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"It may seem like the firm foundation that you have been seeking is very close, even if it's still just out of reach. You nostalgically long for a lost certainty that could guide you through the choices ahead. But your potential growth may depend on your flexibility and your willingness to let go of your dream for stability. Be open to fulfillment in the present moment and not in some distant future."

My husband just called from the car after getting out of a meeting.  His manager just got word that she's been promoted.  This leaves her position open.  This is the position that he was working towards.  If you believe in prayer, voodoo or good magic, do it now.  He's not formally applied for this position, frankly we don't even know if they've posted out for outside applicants either.  I do not know if they were looking to find an internal applicant or external, but, for the love of chocolate bunnies, He Could Use This Opportunity.  He had no indication that she was moving on - and it came as a shock.  Just last week he sat in with her for his review.  At the time, he got a good review, a bit of a "promotion" (in the form of a title added to his status) and a raise.  Please.  Please.  Please.  It may be a long shot... but... but... but... he deserves an opportunity like this.  Especially right now.  Especially right now.  I don't want to get any part of excited about this - reading anything into it, because of the high level of unlikelihood that it would happen, but... there is a little glimmer of hope.


Bob always does our taxes himself, and second-guesses them and brings them to a professional, at at cost.  This time around, he finished up the paperwork and headed to a different preparer, who had just figured out that a few family members had missed out a few bucks here and there, and got them heftier returns.  He figured that maybe he could add a few dollars to ours, and off he went.  The result? 

$80.00 for the professional preparation > $100.00 added to our return in total.  Take the gas and time wasted into consideration, and the four year old that went with him to shut the lights off in her office and it makes no difference.  He doesn't get that I found any humor or irony in this.  What's even better?  Her office just called here, to let me know that his form of payment is not acceptable.  They don't accept American Express, and he needs to offer alternate payment.  I made some remark about how he uses the Amex for everything, we get points, and he pays it off every month, blah blah blah, like I need to explain that to anyone, but somehow I did.

Why I can't watch daytime TV.

...because, when I have it on, I get sucked into the commercials Aimed Directly At Me - The Underemployed At-Home Adult!  Even if I ignore all of what is on the Today Show, I look straight up at the commercial Aimed Directly At Me:  "Blah, blah, blah, get your degree, get a job, get a life, don't abandon your family, be Happy Forever, Simple!  All this, you could put on your credit card!

I immediately go to the school's website, to see if they had any online options, what the financing was, and to see what degrees or certifications were available.  That particular one turned up nothing, and I started Googling "how to get an online degree." 

Yeah, well, nobody wants to give you information online, they want you to get on the phone with an advisor, for a sales pitch.  (Note:  You can't really pitch something to someone who hasn't got any money to pay for it, hence why I'm a "terrible" salesperson in general, I can unsell you out of anything.)

I X-ed out of each website after following each chain of questions, where/what course/what level education have you attained - "do you understand that you will be contacted by an academic adviser?" X-CLICK. 

I don't need you to call me to tell me anything, I need to READ your fine print. 

I need to know MY five W's. 

WHO - Whose college is this, is it available online, because I can't afford to take time out of the house with babysitters to pay for school right now. 
WHAT - What majors are available? 
WHEN - When can I do my work - can it all be online? (PLEASE?) 
WHERE - Where can I sit?  On my couch?  (PLEASE?)  IF not, where are your most local campuses?  (Can I dorm?  KIDDING!) 
WHY - Well, that's up to me.  And, we know WHY I need an edjamahkayshun.  I can't get me no job!

(Don't give me any poop about sucking it up and flipping burgers, I told you I'd make coffee, that's close enough, and I can't get a job doing so.)

I need some learning.  Some quality, "distance!" learning.  I would do spectacular.  I would find a way to pay.

So, here's the thing.  I have one idea.  I want to learn nutrition.  I want to work in nutrition, somehow.  It doesn't have to be a traditional situation, (i.e. nutritionist at a hospital) I would consider doing all sorts of creatively different options in the field.  Maybe, become an RD in the future?
But... how?!  What is the course of action?  Where to begin?  What school?


In my brain.


Sick baby = too much 'net time.  I'm still housecleaning the blog.  If you come back and see a blank page, I went too far.  What sucks the most is that I Pay To Post This poop.

All done.

The "freaking holiday" is over and done with, the tree is going outside today, and I'm back.  The kids got too much, but actually it was less than last year, and the clutter is hardly as bad as previous holidaze.  Santa brought significantly less than last year, because he must have invested more in dollars than quantity, you know?  The kids are getting older, and "toys" are now, XBoxes and MP3 playahs.  We were at my MIL's last night, I should have brought my camera, as all the kids (mine included) were sitting on the couch with MP3's, Ninentdo DS's, & PSP's.

Anyways - it's update time, I guess.  I haven't weighed in or anything in a while, I'm guessing I'm near the same weight as previous - which was 176 lbs.  I haven't been eating great, due to the availability of naughty holiday foods, like cheese and cracker trays, nuts and cookies, which I tend to pick at instead of eating a meal at holiday functions.  So, I suppose today is the first day of the post holiday re-diet.  I won't wait for January 1st, because weight loss isn't a resolution for me, it's a must.   That, and the spouse is on vacation right now, and I can get things done while he's here to fix the baby when she's broken and stuff.

For me, it's back to basics with my eating.  I'm going to do some liquid protein dieting for at least a few days I think.  I've got plenty of protein stocked up, I spent my $100 gift card to GNC yesterday and bought Vanilla Praline flavor powder, chocolate flavor and two boxes of the Pure Protein bars that my husband and I like, for me the Chocolate and Chocolate Peanut Butter for him.  The "diet" translates into as many calorie free drinks I want including coffee, and measured amounts of caloric drinks like protein shakes, low-sugar yogurt smoothies, broths, cream in the coffee, etc.  If I get the urge to eat real food, it's got to be lean protein only or vegetables.  That is:  generally cottage cheese or turkey breast for protein, and cucumbers, pickles, celery and the like for some crunch because they don't hurt my belly and quell that urge to munch or eat out of head hunger.  If I do this, I almost always immediately drop a few pounds to get the loss jumpstarted.  Of course, exercise will most definitely help this along, and I'm going to try to do what I can with getting on the treadmill, and maybe a couple outdoor walks while the spouse is home here on vacation so I can go without a parade tagging along. 

