As Much Fun As... Monkeys Jumping on the Bed

Selecting a 529 Plan for Seth

Sun, 4 Jul 2010 23:02:01 -0500

529 Tax-Advantaged Education Savings Plans are a topic I’ve posted about several times. My original post on June 1, 2007 describes what these plans are, how they work and how we selected Grant’s. On March 18, 2008 I revisited the topic, covering gift tax implications and looking at changes in the offerings even just since opening Grant’s account. On December 2, 2008, I discussed the low prices of Grant’s 529 plan which were tracking the trend in the overall stock market.

The specifics of this year's 529 evaluation process were a little different from Grant’s selection, but the principal was the same - identify plans with flexible plan terms, very low cost and reasonable past performance. I again enlisted my father to narrow the field while Scot & I were distracted by a certain little someone. The methodology and numbers are detailed in documents I'll send if you're interested, but here is the summary: our 2010 finalists are College Savings Iowa, Michigan Education Savings Plan, Utah Education Savings Plan and Nevada-Vanguard 529. These are the full plan names; although I just use the state name in the rest of the post, keep in mind that there can be more than one plan per state with very different terms. Other than Nevada, the others were finalists three years ago when we went through the exercise for Grant.

Nevada and Utah have both edged out Michigan in asset-based fees - Michigan is at the same 0.45% that it was when we selected it for Grant's plan; at that time it was the lowest cost non-resident plan available. When I originally selected a plan for Grant, Utah had an annual $25 non-resident fee that effectively wiped out their cost advantage for non-residents. Earlier this year the plan reduced fees, including waiving the $15 per year annual account fee for non-residents and reducing some asset-based fees. Utah's asset-based fee for one of the 100% equity portfolios is a very attractive 0.301% and 0.205% for another. Nevada also come in just below Michigan at 0.44%, but has a $3000 minimum initial investment.

A hypothetical $10,000 investment left to grow for 10 years in a 100% stock portfolio, assuming 5% growth would have the following total cost over those 10 years:
Iowa: $628
Michigan: $568
Nevada: $555
Utah: $402
This information is taken from the plan brochures.

For perspective, let's continue the scenario and instead of assuming 5% growth, assume the past 5-year average annual performance of each fund continues for the next ten years. If that were to happen, this would be the return for each fund (without compounding):
Iowa: $3100
Michigan: $3260
Nevada: $3550
Utah: $4020
The cost for the 100% equity option for these low-cost plans is roughly 1/10 to 1/5 of the return.

The Nevada plan has an interesting feature of allowing you to link a Upromise account to make contributions when making retail purchases.

One of the nice things about the Utah plan that was added this February is the option to select a custom mix of the various funds in the plan. So, for example, if you were looking to get broad US stock exposure with some bonds and international equities you could create a portfolio made up of the Vanguard Total Stock Market Index Fund, Institutional Total Bond Mkt Index Fund, and Developed Markets Index Fund. I like this kind of approach for long-term investments. As the beneficiary ages, you would want to be sure shift percentages and add other less risky options, and this could be done with more precision than the other options.

The Utah plan materials describe how to calculate the asset-based expense ratio for a custom portfolio. Depending on your asset selections, the fees for this can be higher or lower. It's just the weighted underlying fund ratios plus 0.22%. Since some of the funds are institutional funds and most are index funds, the expenses of most of the underlying funds are extremely low - as low as 0.025% for an S&P index or 0.06% for the Total Stock Market Index. Some international options are notably more expensive, but if used in moderation the cost structure would still be competitive. Utah also automatically rebalances the portfolio to the target percentages you set once per year. You can change your investment selections once annually (federal law limit on all 529 plans).

The Utah cost differential is enough to win me over for a new account. I'm going to use Utah for Seth's plan. I think for now I'll leave Grant's in Michigan, though. TIAA-CREF's original 3-year contract with Michigan can be renewed for up to two one-year terms by the state. The initial 3-year period ended March 31, 2010, and I'm guessing that come March of 2012 if not next March, there will be a definite expectation on the part of the state that fees will follow market trends and come down. Given the sizable assets under management in Michigan's plan I expect they'll get a great deal, and that it’s not worth moving our account yet. So for now, I think I'll keep Grant's with Michigan and see what happens when the business is re-bid. If the costs don’t come down, a rollover to another plan might be in order. Since I made sure to avoid plans with sneaky fees, I’m not worried about it being a problem to move on.

