U-N-C

In my last post, my rheumatologist said it was OK for me to take the conservative treatment route until I cried Uncle. I'm more than half way to crying "Uncle." And I mean crying.

My horrible morning is now affecting my afternoon. As I was getting baby Katie ready for daycare this morning – she started this week – everything came to a head. The pain and stiffness has been wearing me down, being up at night to feed the baby has been wearing me down and having to part with my precious newborn has been eating at me all week. A minor argument with my husband over how exactly to prepare the bottles for daycare was the proverbial straw. A brief bout of shouting brought tears of frustration, anger and resentment that just kept flowing. Even now as I recall it, I'm tearing up. The pain makes it all worse – or is it the other way around?

Even as I was in the midst of a good cry this morning, my rational self was thinking, "This is just the pregnancy hormones shifting downward suddenly." But then I wondered if it could be the inflammation building. What came first this week? Did feeling down about having to put Katie in daycare at only 9 weeks of age increase my inflammation, which increased my pain? Or has the inflammation, which has been increasing since late in my pregnancy, finally trigger a bit of depression, which caused me to feel stressed out, overly tired and in pain? I study released last week suggests the latter explanation is most likely. German researchers say an increase of inflammation-causing cytokines can cause an imbalance in the brain that leads to a deficiency of serotonin and an increase in feelings of depression.

I could almost feel the bad chemicals flowing through my blood vessels as my stress level rose. I tried to calm down -- I didn't want to upset the baby. I continued getting her ready for daycare, with tears running down my face. She stared at me as if she knew something was wrong and then she smiled, like she wanted to cheer me up! I nursed her and she smiled. I changed her diaper and she smiled. She was completely carefree and happy, and I didn't want to screw that up.

I re-did my makeup and took Katie to daycare, trying to be my usually happy self, and it almost worked. Even though it's only day four at Katie's daycare, the caregiver seemed to sense that I had been upset this morning. I admitted to a certain level, but didn't go into how much the pain in my joints seemed to magnify the difficulty of leaving Katie for the day. Just yesterday, the same woman had commented on Katie's long fingers. I told her (as I stated in a previous blog entry) that Katie apparently had my grandmother's pretty, delicate hands, although I only saw her hands gnarled and curved because she had RA so bad. I didn't tell her I had it, too, or that I worried Katie someday would as well. Maybe I was too tired to get into a conversation about it or felt it was too soon in our new relationship to divulge such personal information. Looking back now, it was a great opportunity to educate and advocate, but I just wasn't in the frame of mine then.

I came back home and sat down at my desk. I read the news of the day. I made a note to check into the possibility of flu shots helping to reduce the risk of heart attacks, which occur more often and are more often fatal during cold and flu season. I tried to understand how overriding President Bush's veto of the State Children's Health Insurance Program could affect those of you out there on Medicare who need a 'breakthrough" medicine to treat your arthritis. I saw the irony in a new study that will be released tomorrow: the way brain cells communicate with each other may provide the ability or inability to cope with stress and depression. Depressed people showed a 40-percent increase in levels of a compound called BDNF, and researchers theorize that keeping BDNF from being released into a specific part of the brain could increase coping ability. I secretly hoped that today's meltdown was due to a temporary surge of BDNF and that my brain cells would get back to communicating well today. I did a task for a co-worker, though, and admitted I really needed a nap, a walk and a big cup of coffee. I tried to think but felt foggy and just stared at the piece I'm working on for a while. I drank the big cup of coffee. I took a 20-minute nap around noon. But still, my mind just doesn't seem to be working today. I apologize, as I'm trying to work on pieces for all of you to read in the magazine or on the Web site, but maybe tomorrow will be more productive. I'll go exercise later and try to clear the cobwebs. I'll try to get some extra sleep tonight. And I'll feel much better when I get to hold Katie again at the end of the day.

Til then, I'll just have to accept the fact that, being a human with a chronic condition, there will be good days and bad days, and that the bad days also are only 24 hours long. I'm well into those 24 hours, so things should be looking up soon.