It's obvious now that I must keep motivated to drop this baby weight, because it's so easy to get too comfortable at this size which is just under being really "fat" for me - and let more pounds creep on.  Also, my sister in law is going in for her WLS in a few weeks, and she needs positive "role models" for WLS to keep motivated in those first few hellish weeks, I'm sure. 

When she's had her surgery, that makes us four people in the same family who've done it.  When we're all down to goal, we'll have lost an amazing amount of weight.  I can't wait to do a before and after photo of all of us next year sometime.  That's motivating on it's own, not to mention the fact that I'm a bridesmaid in April and need to look decent in a dress that shows more skin than I'd ever allow out in public.

As for MIL - she's passed the 100 lb. lost mark.  She's dealing with severe hair loss, and occasional digestive discomfort, but overall she's okay.  She's eating well in my estimation, drinks protein shakes and eats real food too, and doesn't get too sick very often.  I don't know what her goal is, but she's diligent with checking in with her doctors - so I am sure they've conferred with her and told her what the expected loss will be for someone her age and size.  I don't know her stats - but I know she's tracking them on a paper by the scale, and she's down at least 100 lbs. since the summer.

As for my immediate family - we're doing okay.  There's no junk really in the house - the kids don't clamor for it if it's not available.  I can't wait for warmer weather to return so they can spend their free time outdoors more than now.  Now it's just cold with no snow, which isn't much fun, and they've been catching colds and flu and not feeling well.  I don't weigh the children, so I have to go by how they appear - and I'm afraid that putting an overweight child on a scale is upsetting to them enough without them knowing that I'm trying to help them lose a little weight, too.

Okay, must run, baby is broken... more later.

"So, the rumors are true."

I said I would share more about the reunion.  One of the class officers (I think, I got a lot of comments from random people) said to me "So, the rumors ARE true, you do look fantastic."  In other words, "Last time I saw you, you were the size of a house, and now, you're slightly smaller than an elephant!"  As for everybody else - most of the girls (women, we're growed-ups now) looked fantastic, many very professional/put-together, many very freaking thin, some too anorexi, thin, some sorta chubby, some post-baby chubby, but I don't recall anybody being really obese, which surprised me.  (Though, us fat folks sometimes avoid this kind of thing!)  The boys, as expected were balding and getting chubby.  I didn't recognize many of the men, because they all looked so much older.  The night just really accentuated that we're getting old and need to get our crap together.  I think I win the "most kids with the same husband" award - but we have some catching up to do in the income/buy a really big house/get a job with a fancy title area.  (I knew that, though, these people have had ten years to go to college, get varied degrees, jobs, etc... I had babies!)

I just pulled the memory card out of the camera - and realized - I only took three pictures.  It would have been slightly weird taking pictures of people I haven't seen in years, right?  Also, because lots of people didn't really know who the hell I was, it would have been weirder.  So, here's a picture of me and an old friend from school.  (Yeah, we have nearly the same hair, and ignore my chinage.  It too, shall pass.)
I took three photos all night.


Eh.  What's that song?  High school never ends?  I wish more of the friendly faces I remember from school showed up tonight, but as most of them would say, they "hated all those people, why the hell would they pay to see them again?!"  Oh well, we can't all be totally anti-social all of the time.  More later, baby calls.

5, 10....

HS Graduation - at about 200 lbs - 1996

Diva commented about the reunion, and mentioned the five year.  We also went to the five year reunion, like I said before, but everybody got trashed.  I can't say that I even got a sip of a beer, since I was pretty much PREGNANT at that time!


Leave it to me - pregnant at the first reunion, exclusively breastfeeding another baby at the second one. If I'm pregnant or nursing in ten years time for the 20 year reunion, remind me that I'm PRACTICALLY (if not already PLEASE DON'T MAKE ME A...) GRANDMOTHER at age 37.  (Sorry, Ma, I did it to her at nearly that young, and practically times two now that I think of it?)  When that time rolls around - I'm going to have a 19 year old, 17 year old, 14 year old & a 10 year old, and if I even had ONE IOTA of an urge to make another baby - feel free to tell me that I'm lucky I'm not a granny - AND - lots of childrens around the world could use an adoptive family.  :-)

S U G A R!

I might not wear a sheet.

I spent a very long time last night online looking for a suitable dress to wear to my brother-in-laws' wedding that is happening, uh, very soon.  I was avoiding the dress-purchasing because I had a feeling that I might be post-partum at the date of the wedding, (albeit like, three days post-partum, and depending on how this baby makes her entrance, head or foot-first, I may not be so much fun dancing at a reception, so...) I was waiting to see. 

Well, one trip to the mall let me know there isn't anything that will fit my newly expansive ass that I'd be able to buy the day before the event and just put it on.  Not only that, I'm cheap, and spending money on an outfit I will only wear once kills me.  (Well, technically it kills HIM, but he's wearing a tuxedo that was rented FOR him.)  I'm the hot date of the Best Man, so I will be on camera, and I don't WANT TO BE WEARING A MUU MUU.  It took me a year not to have to order my special occasion outfits from Lane Freaking Bryant, I refuse to do it now.  Even though, technically, I'm in the size range again, I won't do it.  No. You. Can't. Make. Me.  So, I searched Motherhood, and all of those online maternity shops, to find that what I need, would cost hundreds of dollars.  Uh, no.  I'm never going to be large enough to fit into a "XL Maternity Special Occasion Dress" EVER again.  If I can't wear it twice, it's not worth the money.  Sorry.  I ended up finding a "little (big) black dress" on clearance at one of the maternity shops online.  I'll still need me some Spanx Mama (didn't know they had these?!?!) hose, some cute shoes, and a shawl, wrap or fancy cardigan to cover my chicken flap arms, but I won't be wearing a sheet!


Now, with less iron!

I'm a superhero.  I'm Anemia-Girl!  Can you imagine the spandex maternity suit I could wear?  I could be all pasty and white and be on the search for healthy red blood cells!