- Anita

Seth’s 8 Month Birthday

Fri, 2 Jul 2010 21:12:19 -0500

These days Seth:
• can climb stairs. He started a few days after his seven month birthday and sent us scrambling to find a gate solution for the wide and irregularly-shaped stairwell in the new house.
• moves about mostly by army crawl. Sometimes he crawls on hands and knees, and he also cruises along furniture, albeit not with great speed yet. He once made his way across the kitchen using a chair for support. 
• pulls himself up regularly.
• can sometimes work himself back down to the floor from standing next to furniture without dropping.
• is still working on learning the “more” hand sign.
• has no teeth, but is starting to act like he’s teething.
• stands in his crib.
• does NOT want to be put in his car seat. Once we start driving, he’s usually okay, though.
• often really wants to be held during dinner. He then grabs anything remotely reachable on the dining room table.
• eats, eats and eats. He’s probably taking in 34+ ounces of milk, cereal and two tubs of baby food most days. He also enjoys Puffs. Spinach is the only food we’ve given him that he didn’t immediately demand we shovel in as quickly as possible.
• will do a wobbly walk while holding hands for support.
• will try to climb up and over our shoulders to get interesting things, especially paper.
• has been spitting up more again.
• coughs a lot in the early morning, but not the rest of the day. 
• has no interest in lying on his back during a diaper change. He is quite the wiggle worm. Luckily, there is a towel bar just above the changing table. After getting him cleaned up, he’ll stand and hold onto it, being relatively still long enough to get a clean diaper on.
• grunts and growls. Responding in kind gets a big smile. He doesn’t regularly make the usual baby sounds like ah-goo, ba-ba, ab-ba or da-da, though.
• seems to enjoy being called “Smiles”, Daddy’s favorite nickname for him.
• loves watching his big brother. Grant can make him smile and giggle almost on cue.
• his favorite toy this month isn’t really clear. He likes a stuffed Tigger that he gets to have in the car.
• likes to eat paper like his big brother did at this age.
• is going to bed more regularly around 8 or 8:30 and waking at roughly 6:15 most days. We still see a lot more of the 5 o’clock hour than we would like, and he is definitely at the short end of the 10-12 hours per night that he’s expected to get.

-Scot & Anita

P.S. We updated the previous blog entry (Grant’s 3 1/2 year entry) with a couple more pictures today.

Grant’s 3-1/2 Year Birthday

Tue, 22 Jun 2010 13:42:02 -0500

Although we’ve turned over the monthly update to fast-growing Seth, Grant still has new tricks all the time and is well worthy of a half-birthday blog!