Decisions, Decisions

Today's my first day back to work since having baby Katie, and my 7 a.m. rheumatologist appointment was a great way to start it off. As I sat in the waiting room nursing Katie, I was internally lamenting over the fact that when my appointment was over, I'd hand little Katie over to my husband for the day and get back to reading/writing/editing. Of course I instantly became used to holding her through the day, and, as any mom knows, it's immensely hard to cut back on that. That bond forms pretty darn quick and is amazingly strong. Any attempt to loosen that bond is made even more difficult by friends asking, "Do you HAVE to go back to work?" Financially, yes. (And then guilt sets in.) But when I overheard an older woman's plea to the receptionist at the rheumatologist's office this morning, I knew I had an important job to return to.

The woman's disability payments had been cut off suddenly, apparently due to a mix-up in paperwork. She was desperate, and I could tell by looking at her that she had been affected by RA for many years. She obviously had trouble maneuvering physically, and now I knew she was having trouble maneuvering through the healthcare system. My heart went out to her, especially when she had offered to hold Katie for me to make it easier for ME to fill out my paperwork! She was so sweet to me, but so spicy when it came to dealing with her current problem.

I internally cheered for her when I saw her massive folder of papers accumulated over decades of doctor visits. Every good patient should have one. And I smiled when the petite woman seemed 7-feet tall as she succinctly explained what had gone wrong and how it needed to be fixed. She was organized and assertive, just as we tell readers to be at their office visits. I don't know her outcome, but I have a good feeling she got what she needed and will be just fine.

I went in for my appointment -- my first since delivery -- and had an important talk with my doctor. This is where the tough decision comes in. I've been breastfeeding Katie almost exclusively, except for a daily bottle of formula to keep her used to it in anticipation of starting daycare next week. However, the doctor noted the swelling and tenderness in my fingers, wrist, feet and ankles. There's no denying it's there. I could go back on the DMARD now and stop nursing, or I can manage my arthritis conservatively and continue breastfeeding. My choice boils down to this: Prevent deterioriation of my joints and ease my pain, or give Katie the benefits of breast milk -- one of which may be reducing her future risk of developing chronic diseases. I opted for the conservative route, you'd think because maternal instinct is to take care of the baby before self. As it turns out, breastfeeding Katie may help me, too.

According to a 2004 study, women who have breastfed their babies for a lifetime total of more than 12 months (so a year for one baby or a total of 12 months among several children) have a reduced risk of developing RA. Well, that didn't hold for me. Among my three older children, I've breastfed for a total of about 48 months already -- 12 months or longer for each child. In digging deeper, though, I found a study from the University of California San Diego that shows women who have breastfed longer than 12 months have "significantly higher cortisol levels than women who breastfed for shorter durations or not at all." And that association was found to be stronger in women who had three or more children (phew!). Why is this good news? Because, as the researchers explained in the 2001 study, "increased cortisol and increased duration of breastfeeding may play protective roles in certain autoimmune diseases, such as RA." Apparently, cortisol – a hormone often associated with increased stress – may contribute to the beneficial effect of being a lactating mom.

So a lactating mom I am. And I'm also going to have to be a really good patient. That is, taking the conservative route takes work. As my rheumatologist said, I've got to stick to a routine, make sure I eat really well and regularly, take rest breaks, try to sleep well (even though it's disrupted with night feedings), keep my stress level down and get some exercise. The goal is to stave off a postpartum flare so I can stay off medication for now, all while protecting my joints from sustaining damage and keeping pain down so I can function as well as possible. It's not as easy as taking the medication, which gives me some confidence that my joints won't deteriorate and my pain will be minimal. With that confidence, doing all the good things simply makes me feel better. Right now, doing all the good things is how I will get by until, as the rheumatologist says, I cry Uncle.

Those nasty postpartum flares tend to happen most often between three and six months after delivery. I'm at two months now and truly hope being a good patient will get me through the coming months without a worsening of my RA, so I can be a good mom and worker, too.