Anyways - back from my blood check and B-12 injection.  I'm now more anemic.  The suckage that is gastric bypass and pregnancy is officially kicking my ass.  I'm going tommorrow for a IV iron infusion of a different form (since I was allergic to the first trial medication) and if I'm allergic to THIS new iron, it's blood transfusions for me.

If I am NOT allergic to this new iron, I'll be parking my butt in the hematology clinic every week for an IV infusion until my blood returns to normal.  I said to the doctor something like, "Well, once the baby is born and I'm ::quote fingers:: back to normal ::end quote fingers::, my blood will start to get better, right?"  She said, basically, no, it's not the baby, it's the bypass.  Apparently in her experience, the longer you're post-op from a gastric bypass, the more nutritionally deficient, vitamin deficient and anemic you become, the pregnancy really isn't the underlying cause of this.  She says that the hard part is treating it now because I'm still pregnant, and they'd like to avoid anything that may be a risk to the fetus.  Afterwards, it's all good, I'm fair game, and they can treat things more aggressively.  She also said, again, these problems may be a lifelong thing for me now, but these are the choices we make - obesity vs. "Anemia-Girl!"

Dananananananana, Anemia-Girl!

Oh, but on a positive note, I didn't gain weight.  Also, I'm back on my cottage cheese.  Yay for cottage cheese.

Appy Hanniversary.

My oldest daughter asked me yesterday morning, "Where are you going for your anniversary?"  I told her, probably nowhere, since it's Monday, a workday, and we really didn't make any plans.  I probably should have made at least dinner plans, because then spending my anniversary in the birthing unit triage would have been more of a disappointing evening.

I mentioned the other day that I've been having lots of contractions, especially in the last few days.  Yesterday, I found myself pacing because they were actually starting to hurt.  Once I noticed that I was hanging over a windowsill because of a contraction, I called the OB's office.  I went in, had a Fetal Fibronectin test done, and scooted up to the hospital for some fetal monitoring.  The FFT came back negative, which means I'm unlikely to give birth in the next two weeks.  It's like eight weeks too early for any of that business, thank you.  The nurses kept me on the monitors for quite while, and they did see lots of contractions, though they were mild and didn't get more painful.  The fetus seems fine - since she was beating my uterus senseless with some serious movement.  Bob was watching the monitors velcroed to my belly, and the baby was making them shake, rattle and roll.  I wondered even if what I was feeling might have been "the move" from breech to head-down.  Her heartbeat got lost twice, as she moved away from the monitors, and my belly seemed softer in the upper area where she was lying.  I'll never know if it was it, since we didn't have an ultrasound.  I am still feeling mildly crampy, but there hasn't been anything else beyond what was bothering me before to suggest a problem.  Unless something shows up on the urine culture, I just have to get used to be being uncomfortable.  I'm going in for a re-check on Thursday for the results of the culture and to see if anything has changed for the worse.

It looks like we have half of a name.  At least a possible middle name.  That's progress, right?  I figure if she's perhaps coming a wee bit earlier than a full eight weeks from now, we should pick a name, and maybe start getting some things together?

And, yeah, it was our anniversary.  Seven years - whoa.  (Well, seven years married, many more years actually together before that.)  The nurse on duty last night said to us, "You guys look so young, it's like you're having your first."  I just laughed.  Bob says to her, "I'm getting old, I'm almost thirty."  Her voice got real quiet, and she tells us that there are some moms on the floor that are thirty, thirty-seven, forty, and so-on, just having their first babies.  She's all like, "But, just think, when you're that age??"  I'm all, "Yeah, I could be a grandma."  ::shiver::

Do you take this woman to be your chubby bride?



I don't have any photos of us together, because it's usually him or I holding the camera.

Happy lucky seven year anniversary.  :)


We went camping again and I forgot to blog.  It didn't occur to me because the kids actually had a bit more fun this time, and it was a shorter trip.  Anyway - we're home - we're all alive.  I had an ultrasound on Monday right before we left.  I'm still having a girl, who apparently has a large head.  This is not suprising, as I have three very big bean heads sitting here.


She's measuring average otherwise, but I don't have any indication of the weight.  The placenta has shifted entirely and is no longer a risk.  She's still in the wrong place, not head down, but entirely sideways.  I've got a head on one side and feet on the other.  While laying down, my belly appears square.

29 weeks pregnant.

The high-risk OB who's been giving me the ultrasounds was clearly happy with the results this time.  His only worry right now is my blood, because it still stinks, and is only going to get worse.  My current hemocrit levels are quite low - and he says that he'd like to get me some iron IV infusions soon.  He mentioned something about a critical level - and if I were to go any lower at my next visit with the hematologist it will be absolutely necessary.  I'd rather not have to deal with a blood transfusion the day of the baby's delivery - which is likely at this point if the blood levels do not increase.

In other news, my mother in law has been having some side effects of her gastric bypass and is absolutely miserable.  She said yesterday that if she knew about "anything like this" she'd have never had the surgery.  I don't know how serious any part of her symptoms are, or if they're just more intense because she's older.  Some of the things she's experiencing are things that Bob & I also had, but she's on her own and doesn't have somebody in her house also going through similar issues like he or I did at the time.  She has lost quite a bit of weight, but has been so sidelined with the side-effects that she's not seeing the results of the weight loss yet.  I told her things will get better very soon, and she'll be thrilled, soon.  Not now, but, soon.

Okay, the husband has a few more days of vacation left, and we're supposed to be getting things done - and nesting of sorts, since he's not off again until the birth.  We're headed up Babies-R-Us later today to see if they've got the crib I picked out actually out for display, and maybe pick a few things up.  I've got most everything we need listed on the Target Registry - but much of it isn't carried in the store locally?!  I would like to see some of it in person before I buy it, you know?! We of course kept nothing, since we weren't having any more kids.  We have to rebuy every little thing.  (Except boobs, I suppose I kept those, since I refuse to pay hundreds of dollars for stinking formula.)  Okay, listening to Bob on the phone with our health insurance discussing the potential size of the bill that we're going to receive after the fetus is born.  What fun! 

I've figured it out.