These days Grant:
• is back on an 8pm bedtime schedule. He usually stays up playing quietly or reading until 8:30 or 9.
• says the most amazing things:  He usually has at least one really funny or insightful thing to say at the dinner table. Yesterday, Anita had dropped some ingredients while cooking, and Grant helped pick the pieces off the floor. A while later she said something about having to “do it again”. Grant said, “Are you going to knock all the food down again?” Grandpa and Scot just laughed and Grant could not quite figure out why. In general his conversation strikes us as very much more grown-up than it did a few months ago.
• will talk, talk, talk non-stop to us and at school. But he gets very quiet around new people.
• in particular, loves telling us about words that rhyme. He thinks hard about it sometimes and comes up with many hilarious examples, and other times just stumbles onto them. “Walk and talk rhyme! Walk and talk!” Usually he quickly drives himself into a giggling fit by making up word. “Pillow and killow rhyme! Ahahahah! Killow isn’t a wooooord!”
• loves to play his first board game - “The Ladybug Game” which he recently received from Anita’s friend, Kelly.
• eats well, enjoying a variety of vegetables from our garden and CSA. But he has started to expect dessert every night which we think is a little excessive.
• loves to go to the pool, but doesn’t really want to learn how to swim. He would much rather just cling to an adult. He was a better swimmer after swim lessons last year (happy to jump “all the way in” over his head, happy to blow practice bubbles) than he is this year. The only evidence we have now of his graduation from “Starfish 1” is the certificate of completion. Hopefully by the end of the summer, living walking distance from the community pool, he will be swimming for real.
• helps out around the house. In addition to setting out silverware for meals which has been his “thing” for a while, he also enjoys vacuuming and mopping the floors. If we get either of them out while he is around, we had better offer him a shot at it or we’ll hear about it. He is surprisingly vehement in insisting we’re not allowed to go back over areas he’s done. As a result, we have been coaching him on technique, and he is getting surprisingly better.
• is very reluctant to try new things, but often enjoys them once he tries them. It can be quite frustrating as a parent if you know he will enjoy something and have to really almost force him to try it. He eases into things very slowly and gradually, and then once he gets into it he often gets really into it and you can’t stop him. Argh!
• has several great friends whom he talks about regularly. Our neighbors Noah (slightly older) and Phineas (slightly younger), Zoey (his age), and classmates Gabriel and Samson are often featured in stories, and he loves to run to play with them. He also gets inspired by their more adventurous attitudes (for example -- Phineas is a good swimmer and will swim a fair distance, or down to the bottom, on his own), which is usually a good thing.
• loves Seth, and especially loves to make him laugh.
• is learning to put his small toys in places where Seth can’t reach them once he’s done playing with them.
• thinks he wants to try his bike without training wheels. We let him try it once but he really didn’t seem to have the necessary focus. Another boy his age in the neighborhood, Leo, is pretty good on a bike so we know it’s possible in theory, but we’re a little skeptical that Grant is ready.
• has switched from baths to showers. His own idea, but it’s working out really well. He helped pick out a duck pattern shower curtain which actually looks great in his bathroom, too.
• can pretty much take care of himself completely on the potty now.
• loves watering plants in the garden
• still dresses himself every morning (picks out his own clothes, too) and comes into our room to ask us to get breakfast. Usually we are up a bit before him because of Seth, but not downstairs yet; this is around 7am.
• if his fireman shirt is available in his shirt drawer, it will be worn (if he had a Thomas the Train shirt that might get top billing). After that come the alligator, Corvette, monkey and Boeing airplane shirts.
• has reached the lesser-known milestone of having worn out an article of clothing rather than outgrowing it - a sock has a hole!
• is still working on the differences between wants and needs
• has learned how to pass a toy through a roll of toilet paper to see if it’s too small for Seth. These toys have to go back in his closet when he’s done playing with them. We also have been working on teaching him which larger toys are dangerous for Seth due to small parts. He has been pretty good about putting these things away.
• is getting better at brushing his teeth like a grown-up, spitting out the toothpaste, so that we can consider graduating from the toddler toothpaste. Not quite ready yet though.
• reads three stories before bed every night: one story from his Spark Bible, one story from a regular book (or sometimes a second Bible story, it’s up to him), and one baby story for Seth. Then we say our regular prayers and kiss goodnight.
• is very, very good about staying in his room at night, at least until he has slept for a while. Some other rules, he tends to test and break, but for some reason that one is ironclad in his mind. He will come right to the door, talk to us or sit and read a book there maybe, but he will not cross that threshold before about 2 am, and that is rare.
• gets “timeout” for misbehavior. He has to sit in a corner by himself, quiet and not playing, until we tell him he can come out. There is a little room for flexibility on this, for example if he is misusing a toy, the punishment is sometimes that we take the toy away (for toys where he has done this repeatedly, he will sometimes lock the toy away himself if he sees us catch him abusing it). Or if he makes a mess, sometimes the punishment is to clean up the mess. When he does get a timeout, he usually (but not 100%) will obey the timeout and sit in his corner, but he does sometimes get into a very impish mood where any kind of stern talk or punishment just makes him laugh and try to escape. If he’s in that mood and gets in trouble, punishment is hard on everyone because a parent has to pretty much physically hold him in timeout (which isn’t really a timeout, and is giving in to his demand for attention) and, once captured, his impish giggles turn into blood-curdling screams. Fortunately this is fairly rare, but it has happened a few times.
• loves to flip down the back cushions on the couch to make a boat. We are regularly invited aboard.
• pretends to be a doggy a lot. He has recently started recreating a scene from one of his nature books - he likes to play shark with us being dolphins.
• uses his “whiny voice” too much for our taste. We are trying hard to tell him that we only want to talk to him when he uses his normal voice.
• anything related to Thomas the Train makes a favorite toy for him right now.

