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A Piece of My Mind
August 13, 2019

A Delicate Bond

Author Affiliations
  • 1Division of Child and Adolescent Health, Department of Pediatrics, Columbia College of Physicians and Surgeons, New York, New York
  • 2New York-Presbyterian Morgan Stanley Children's Hospital
JAMA. 2019;322(6):505-506. doi:10.1001/jama.2019.10610

I had somehow managed to get a precious 30 minutes of fitful sleep when my phone, held anxiously in my hand even as I slept, woke me up.

“Hi! This is the pediatrician calling. I wanted to let you know that the results came back and her bilirubin is 19.2...”

Her voice faded away almost immediately. As a pediatrics resident, I had long ago memorized the bilirubin value requiring a 5-day-old infant to be admitted to the hospital for phototherapy treatment. My daughter’s level was 1.2 mg/dL higher than this cutoff, so I finished packing the only half-unpacked hospital bag through tears. When I placed her New Year’s Eve dress on top of the pile, even though it was a gift and deep down it still felt silly for such a small baby, my sobs came in heaves. Wincing from pain as my cesarean delivery incision site throbbed with each motion, I slowly made my way downstairs to tell my husband.

Our readmission was typical, like so many “bili babies” for whom I had cared while on inpatient service. I smiled as my co-residents congratulated me, joking that I could write her admission note, and I was unable to stop myself from plugging her latest test results into Bilitool.org as they returned. To my friends and fellow health care workers, I was upset but fine; simply a slightly overwhelmed but lighthearted new mother making the best of a bad situation.

But overnight, as my co-residents plowed through other admissions, only a few nurses, my family, and my husband saw what I really felt. Watching my baby under the glowing purple light as I pumped my aching breasts to maintain my milk supply until she hopefully learned to latch, a sudden wave of panic overtook me so suddenly and so violently that I thought I had been transported out of my very own body. What was wrong with my daughter? Late preterm babies with jaundice are a dime a dozen—my favorite, easiest patient case as a resident. But this was my baby. Was she okay? Why else would she need to be back in the hospital so soon after discharge, with what felt like nonstop vital sign checks?

My postpartum anxiety, although triggered by this sequence of events, is hard to blame solely on our readmission. Rather, it is almost certain that a combination of genetics, hormones, and other environmental stressors made my struggles with anxiety and depression as a new mother inevitable. Yet in that moment, and even in retrospect, the feeling remains: the medicalization of the “miracle” of having my beautiful baby and the interruption of our intense bonding at home were devastating.

My daughter, like almost all “bili babies,” did great: a few hours under the purple lights was all she needed, and we were discharged home the next day. With intense support from family, friends, physicians, social workers, and therapists, I too was able to heal from the throes of postpartum panic and settle into my new normal as a tired, stressed, but happy mother. Yet the effects of our admission were real. Already struggling to latch, the time in her isolette made it hard to read feeding cues. Despite encouraging breaks for breastfeeding, there was still so much less chance to work out our routine than at home. Despite attempts to regain lost ground, by a few weeks of age my baby would only take milk from a bottle. I found myself painfully pumping around the clock for the next 7 months in a desperate attempt to provide breastmilk for my stubborn nonbreastfeeder. The physical distance from my daughter (in her isolette) and from our new home worsened my struggles to connect. Not having “bonded” immediately, I felt layers of guilt overlying my anxiety. Was I a bad mother for not instantly experiencing maternal bliss? At our follow-up appointments, for many months after her admission, I felt an underlying sense of dread. Would something else be wrong? Would anything get in the way with my ability to connect with my child?

Within a few weeks, I was back at work, caring for babies in the hospital. I had admitted hundreds of patients during the years of my residency, but doing so after my own experiences, it felt as if a veil had been lifted from my eyes. I saw myself in each mother and saw my daughter in each patient. Before becoming a mother, I was already a kind and compassionate person. This translated well into my clinical skills counseling families, actively listening to concerns, and providing reassurance and guidance. But having experienced the intense pain, joys, fears, highs, and lows of such a simple readmission brought a crucial point to the foreground. Despite our best intentions, pediatrics—especially in the fragile newborn period—is so much more than medicine. In those early moments, we as physicians are witnessing an incredible event: the creation of a family. And when these new families are in the hospital, the delicate bonds that are forming become our responsibility as well.

Looking back, I am pained by some of the advice I gave before understanding this: pushing exclusive breastfeeding at the cost of maternal-infant bonding for exhausted mothers who just needed to give a bottle; refusing to order unproven but harmless gas drops for a mother who just wanted to feel in control of her baby’s colic; or firmly reciting a laundry list of parenting no-nos mere hours after a baby’s birth. In the end, I choose to forgive myself for any distress I may have caused these new parents: I simply didn’t know any better. In pediatrics, we learn the science of infant health, the perils of misdiagnosis and untreated disease, and the potential devastation of newborn illnesses. Modern medicine has been a miracle, and without it, so many children would suffer and die. However, as we focus increasingly on evidence-based approaches and work nobly to improve infant health, it is easy to create a culture in which childbirth, postpartum recovery, and maternal-infant care become aseptic, and we as physicians forget the very bond we are working so tirelessly to protect and foster.

It is heartening to see efforts in medicine that aim to place infant bonding front and center. Keeping newborn infants with their mothers during hospitalization is increasingly common and should absolutely become the standard of care. New guidelines for neonatal fever that use evidence to minimize intervention and admissions will have a huge and lasting impact on the experiences of so many families. Similar efforts are being made to review hyperbilirubinemia guidelines, and we will hopefully see fewer readmissions over the years as a result. In addition, to make lasting and maximal impact, we must fundamentally reframe how we view and teach pediatric medicine. All of our guidelines, algorithms, studies, and expertise only matter if they improve not just morbidity and mortality but also the overall well-being of children and families. When we commit to teaching the art of the parent-infant bond and how to make clinical decisions that protect and nurture this connection, we will finally fulfill our obligation and privilege as the healers of children.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Rebekah Diamond, MD, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway, CH 1-102, New York, NY 10032 (rcd2143@cumc.columbia.edu).

Conflict of Interest Disclosures: None reported.

Additional Contributions: I thank my husband and daughter for allowing me to share our story.

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