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I've had an epiphany.  Vacation = more bonding & time than anyone needs.  We never spend this much time together in one spot, ever, even if we were at home on vacation.  That, and the fact that Everything Costs Money.  Bob had put a budget on this week - I want to say it was $100 a day per day for "activities."  Well, that was blown out of the water on the first day, and we're really not doing jack.  I am blown away by the amount of cash some folks drop in this place.  I met a Dad of four or five kids the day before yesterday in line while making reservations for a dinner show (which cost us $50.00 for cold pizza)  He went into detail about how he asks his brood to save up all their change all year long for this camping trip - and Daddy will match the funds.  This year - the kids saved a bundle - to the tune of like $600 each - and he matched it times four or five.  This was just for their personal spending money, for weenies, arcade, etc.  We told our kids they were limited to $10.00 a day.  That's it.  (Of course, that was for them to buy something special, or to go to the arcade, or something extra, not counting normal meals or anything like that.)  Let me tell you - that doesn't fly here.  Everything costs.  I took the kids to go to a Free Craft this morning - which included - a Foam Plate, Glue, and Foam Bits to stick on the plate.  By the time we got here (about five minutes into the session) all of the bits of foam were gone aside from a few choice dinosaurs and some random stars in orange and red.  The kids ask me what they're supposed to make with "this?!"  We make decorated meat plates, why?  I don't know.  But, conveniently located next to this Free Craft?  An Arts and Crafts Session with a hired artist where you can choose to paint ceramics or wood of your choice, or make a tye-dye tee shirt!  I snuck the oldest to paint ceramics since the other two got involved in watching a puppet show nearby.  The ceramic that she really wanted was $35.00, but after seeing that I had only a $20.00 bill on me, she caved for a small bunny that she could paint as a gift for her new baby cousin coming very soon.  We sat and painted this bunny, when she noted that the ear had been re-attached with superglue.  I brought this to the attention of the woman in charge of the painting, and she assured me that this bunny wouldn't lose his ear again, and that the paint would cover the *obvious* crack.  Um, okay.  I asked to switch, and she says "no."  We paint the bunny, he breaks... this woman reglues the ear, blaming the break basically on my child.  I'm not in the mood to argue especially in front of the kid who's already upset that this gift is already broken, so we finish the $10 dollar broken bunny.  He is sorta cute - but... he's a broken bunny. 

Am I blooding to death?!

The night before last, my son came running in the front door with his little sister trailing behind him.  They had just gone out to play and I was on my way out, when I heard little girl screams.

"We have a problem here!" he announces, at least three times.

From the ear-splitting decibel of her shrieking, I immediately think she's broken a body part- (we've already had a broken bone this summer from another child) and that we're off to the doctor for x-rays and a cast.  She comes in the door, holding her elbow, screeching. 

"I need you.  I need you.  Hold me." she cries.

At this point, I'm looking for injury, and she's holding her elbow and doesn't want me to look.

"Don't touch it, I need you.  Hold me." she's now whimpering.

I see blood on her shirt, and on her brothers' shirt.

"Blub!  I'm blooding to death!" she screams.

I find the injury.  It's road burn.  She got on her pink Barbie scooter sans shoes and fell in the driveway.

"I need stitches, I'm blooding to death!" she exclaims.

She didn't want a big Band-Aid, she only wanted "little ones that won't sting!"  I talked her into one really big bandage, let her use a anti-bacterial wipe on it herself and got her to take a sink bath to wash the driveway dirt out of the scrape.  Of course she didn't blood to death, it was a big scrape on the surface, and didn't do very much damage.  She's healed a bit, and has gone camping with the extended family (with the health insurance cards, just in case) and is happy to tell us "We're camping, and you didn't get to go."  Well, fine. 


We're going camping with the kids next week- and I just noticed that the campground has wi-fi.  That's roughing it.  I'll bring lots of Band-Aids.

Breastfeeding After Gastric Bypass

I'm a big pro-nursing advocate, and lately I've been wondering if nursing after gastric bypass will be just as hard easy as it was last time.  I nursed my third child exclusively, from birth to age 3.

(Edited to add, the post bariatric surgery baby was born October 2006, I nursed her for five weeks and gave up.  I had serious trouble with getting a decent milk supply.)

Coincidentally the third child weaned abruptly with my stay in the hospital for the actual weight loss surgery, but she was by then only comfort nursing and we were more than ready to end it. Even though we had a rough beginning, and it took a long time for me to establish a good milk supply, it worked out in the end, and she was by far my most normal-weight baby.  I formula fed the first two children after very short failed attempts at nursing, and they were both overweight as infants also. 

I've been wondering, will I be able to establish a normal milk supply?  Will I be able to provide enough vitamins, namely B-12 with the supplementation I'm recieving through B-12 injections?  Will my state of anemia cause problems - or will it gradually improve once the baby is born, and not cause problems?  Will I be able to safely lose the baby weight I've gained while nursing and ingest enough calories to maintain my milk supply?

These are things that any pregnant post weight-loss surgery patient needs to be aware of.  There are potential problems, but it seems most if any can be avoided or treated with monitoring up front.

A question from-

"A lactation consultant referred a 3 week old infant not back to discharge weight. Mom had a gastric by-pass 3 years ago. The pediatrician wants to supplement with formula about 4 times per day and is also supportive of herbal supplements (e.g., fenugreek, mother's milk tea, brewer's yeast) for Mom or prescribing Reglan. With lactation consultant support they got a good pump, also a starter SNS, and 2 different feeding cups, and nipple shield. Still weight gain was marginal. Could the mother's gastric by-pass be a contributing factor in this problem?" This situation of a breastfeeding woman who has had a gastric bypass is probably rare.

The answer from:

However, there have been a few cases of significant nutrition problems in infants with mothers who had gastric bypass. Two case studies were of infants who were diagnosed with vitamin B12 deficiency and megaloblastic anemia (1,2). This was secondary to decreased vitamin B12 in the breast milk; the mothers had subclinical vit B12 deficiencies. In another case, the 4 month old infant was diagnosed with failure to thrive (3). Creamatocrit analysis of the breast milk indicated only 39% of the normal fat content of breast milk, and thus the energy level of the milk was reduced. In the case described here, there may be infant factors contributing to the lactation problems, but they seem to be addressed appropriately by the lactation consultant. There may also be stress or emotional feelings in the mother that is contributing. In any case, frequent monitoring, including signs of vitamin B12 deficiency in the mother and infant, is indicated. A creamatocrit may also be useful at some point.