-Scot & Anita

Seth’s 7 Month Birthday

Wed, 2 Jun 2010 21:31:57 -0500

These days Seth:
• can crawl very fast, and does so whenever he sees something he wants across the room (he’s best on hardwood, but he can go on any surface).
• is starting to pull up. We now keep his crib sides at maximum height.
• can stand holding on to something like a couch as long as he wants.
• can sit as long as he wants, and go from sitting to crawling.
• eats baby cereals: oatmeal, rice; pureéd veggies: carrots, sweet potatoes, peas; and pureéd fruit: bananas and apples. For the most part he eats very eagerly and, in the last few days, surprisingly neatly. He starts with half a “size 1” tub which is 4 oz., and gets the full 4 oz. after that.
• still goes 3-4 hours between feedings of 8 oz of milk or more (seemingly a lot more in the morning when he nurses). He tolerates cool milk now, though still prefers it warmed.
• loves to play with Grant. Grant makes him giggle more than other people.
• loves to smile. Everyone mentions this when they meet him.
• is starting to babble a bit more, and occasionally makes sounds like “dada” that might not be totally random.
• likes to go to the pool and watch from his stroller while Daddy and Grant play in the water nearby; will sit quietly like that for 30 mins or more.
• is establishing the bedtime routine we laid out last month: ideally, gets a dinner (of milk) around 7, maybe with some cereal or baby food, then a diaper change, then some rocking or other pre-bedtime calming, then a book (read by Grant and Mommy or Daddy). He then usually plays for a few minutes while Grant is getting into bed, and usually goes to sleep with little fuss after that.
• still loves his musical mobile at bedtime when he’s fussy.
• sleeps 8:30-6:30 roughly, somewhat more predictably than last month, and often stays in his crib fairly quietly until 7.
• has not established a firm nap schedule, but usually has one in the morning and one in the afternoon.

-Scot & Anita

Creepy Crawlies?

Mon, 17 May 2010 17:33:28 -0500

In the last few days Seth has hit both the “sitting unassisted” and “crawling” milestones. He’s still getting use to his new abilities and doesn’t have them fully sussed out, but he can sit happily for several minutes, and crawl wherever he wants to go.

We need to get those outlet protectors. No more procrastinating!

At Seth's 6 month appointment, he was 16 lbs 15 oz., 28" long, and 45.2 cm head circumference. (We didn’t get a chance to include that in the birthday update.)

We also closed out the “guess the medical bills” contest for the care associated with Seth’s run-in with Meckel’s Diverticulum. The challenge was to guess the total bills for two ER visits, the ambulance ride from southern New Hampshire into Boston, tests, surgery, inpatient charges, and a followup doctor appointment before any insurance payments or discounts. The total charged was $32,781.81, of which we paid $20 (just an office visit co-pay for the followup), the insurance paid $26,846.43 and the rest was discounted according to contracts between the insurance company and the providers. The average guess, though, was $99,964.83... with a standard deviation of $83,507.38. The 32 entries ranged from $15,000 to $327,000. Wow. And wow. This exercise made us realize at least part of what’s wrong with healthcare. We are talking about expenditures on the order of a house without any real knowledge of how much it should cost (let alone an inspector’s report to information us about the quality of the work being done)!

In our last post we wrote mostly about Seth and about the fact that Grant has been trying some unfortunate tricks to get our attention, and left out some of the fun ways he’s been getting our attention. It seems like we’ve been saying this for years already and I guess we’ll be saying it for years to come, but Grant is really putting thoughts and words together in amazing ways. One of our recent favorites went something like this:

Daddy: “We’ll have some of the leftover pasta for dinner.”
Grant: “But some of the pasta was burned!”
Daddy: “Okay, we’ll avoid the burned bits.”
Grant: “What does ‘avoid’ mean?”
Daddy: “It means ‘stay away from.’”
Grant: “Uhhh...okay. You guys can avoid that. I will stay away from it.”

And a strange one: “When I turn 5 and Seth talks to me, I’m going to run really fast... and I won’t hurt myself.”

