throughout the body, delivering it to our tissues, and in order to do this effectively, requires iron.

Required for enzymes

Iron is a building block for many enzymes including those required for our metabolism. Iron is also important for the creation of neurotransmitters in the brain. Neurotransmitters are chemical messengers that send signals from one neuron to another. Neurotransmitters such as dopamine are also required for circadian rhythm; our natural sleep-wake patterns.

Important for the growth of babies and children

Iron is a nutrient we focus on when introducing solids to babies. This is because during the third trimester of your pregnancy, your body passed iron onto your baby. These iron stores protect your baby for about 6 months. After 6 months, their iron stores begin to decline and they need to consume iron from solids alongside breastmilk. Breastmilk itself contains a low amount of iron but contains an enzyme, lactoferrin, as well as vitamin C that helps increase the absorption. Iron from animal foods is much better absorbed than plant foods (as you’ll read below). Recent evidence also demonstrates low iron levels in children and iron-deficiency anemia is most common in children age 6-24 months when their nervous system is rapidly developing.

Iron-deficiency anemia in children also increases the risks for cognitive impairment, ADHA and restless leg-syndrome. It is associated with impaired and disordered sleep as well. Iron-deficient infants and those with iron-deficiency anemia tend to wake more frequently at night and are described by their parents as being restless.

Lost in athletes and menstruating women

The need for oxygen is higher in athletes and those who are physically active. Because iron is needed for hemoglobin to carry oxygen, those who are physically active need more iron. Myoglobin, in our muscles, also requires iron. Iron can be lost during physical performance in sweat and hemolysis (the breakdown of red blood cells) cited here. Women loose blood monthly during menstruation and so, have higher iron needs than men. This is especially true for female athletes.

Vegetarians and vegans needs more iron

Iron found in plant foods is referred to as non-heme iron. Animal iron is called heme iron and has a higher absorption rate than non-heme. Non-heme iron has a very low absorption rate and is further impacted by certain substances in these plant foods. Phytates, oxalates, polyphenols and phosphates all inhibit iron absorption. Phytates are found in nuts, legumes and soy. Oxalates are found in spinach, rhubarb and beets. Polyphenols are compounds found in tea, red wine and coffee. Phosphates are found in sodas, which should be avoided anyway, due to their lack of nutritional value and high sugar content.

More is needed during pregnancy

During pregnancy, the need for iron increases to help build the blood supply needed for the placenta and growing fetus. Blood work is done early in pregnancy to check iron levels and then again after 24 weeks to re-check. The iron is checked again as typically women have enough stored iron (ferritin) to last about 6 months. For this reason, it is not only important to take an iron supplement during pregnancy but also before pregnancy to ensure adequate iron stores and hemoglobin levels. Typically, the range for hemoglobin levels during pregnancy (and women in general) is 120-160 g/L. Around 6 months (24 weeks) typically a drop is seen to below 120g/L.

Because the type of iron impacts absorption and because you may have entered into pregnancy already deficient, it’s important to work with a Naturopath or a Functional Medicine Doctor to have your iron levels tested and supplemented accordingly.

Lack of iron leads to deficiency

When not enough iron is consumed, we don’t have enough in our hemoglobin and begin to experience iron deficiency symptoms. The first stage of iron deficiency is called “iron depletion” followed by “iron- deficiency without anemia” and the final stage is “iron-deficiency anemia”. The below symptoms can be seen in iron-deficiency anemia but also might be seen in earlier stages of iron deficiency.

Shortness of breath
Brittle nails
Brittle hair
Extensive hair loss
Weakness
Tiredness
Easily bruised
Dark circles under the eyes
Pale skin
Cold hands and feet
Poor concentration
Heavy menstruation

Iron deficiency can also occur with sub-optimal intake of certain vitamins such as B12 and folate. When this occurs, the shape of hemoglobin is altered and its ability to carry oxygen is impaired. This is referred to as vitamin-deficiency anemia. Anemia can also be a results of genetic conditions.

If you suspect you might be iron deficient, speak with your primary care provider and have your blood work done. Not only should you have your hemoglobin tested (the primary go-to) but your ferritin levels (which measure the amount of iron your body has stored) should be tested as well. The reason is, as our hemoglobin levels drop, our body pulls from our back-up supply; what has been stored in our body. So in theory, you could have normal hemoglobin levels but your stores could be close to depleted meaning in a few short months (or weeks depending on your activity level), you’ll likely experience more symptoms and they will be more severe.

To correct an iron-deficiency anemia, you can supplement with iron. When choosing an iron supplement, be sure to select one that is non-constipating as this is an unfortunate side-effect of many irons on the market. Some of my favourites that I have used personally include Floradix/Floravit, Blood Builder and Vital F. It’s also best to use this under your primary care providers (ideally a Naturopath or Functional Medicine Doctor) supervision as you can in fact, consume too much iron. They might suggest a protocol that includes cycling off the iron every few months, have you take as the bottle directs, or change your dose entirely. This is why it’s best to know your numbers before you begin supplementing.

As with any other health concerns you might have, always do your research and speak to your most trusted health care provider to determine what is best for your individual needs.

References:

Dosman, C., Witmans, M., & Zwaigenbaum, L. (2012). Iron’s role in paediatric restless legs syndrome – a review. Paediatrics & child health, 17(4), 193–197. https://doi.org/10.1093/pch/17.4.193

J Dev Behav Pediatr. Author manuscript; available in PMC 2014 Feb 1.Published in final edited form as:J Dev Behav Pediatr. 2013 Feb; 34(2): 120–128.doi: 10.1097/DBP.0b013e31827d5848

Ji, X., Grandner, M. A., & Liu, J. (2017). The relationship between micronutrient status and sleep patterns: a systematic review. Public health nutrition, 20(4), 687–701. https://doi.org/10.1017/S1368980016002603

Moturi, S., & Avis, K. (2010). Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont (Pa. : Township)), 7(6), 24–37.

Peirano, P. D., Algarín, C. R., Chamorro, R. A., Reyes, S. C., Durán, S. A., Garrido, M. I., & Lozoff, B. (2010). Sleep alterations and iron deficiency anemia in infancy. Sleep medicine, 11(7), 637–642. https://doi.org/10.1016/j.sleep.2010.03.014