According to

Who needs vitamin B12 supplements?

By Kelly Bonyata, IBCLC

Infants of well-nourished mothers with adequate vitamin B12 intake do not need vitamin B12 supplements.

It is recommended that mothers who do not eat animal proteins or who are otherwise at risk for vitamin B12 deficiency get adequate amounts of vitamin B12 during pregnancy and lactation via supplements or fortified foods.

Since vitamin B12 (cobalamin) is widely present in foods from animal sources, dietary deficiency is rare except in those eating a strict vegan diet (no fish, meat, poultry, eggs or dairy products). Most infants, children and adults in the United States get the recommended amounts of vitamin B12. If a breastfeeding mother has an adequate B12 status, her baby will receive sufficient amounts of vitamin B12 via her milk. A simple blood test can diagnose current vitamin B12 deficiency.

In the US, the DRI for vitamin B12 for adults is 2.4 µg per day, 2.6 µg during pregnancy, 2.8 µg during lactation; the DRI is proportionally less for children. The DRI has a significant margin of safety built in. Unlike other B vitamins, small amounts of vitamin B12 are stored in the liver so daily consumption is not necessary.

Who is at risk for vitamin B12 deficiency?

  • Anyone who is on a strict vegetarian or vegan diet (no fish, meat, poultry, eggs or dairy products) and is not getting adequate amounts of vitamin B12 through supplements or fortified foods.
  • Anyone who has had gastric bypass surgery, has pernicious anemia or has certain gastrointestinal disorders and is not getting adequate amounts of vitamin B12 through supplements or fortified foods. Some medications may also decrease absorption of vitamin B12.
  • An infant born to a mother who has been a strict vegetarian or vegan for at least 3 years and who is vitamin B12 deficient herself.
  • An infant born to a mother who is vitamin B12 deficient due to any other dietary or medical reason.
  • An exclusively breastfed baby of a woman who is vitamin B12 deficient.

According to Nutrition During Lactation (Hamosh 1991, p. 157-58), a full-term infant of a well-nourished mother will be born with a store of vitamin B12 sufficient to meet his needs for about 8 months. If the mother is not vitamin B12 deficient herself, then her milk is an excellent source of vitamin B12 and is more than sufficient for baby’s needs through the first year.

There is evidence that babies born to vitamin B12 deficient mothers have low stores of vitamin B12 at birth. Studies have shown that mothers who are vitamin B12 deficient have low levels of vitamin B12 in their milk.

Breastfed infants may develop clinical signs of vitamin B12 deficiency before their mothers do. Vitamin B12 deficiency may develop in the breastfed infant by 2 – 6 months of age, but may not be clinically apparent until 6 – 12 months. Signs and symptoms of vitamin B12 deficiency in infants include vomiting, lethargy, anemia, failure to thrive, hypotonia (low muscle tone), and developmental delay/regression.

There have been anecdotal reports of low milk supply in vitamin B12 deficient mothers, which improved when the B12 deficiency was corrected. Mothers with pernicious anemia are also at higher risk for thyroid problems, which can affect milk supply.

For mothers who are vitamin B12 deficient, increasing vitamin B12 intake increases the amount of the vitamin in her milk."

What are the caloric demands for a nursing mom?  Some moms worry that they won't be able to physically eat enough calories to maintain a solid milk supply after gastric bypass.


Nutrient needs during lactation depend primarily on the volume and composition of milk produced and on the mother's initial nutrient needs and nutritional status. Among women exclusively breastfeeding their infants, the energy demands of lactation exceed prepregnancy demands by approximately 640 kcal/day during the first 6 months post partum compared with 300 kcal/day during the last two trimesters of pregnancy (NRC, 1989). In contrast, the demand for some nutrients, such as iron, is considerably less during lactation than during pregnancy.

I'm trying to find good information regarding breastfeeding after weight loss surgery.  There doesn't seem to be much, if any, out there.  Today, I found this article, for dieticians:

Breast-feeding After Bariatric Surgery
By Julie Stefanski, RD, LDN, CDE
Today’s Dietitian
Vol. 8 No. 1 P. 47

Lactating mothers and their infants have special nutrition needs. Can women with limited food intake after bariatric surgery meet those needs?

An outpatient dietitian at Bellevue Woman’s Hospital in Niskayuna, N.Y., Karann Durr, RD, CDN, searched the Internet, consulted personal resources, and contacted other RDs for advice and information. She was left with nothing substantial. In the end, she and her hospital’s lactation consultant were forced to make professional guesses on the issue—lactation after gastric bypass surgery.

Durr explained, “I had to take the evidenced-based practice guidelines for lactation and the nutrient recommendations for gastric bypass and put the two together. Basically, because this is new, people are reluctant to venture there.”

The human body can adapt to the changing demands of lactation by increasing nutrient intake, improving absorption, decreasing excretion, or using tissue stores. For the patient who has undergone bariatric surgery, it is questionable whether the body’s natural adaptations for lactation can overcome the physiological changes the surgery has created.

According to Jeanne Blankenship, MS, RD, an expert in bariatric surgery and reproductive health from the University of California, Davis Medical Center, “We need to promote breast-feeding to this population—more than 80% of the women who have surgery are of child-bearing age. The numbers are going to keep going up.”

Blankenship further elaborates that “we do know that obese women are less likely to initiate breast-feeding and, if they do, they are less likely to make it to the major marks—three and then six months—let alone one year. What we don’t know is if a woman who was previously obese behaves like an obese woman or like a normal-weight woman in terms of lactation. There are definitely success stories, but I think a lot of these women fall through the cracks.”

Gail Hertz, MD, IBCLC, pediatrician and certified lactation consultant, points out that not all healthcare practitioners may be familiar with the long-term effects of bariatric surgery. “The average pediatrician probably isn’t aware of the impact of gastric bypass on nutrition because typically our patients aren’t undergoing the procedure themselves. In our practice, we do ask breast-feeding mothers about any breast reconstruction or reduction, but if the mother doesn’t volunteer information about her past surgeries, we may not know.”