Grant has also been a very patient big brother, especially at bedtime. Seth doesn’t go to sleep particularly quickly or quietly at the moment. Sometimes Grant takes matters into his own hands by turning on the mobile on Seth’s crib. We often hear him go to his bathroom, get his step-stool and restart Seth’s mobile to help him calm down. At least part of the problem is that for a while we let Seth get in the habit of going back to sleep after his early morning feeding. We have been trying to cut that out and put more routine in, but it is still a challenge. Grant has taken it all in stride.

Grant LOVES firemen. Recently he decided to scale his dresser. Scot saw what was going on and quickly reminded him that it is never okay to climb bookcases and dressers because they might tip over and hurt you. Grant responded, “Then the firemen will come and rescue me!” Daddy, in a moment of desperation to keep Grant from concluding that climbing furniture would score him a personal visit from the people he loves most, blurted out, “And then we’d have to take you to the doctor to get shots!” Now, Grant’s last shot experience made an impression. Needless to say, Grant was not pleased with this idea of having to get shots when the dresser fell down; it has clearly remained on his mind. Several times since he has talked about shots in this context. Argh! Tangling the doctor, shots and discipline together is certainly going to cause future trouble. Ah well. The crisis of the moment was averted. Next time, we’ll have to have a prepared answer for that one.

We also have some older material to catch up on that has been scribbled on notes for the past month or two.

I forget if we’ve mentioned this before. When we have dinner, Grant often says to whoever prepared it, “Daddy/Mommy, thank you for making this.” It’s awesome! I’m not sure what prompted this. It stopped briefly, and it was a little disappointing. But he has started again. :)

We also regularly have conversations like the following at intersections around town: “What does that man’s sign say?” “It says he is hungry/needs work/anything will help.” Usually we keep socks, canned food or candy in the car. Grant will then ask questions like, “Why does that man need socks?” We try to explain the basics of what would lead to someone asking for help on a street corner. At one point recently we ran out of socks and Grant observed that we didn’t help. We said something that led Grant to conclude the next time, “But we can’t help him. Somebody else should help him.” We are trying to show him how easy and important it is to engage with others, and it was heart-wrenching to see that one failure made such an impression. It will be a while before less tangible activities like funding agencies and programs have any meaning for him.

Grant received a half-dollar as an Easter gift. He said to Anita, “I'm going to save some money for later in case you want to have a birthday party.” How did he learn that birthday parties cost money? And what inspired him to offer to save his money for Anita’s birthday party? Interestingly, Grant co-mingles the ideas of birthday, birthday party, birthday cake and birthday present. For example, he might say, “I want to eat some birthday.” Just this month he seems to finally be sorting this out.

Anita and Grant went to the Easter Vigil service which, of course, was waaaay past bedtime (even though the time was moved up to 8 this year). Shockingly, he stayed awake through the whole service. That is not just a regular length service! On the way home, Anita asked Grant about his favorite part (admittedly mostly to keep him awake so she wouldn’t have to carry him upstairs from the car). He answered, “bells.” Anita was skeptical of this answer because when the bell banners processed during the Easter celebration, Grant whined and covered his ears. She asked what his next favorite part was. “Bread,” he answered. Our congregation usually uses wafers at communion, and the use of a loaf of bread in this service did not go unnoticed by Grant. This was getting to be fun so Anita asked again about his next favorite part. “The dark.” Again. “The music.” Again. “The light.” Again. “Talking.” Talking? Ah, the multiple readings of this service were done in more of a story-telling form than the usual lectionary form. Grant was surprisingly attentive. Wow, what a list! I think he just about summed up the whole service. Thanks to Sharolyn, Debbie and Cathy for the work they do to tell the stories of the faith to the two-year old Sunday School class. It is clear in church, at home and in our Bible readings that Grant is just soaking it up!

-Scot & Anita

Seth’s 6 Month Birthday

Sun, 2 May 2010 20:11:40 -0500

Seth is soon going to force us to install gates on the stairs! Of course, this exciting time in Seth’s life means sometimes Grant doesn’t get the attention he wants, and he’s had some very questionable behavior lately, from just being grumpy when he doesn’t get his way, to smart-aleck replies to Mommy or Daddy, all the way to repeatedly bumping or kicking other children “accidentally” during play at music class, school, or out in the courtyard. Monday was a particularly painful day and Mommy escaped to the neighbors‘ house once Daddy got home. There are still plenty of happy moments though, and Grant absolutely loves to feed his baby brother now that we’ve started solid food, so life is really still pretty good despite the occasional acting-out.