Surgical Ramifications
Weight-reduction surgeries are classified as restrictive, malabsorptive, or a combination of the two. Operations such as vertical banded gastroplasty (VBG) and gastric banding aim to limit the amount of food that can be ingested and reduce the emptying rate of the stomach.

The Roux-en-Y gastric bypass (RYGB), bilio-pancreatic diversion (BPD), and the now uncommon jejuno-ilial bypass combine restriction and malabsorption. The RYGB utilizes a 30- to 50-milliliter pouch, formed by surgically separating the stomach. A gastrojejunostomy is created by anastomosing the stomach to the distal end of the jejunum. The BPD utilizes a subtotal gastrectomy to create a larger pouch than the VBG or RYGB. As a more complicated surgery, the small intestine is divided to create a gastroileostomy, bypassing the lower stomach, duodenum, and jejunum and leaving only the distal ileum for nutrient absorption.

Due to the surgical alteration of the gastrointestinal tract using the RYGB and BPD approaches, patients require perpetual supplementation to meet minimal nutrient needs. If eating habits are too restrictive after VBG or laparoscopic banding, deficiencies may occur.

Habits Under Investigation
Conduct a survey of bariatric practitioners and you will find varied vitamin and mineral prescriptions. In terms of pregnancy and lactation, the general nutrient recommendations may not meet increased requirements. Additionally, compliance with recommended supplements can be poor.

Total weight loss averages 25% to 35% of initial body weight at 18 months after surgery. Pregnancy is not recommended within the first 18 to 24 months after surgery due to the active weight loss occurring. After 24 months, weight loss has stabilized or regain may begin to occur. Several articles have been published that address the needs of pregnancy after gastric bypass.

Calorie consumption has been shown to be approximately 1,100 calories per day at one year post-op and 1,300 calories per day at 18 months. Post-gastric bypass patients’ diets have also been shown to be low in nutrients vital to pregnancy and lactation, such as iron, calcium, and folate. Actual vitamin deficiencies, other than vitamin B12 and folate, have yet to be quantified. Due to the absence of standardized follow-up of patients after surgery, there is inadequate information regarding the effects of bariatric surgery on many aspects of health.3 Women who have achieved healthy pregnancies face challenges when it comes to breast-feeding. Limited data exists to help practitioners guide mothers in the right direction.

Will the Maternal Diet Affect Milk Production?
Human milk is a symphony of nutrients that varies between mothers and changes with lactation duration or even time of day.16 In studies of lactation during famine conditions, malnourished mothers were able to produce sufficient breast milk and support normal growth in their infants.17,18 In several instances, maternal nutrition stores suffered as breast milk quantity and quality remained adequate.

“It is definitely true that there is no reason that they can’t breast-feed if their diet is adequate. Compliance with vitamins and minerals is important. It really depends on the type of surgery, how long it has been since surgery combined with their breast-feeding history, age, and, of course, all the factors that affect breast-feeding in the general population,” explains Blankenship. When combining breast-feeding with a history of bariatric surgery, there are several key nutrients practitioners must focus on to achieve success in the breast-feeding relationship.

For lactation, the dietary reference intake is 500 calories higher than guidelines intended for women who are not breast-feeding. This recommendation of 2,700 calories per day is based on energy needed for milk production, energy mobilized from fat stores, and estimated metabolic rate. It is assumed that 66% of calorie needs will be provided by oral intake and 34% will come from fat stores gained during pregnancy.

In one study, participants consumed approximately 1,500 calories per day for the first six months of lactation. Although these women had not undergone weight-loss surgery, their low calorie intake did not affect breast milk production and prolactin levels remained within normal limits.

Vitamin B12
Several important steps in vitamin B12 absorption are affected by RYGB. Deficiencies have been discovered in 30% to 70% of patients one to nine years after RYGB. Hemoglobin or mean corpuscular volume levels may not reveal this deficiency. Secretion of hydrochloric acid may be nearly absent in the surgically created pouch. With decreased acid and pepsin exposure, vitamin B12 can not be cleaved from foods such as meat, milk, and eggs. B12’s attachment to glycoproteins and subsequent coupling with intrinsic factor is also hindered by the pathophysiology of the RYGB.

Mothers who are B12 deficient during pregnancy may give birth to infants with subnormal B12 stores. Further depletion may occur as the infant is undersupplied via human milk from a B12 deficient mother.

In a case study presented in 1994, a 10-month-old, exclusively breast-fed infant was found to have a vitamin B12 deficiency. Two years prior, the mother had undergone bariatric surgery. Although the mother was asymptomatic, she was also deficient in vitamin B12.

In a similar scenario, a 12-month-old, exclusively breast-fed infant of a semivegetarian mother, presented with developmental delay, macrocytic anemia, low folate and B12 levels, a positive urinary methylmalonic acid peak, and a high homocystine level. The infant’s B12 deficiency was corrected parenterally. Two months later, the mother revealed she had undergone bariatric surgery six years earlier. Although the mother consumed vitamin B12 and iron supplements, the vitamin B12 level of her milk was found to contain only 42 picomoles per liter compared with a normal level of 184 to 812 picomoles per liter.

Absorbed primarily by the proximal one third of the small intestine, folate absorption must now occur in a smaller surface area under modified conditions. Folate deficiency has been documented in up to 40% of patients after RYGB and is of great concern in regard to the onset of neural tube defects. Both serum folate levels and red blood cell counts should be evaluated to detect deficiencies and patients supplemented appropriately.

Due to the circumvention of the duodenum in RYGB, the primary absorption site for calcium is omitted. Passive diffusion of calcium must occur along the remaining small intestine. Serum levels may remain stable, as calcium is leeched from maternal stores.6 Reductions in maternal bone content occur during the first three to six months of lactation, but this loss is replaced in later lactation and after weaning. Breast milk calcium secretion does not appear to depend on the current calcium intake of the mother, nor does the intake of phosphorus, magnesium, or sodium. Maternal intake during pregnancy may predetermine the calcium content of breast milk after delivery.

Vitamin D
The ideal amount of calcium and vitamin D gastric bypass patients need to maintain stable parathyroid hormone and 25-hydroxyvitamin D has yet to be determined. Typical amounts of 800 to 1,000 international units (IUs) are provided upon initiation. Infants may be influenced more by the vitamin D status of the mother during pregnancy and by the amount of sun exposure received rather than by vitamin D levels in breast milk. Human milk naturally contains low levels of vitamin D. Additionally, there is little evidence to suggest that lactation increases vitamin D needs in the mother.

Guidelines have previously encouraged two hours per week of direct sun exposure or 30 minutes per week wearing only a diaper to stimulate adequate vitamin D production in the exclusively breast-fed infant.41 The American Academy of Pediatrics now recommends that infants less than 6 months old be kept out of direct sunlight to limit UVA light exposure and suggests that “all breast-fed infants receive at least 200 IU of vitamin D per day beginning in the first two months after delivery.”

Decreased intake of sufficient sources of heme iron, a reduction in the acidic environment required to release heme iron, and changes in absorptive surface area impact iron stores. Iron deficiency may occur in up to 50% of patients after RYGB, especially in women who are still menstruating. Amenorrhea from sustained lactation can actually benefit women as decreased blood loss via the menstrual cycle can boost depleted iron stores.

Although breast milk is a poor iron source, iron from human milk is better absorbed than formula. Lactoferrin, a whey protein connected with infant immune response, has been found in greater concentration in breast milk from iron-deficient women. It has been hypothesized that this increase may help protect the infant from iron deficiency.

Some evidence suggests that standard multivitamins will not prevent a deficiency after bariatric surgery. Women who have undergone restrictive procedures may not require additional iron beyond the standard recommendations.

Fat-Soluble Vitamins
Vitamin A deficiencies have only been reported to occur after biliopancreatic diversion in the nonpregnant population.15 Vitamin A levels should be tested early in pregnancy and patients should be counseled to consume adequate amounts of vitamin A via food. Women who oversupplement may be at risk of consuming intakes of preformed vitamin A in amounts greater than 5,000 IUs, which may cause birth defects. Fat-soluble vitamin content of breast milk has been found to be minimally impacted by recent intake of the mother.

Water-Soluble Vitamins
Maintenance of adequate water-soluble vitamin levels in the body, especially thiamine, requires a continuous supply in the diet. Even patients who have undergone restrictive procedures can develop a deficiency if oral intake is inadequate.

Vitamin C, niacin, thiamine, riboflavin, and vitamin B6 levels in human milk are greatly influenced by the mother’s diet. In studies of maternal supplementation of water-soluble vitamins, vitamin levels increased in human milk and then leveled off. High doses of vitamin B6 should be avoided as production of prolactin may be inhibited.

No consensus has been reached on the extent to which protein energy malnutrition may develop after gastric bypass surgery. A protein intake of 65 grams per day is recommended for the first six months of breast-feeding. Patients’ diets and lab values should be evaluated, and patients should be encouraged to focus on high-quality protein sources to meet minimal guidelines.

According to Kelly O’Donnell, MS, RD, CNSD, nutrition support specialist with the University of Virginia Medical Center, “Our average patient, two to three years out, is consuming about 900 to 1,000 calories per day. Specific food choices are one of the most essential points to stress. Snacks become very significant. Choosing low fat, high protein choices, which are good calcium sources, are very important.”

Lipid comprises one half of breast milk calories and is highly variable. The total lipid content of human milk is not affected by daily intake in normal mothers, although it has been correlated with maternal fat stores.

Breast milk contains arachidonic acid (ARA) and docosahexaenoic acid (DHA), which have been associated with improved cognition, growth, and vision in children.55 Some experts recommend supplementation of ARA and DHA in the diets of both pregnant and lactating mothers, especially for those with limited diets.

A patient who failed to follow nutrition guidelines provided after her gastric bypass several years earlier suffered from anemia during her pregnancy and gave birth to an infant weighing little more than 5 pounds. Growth milestones were not reached and, upon assessing the mother’s breast milk at four months postpartum, an analysis of the fat content, or creamatocrit, revealed a low mean fat and calorie content. After the mother supplemented with formula, adequate growth was displayed in the infant at 6 months of age.

Should We Wait for Weight Loss?
Exaggerated concern with reinitiating rapid weight loss after birth may cause some women to forgo breast-feeding altogether. Blankenship points out that there may be significant psychological issues to consider. “Many pregnancies are unplanned and women just want to get back to the weight loss. Patients have misconceptions about weight loss during lactation and they want to be able to drastically cut calories.”

Regardless of the fact that many studies have reviewed the impact of lactation on weight maintenance, true consensus has not been reached. Greater weight loss has been shown in breast-feeding mothers vs. women who choose to use formula, while other studies have been inconclusive.

Gradual weight reduction, in amounts no greater than 1 pound per week, does not appear to negatively affect the quantity or quality of breast milk produced, though environmental pollutants stored in maternal fat tissue may be released into breast milk with extended weight loss.

Vitamin and Mineral Supplements
Women of childbearing age should be advised to consume a prenatal vitamin containing 1 milligram of folate, 350 to 500 micrograms of crystalline vitamin B12, plus calcium citrate in amounts of 1,200 to 1,500 milligrams and vitamin D. Patients who have had gastric bypass surgery should consume 40 to 65 milligrams iron in the ferrous form daily.8,37 Some guidelines suggest that, during pregnancy, the prenatal vitamin should be given in addition to, not instead of, a daily multivitamin.10 The consumption of two prenatal vitamins may not be advisable because some combinations may exceed vitamin A and iron guidelines.37

Maternal lab values, including CBC, albumin, folate, vitamin B12, calcium, phosphorus, and 25-dehydroxy-vitamin D, should be tested during pregnancy and after birth to detect deficiencies and supplemented accordingly. Infants should be evaluated for appropriate growth, adequacy of B12, calcium, and folate levels throughout the duration of breast-feeding.

Careful Monitoring Equals Success
Carla Woodard, MSN, WHNP, nurse practitioner with the University of Tennessee Medical Center, emphasizes the importance of educating both patients and practitioners. “The challenge for healthcare providers lies in educating women pre- and post-operatively regarding the ramifications of stopping vitamin supplements, which a good number do. Lifelong B vitamin and calcium supplementation is a must for these patients, especially those planning a pregnancy. Pediatricians and pediatric nurse practitioners, as well as women’s healthcare providers, should also be made aware of these dangers.” The increased risk of nutritional deficiencies induced by bariatric surgery, coupled with the demands of lactation, requires careful monitoring by knowledgeable professionals familiar with both bariatric surgical procedures and the nutritional needs of lactating mothers and their infants.