These days Seth:
• babbles various noises, but he doesn’t favor particular repeated sounds yet.
• loves to play with his toes.
• chews on his fingers, wrist, and arm often, usually but not only when he is hungry.
• will briefly sit on his own.
• will briefly get up on his hands and toes, doing a regulation push-up.
• is starting to rock back and forth on his hands & knees, a precursor to crawling. Any day now!
• will sometimes quietly babble in his crib for a little while after he wakes up in the morning, provided Mommy isn’t visible. Once Mommy shows up, he cries loudly until fed.
• starts his day by nursing. He has an 8 ounce bottle about every 4 hours during the day if Mommy isn’t around. He then nurses one or two more times in the evening. He will sometimes go longer between feeding.
• has at least one serving of baby food each day. So far he’s tried rice cereal (good), puréed carrots (seemed to lead to exceptionally messy diapers), and puréed sweet potatoes (good).
• is usually asleep around 8:45 or 9:00 pm and sleeps until 6:15 or 7:00 am (sometimes later at both ends).
• is starting to establish a bedtime routine, which we hope will allow us to move his bedtime earlier soon. He gets a pre-bedtime meal, then a diaper change, then lies down in his crib in the boys’ room. Grant then comes and starts his own routine. After a few minutes it’s time for Grant to read Seth a story, then we have prayer time (still Vespers) and lights-out.
• likes to reach out and touch anything within reach. He’s not picky, he’ll grab placemats, cups, toys and more. Sometimes if someone moves an object out of reach he gets very upset.
• rolls over a lot. In the last few days he’s started rolling over during diaper changes despite our valiant effort to keep him stable. This is a big pain which we remember un-fondly from Grant at this age.
• will move a couple feet in a few minutes on our hardwood floors, mostly by rolling but mixing in some wiggling and almost-crawling.

-Scot & Anita

Tough Month

Sun, 25 Apr 2010 20:53:53 -0500

We’ve had more than our fair share of health scares with Seth now! After the Meckel’s diverticulum adventure you’d think we’d have met our quota, but this past month has been a long guessing game featuring Seth’s suspicious cough.

The cough started as, really, nothing -- just a little occasional dry cough, innocent cold symptoms, the sort of thing kids in day care catch all the time. After a week or so, though, it triggered the doctor visit that we described in his 5-month birthday entry three weeks ago. At that time we were hoping the test she’d ordered would come back clear, and in fact it did. No pertussis (better known as whooping cough), hooray!

But...

A day or two after the test result came in we got a distressing phone call. The county health department asked a battery of questions and concluded after the 15 minute phone call, based on Seth’s symptoms and the fact that the county is the center of a pertussis outbreak at the moment, that they would classify Seth’s cough as a “probable” case of pertussis. Ack! Pertussis is super-contagious, and sneaky -- adults can carry it with hardly any symptoms, and even in kids you often don’t know it’s pertussis until they have been spreading it for a few weeks. At that point, it’s difficult to treat it effectively (since the worst symptoms are actually a result of the toxin produced by the bacteria in weeks prior), or even test for it accurately. It starts out with...you guessed it, innocent cold symptoms.

We spent the next week and a half on pertussis watch, with each of us parents having a concerning bout of coughing (in fact, I was laid up for days with a brutal allergy attack and sinus infection), until finally the worst seemed to happen: Grant started coughing. We immediately brought him to see the doctor, who ordered another test (likely to be accurate since we caught it early) and looked him over. The doctor (not our regular pediatrician, but a friend of ours, it turned out) was very encouraging, though, and prescribed antibiotics that would at least keep Grant from spreading the disease further after he completed his course -- which would be finished just in time for our long-planned housewarming party. Whew! First sigh of relief. The second: Grant’s test also came back negative. With two negative tests including one early in the “infection”, and no severe escalation of symptoms, in all likelihood the entire saga (including days of missed work and day care) was for nothing more than...you guessed it, innocent cold symptoms.