— Julie Stefanski, RD, LDN, CDE, is a clinical dietitian, adjunct professor, and freelance writer in York, Pa.

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Enough With The Pickle.

School starts early this year - first day is actually in August, before Labor Day.  Before that we're going "away" twice - which we haven't done in a very long time.  I figure going anywhere next summer will be more difficult when we're a bit more outnumbered.  I have a feeling it will be more difficult, but at the same time easier, because two of the kids are at particularly difficult (stubborn?!) ages rightthisverymoment and will be much more mature in one year especially when the little one is magically turned into a "big sistah" in 97 or so days.  You know your summer is already wearing thin when the conversations at 8am go like this:Pickletop2sm

"Please stop doing that with your pickle."

"You're really bothering me with that pickle."

"Enough with the pickle."

"If you do that with the pickle one more time, it's going in the trash."

Now, later, it's:

Dad:  "Go close the door.  Close the door.  The air conditioning is on, please go Close The Door.  Close the door.  Close the door."

Difficult child #1: "I wasn't the last one in."

"Please just close the door."

"But I wasn't the last one in!"  ::pouting ensues::

"If you don't close the door you're not (insert next activity here), so just close the door."

"But I Wasn't The Last One In!"  ::tears begin::

My cat ain't got no balls, blues.

Deballed cat.

The cat got deballed today. This is a good thing. But, much like the kids hanging out in the 'hood today, he's high as a kite.

Deballed cat.

He's pawed all of the food out of his self-feeder onto the floor. He's trying to eat only the white pieces. But, he's happy. Deballed cat.

Cat Under The Influence.


You'd think I'd have lots of time for getting online since I'm not working out of the house right now.  Not so.  The kids are winding down with school, and very soon will be home All Day Long.  While I'm making a general effort to not overdo it and break the fetus, I can't not do "anything" - living is messy and requires clean up at all times, or we'd be living in a pile of dirty laundry and dishes.  The good part about being out of work, is that if I truly feel like crap and must stop the world for a moment, I can.  I don't generally need to do that, but being here allows that to occur if necessary.  The hardest part, is allowing the big kids to go out to play without abandoning their little sister and making her cry, or keeping her involved with me so she doesn't notice that they've gone to play with all the kids and left her with me.  She's just too little to let her "go outside" unless I'm going to be right nearby.  Kids can't really just go out to play these days.  It makes me cringe to think about just opening the door, shooing the kids out, and calling them home for supper.  It's sad, and makes me want to move out into the country somewhere - somehow thinking that would be safer?  Perhaps if we had a few acres to run and play on --- or would they be lonely without neighborhood kids?  Is this just the way things are today?

In other news, the mother in law came through her gastric bypass surgery pretty well.  She had a rough first few days, but seems well now and very positive.  She hasn't had an official weight loss yet, but has been pumped full of IV fluids for days and days since she had a repeat visit to the hospital for dehydration and such.  She's at home now recovering, and looks healthy at this point.  It's amazing to see the immediate change in someone - she's like, "Oh, that popsicle really filled me up."  When you've been there, it really makes you laugh.  It brought back all the post op side effects, and all of the HICCUPING?!

Yesterday, my sister in law reminded me that I've got to get into a dress for her wedding coming next spring.  Oh boy.  That's a good motivation though - to get into a normal size again after the fetus arrives.  I told her I can't even imagine getting fitted in September/October when she's ready to look for dresses, but I will make myself ready by January 1st.  She's also pregnant, due August, and wants to get fittings done after her baby arrives.  I'll be a pumpkin at that stage - the dress will have to wait.

The phone is now ringing again, must run... but... will check in again.

Time out.

Sometimes being a growed up stinks. Because.  It just does. 

I was asked to make a choice today. 

Either voluntarily take a pay cut (more than three dollars an hour) to continue working at the level I have been since my health became an issue, or go revert to the job title I was hired at and do it one hundred percent full time.

A little history here if you don't know - I'm dealing with some health issues due to the leech-fetus.  When they presented a few weeks ago, I was cut back on my job duties to cut stress and a few hours each week with a doctors' note, and it was to continue as such until the issues were resolved or I couldn't work anymore or got put on bed-rest.  Obviously my health hasn't changed for the better or worse yet, and I've not been able to put a timeline on my ability to work full time.  Right now, I'm doing an average of 75-80 hours every two weeks, at a slightly different level than I was hired to do - and it's already stressing me out.  I can't imagine taking on more, now, until after I'm no longer pregnant and feeling like dirt.

This isn't a choice I can really make.  I cannot afford to take less pay - nor can my health afford to take on more stress or working hours.  If I take the pay cut, I cannot afford to physically go to work, that's just enough to make it not worth it to leave the house after child care is accounted for.  If I take back my position at the pay I'm already making - and take on more stress and eventually more hours - it's going to suck the life out of me, and I can't afford to quit either.

What would you do?

I Vant Your (Type A) Blood.

I had an appointment with a hematologist yesterday.  While the blood work hasn't returned from the lab yet, for the more detailed results, the doctor says I am still anemic.  My red blood cells are "too small" and a bit too low in number.  She initally suggested iron infusion therapy, and then took it back, stating that she hadn't really given it to pregnant patients, and that it did definitively cause birth defects in lab animals.  I know that other folks have had that therapy while pregnant, and some have had bad reactions and anaphalaxis also, so I don't mind forgoing it myself.  She suggested that we control the anemia with blood transfusions as necessary, and we'll know more when the bloodwork is finished.  We chatted about B-12 deficiency, just in case I am already lacking.  The nurse gave me a B-12 injection, just as a precaution, and if my B-12 is low, I'll go back for 4-6 more shots daily, and then weekly.  While checking symptoms, I definitely have many of the "symptoms" of anemia, and a few of low B-12, but it hasn't been very low before, so we'll see. 

Today, I have a prenatal visit with the midwives, and since their office is right near the hematology clinic, I was able to drop off the preliminary bloodwork yesterday for the nurses to peek at before I go in.