In the end we had a wonderful and healthy party:

And finally got a chance to start another long-planned project: introducing Seth to solid foods, with Grant’s eager assistance!

We also had a wonderful day yesterday hiking with friends -- Seth’s first hike, I think, though definitely not Grant’s. Grant just had a great hike with Mommy the other day, actually, and saw lots of wildflowers:

Grant and Seth at Barton Creek:

-Scot

Twins?

Thu, 15 Apr 2010 12:55:38 -0500

People often tell us that Seth looks exactly like his big brother. Usually this is combined with the observation that neither of them looks much like either of us, but regardless, I definitely agree that Seth reminds me a lot of Grant at the same age. Here are a few comparison shots:

-Scot

P.S. All the left photos are Seth and all the right photos are Grant. The title photo is Seth.

NIH Conference on VBACs

Sat, 10 Apr 2010 15:16:08 -0500

A friend of mine recently sent a Newsweek article that highlighted a recent National Institutes of Health Consensus Development Conference on Vaginal Birth After Cesarean Section (VBAC). For the past 30+ years, these conferences have addressed a variety of issues of broad public health importance that involve either controversy or unresolved issues that can be clarified, or a gap between current knowledge and practice that can be narrowed. The Newsweek article itself is interesting. Even more interesting to me, though, was the draft statement and the collection of session abstracts available on the conference website.

As with many health topics, the internet is brimming with "information" on the decision between a VBAC Trial of Labor (TOL) as it is called and an Elective Repeat Cesarean Section Delivery (ERCD). It’s a minefield out there. Some websites leap to cite a study that shows a very definitive outcome that reinforces the position of the website owner. But when you look closer you find that the study involved only 13 people. In my opinion, this is not real information, yet it gets rebroadcast everywhere. If you focus instead on reputable medical sites, they tend to be perhaps overly careful in what they say for legal reasons.

So where is the data?

In going through the abstracts from the conference, I found just the kind of information I was looking for last year - meta-data. Many studies on VBAC were evaluated to determine which results have been consistently reproducible in well performed studies. Much of the material in the abstracts was familiar to me from the research I had already done. If you're considering VBAC vs. ERCD and have an analytical bent you will probably find the abstract collection similarly interesting. It’s a long document, but it took much less time to read than all the websurfing I did. You can even find webcasts of all three days on the conference website if you’re ready for that time commitment. For the less analytically inclined there is also a summary statement. For this post, though, I thought that I would highlight a few items that were surprises to me, even after my past research.

* The overall mortality rate in the US associated with becoming pregnant (pregnancy through delivery) is on par with breast cancer - both at 13/100,000 persons, based on death certificate data. (page 7 of the statement)

* Mortality rate among women with a prior C-section who attempt a TOL is 3.8/100,000 vs. 13.4/100,000 for ERCD. "Twelve studies, involving 402,883 patients, provide high strength of evidence that the risk of maternal mortality, while rare for both TOL and ERCD, is statistically significantly increased with ERCD (3.8 deaths per 100,000 for TOL [95% confidence interval (CI): 0.9 to 15.5 per 100,000] compared with 13.4 per 100,000 for ERCD [95% CI: 4.3 to 41.6 per 100,000])." (page 38 of the abstracts)

* Perinatal death (death around the time of birth) is higher with TOL vs. ERCD. "Eight studies provide low to moderate strength of evidence that the risk of perinatal and neonatal mortality is statistically increased with TOL (1.3 deaths per 1,000 births [95% confidence interval (CI): 0.6 to 3]) versus ERCD (0.5 per 1,000 [95% CI: 0.07 to 3.8]) for perinatal death." (page 61 of abstracts)

* There is an apparent higher risk of asthma to children delivered via c-section, with an estimated risk difference of 100 to 200 per 10,000 deliveries. This needs to be studied further. (page 70 of the abstracts)

* The abstract includes a very interesting discussion of the AGOG recommendation that a physician and anesthesiologist be "immediately available" during a TOL (but not necessarily during other deliveries). The abstract asks the question, "Given that women can be identified who face a peril similar to that of women undergoing a trial of labor, what evidence supports holding VBAC to a greater personnel requirement?" Here are a couple snippets. "Obstetrical emergencies that create risk similar to those faced by women undergoing a trial of labor may well exist. Abruptio placenta, for example, has a 1% worldwide prevalence and has been reported to increase perinatal mortality 25-fold at term." "Other complications with a short timeline from diagnosis to damage, for which an immediately available team would potentially be salutary, include hemorrhage, prolapsed cord, and fetal bradycardia. In some, these events are much more common causes of emergent ("crash") cesarean sections and hypoxia than are ruptured uteri." (page 89 of the abstracts)

* "When analyzing the cost of providing services, specifically VBAC, the gorilla in the room is medicolegal liability." (page 78 of the abstracts)

And the kicker for me...

* "...the number of scheduled surgeries to prevent one adverse event would not be vastly different if all hypertensive women underwent a cesarean section at 39 weeks than if all women with a prior cesarean section underwent an elective repeat." (page 89 of the abstracts)

Should hypertensive women undergo a prophylactic C-section due to concerns about adverse outcomes in a vaginal delivery? The abstract describes this idea as "an intervention that is far from any current standard of care." And yet today other women with similar risk level (i.e. those who have had a C-section) are doing exactly this. I am getting an even better idea of why VBAC qualified as a conference topic.

For me, I think that if I had access to this material last year, I would have been even more confident in my decision to attempt a VBAC. I had seen VBAC-favoring websites claiming a higher maternal death rates in ERCD over TOL, but I had discounted them due to their potentially biased source. Actual perinatal and maternal mortality rate differences between TOL and ERDC was an important piece of information missing in my decision-making. I was familiar with increased perinatal mortality rate associated with TOL, although I didn't have a good quantification of it. I knew that each C-section increases the risks of complications for babies in future pregnancies. I thought I was familiar with increased maternal mortality rates associated with TOL, but now I know that was downright wrong. Although both are extremely unlikely, if you had asked me which was more likely to lead to death, I would have said TOL! I am rather displeased to learn not only that my understanding was incorrect, but that statistically speaking a mother is about 3.5 times more likely to die in a repeat C-section.

Discussions of TOL usually involve a lot of talk about uterine rupture and the possible very bad outcomes associated with it, including hemorrhaging for the mother, oxygen starvation for the child and death for both. Death is not regularly discussed when covering ERCD beyond mentioning "as with any surgery, it is possible." You can read more about my VBAC decision process in the entry on Seth’s birth story. As I mentioned in that post, when I first heard the 1% uterine rupture risk, it sounded like we were talking about a near 1 in 100 chance of death for me and/or the baby. My own reading eventually clarified that death and severe damage due to uterine rupture occurs only in a fraction of ruptures.

So where does that leave us? We started at “once a C-section, always a C-section.” Then VBACs were encouraged in the early 80‘s. Then after some very well publicized cases of adverse outcomes resulting from uterine rupture, AGOG published guidelines recommending that a physician and anesthesiologist be “immediately available” rather than the usual “readily available” standard. Somewhere in there lawyers got more active and malpractice insurance blew up. More hospitals and doctors shied away from VBAC in the face of increased staffing standards and legal concerns. Those who continue to offer the practice couch it as “a personal choice.” Meanwhile C-section rates are higher than ever and more C-section related issues are showing up in mothers and children.

Whew!

We’ll have to see how the results of this conference play out. Hopefully more research will be done on the open areas cited by the conference to bring even more data to bear, but for now I’m convinced that for most expectant mothers with a prior C-section, VBAC is a very good choice indeed.

- Anita

Seth’s 5 Month Birthday

Sat, 3 Apr 2010 09:25:04 -0500

Seth has continued packing on the pounds and showing off new skills, but he has had a horrible cough for two weeks. It gets especially bad at night so we thought it might be croup. His doctor on Friday pretty much ruled that out, saying that he sounds a lot worse on the outside than he does on the inside with her stethoscope. It’s likely just a persistent viral illness...that might linger for up to another two weeks! She cleared him to return to day care, provided that the test results expected back on Monday are clear. He is now 16.25 pounds, up over a pound since his trip to Boston last month -- his initial weigh-in on Friday was actually even heavier, but that was with a soaking wet cloth diaper, so Scot re-weighed him.

These days Seth:
• has lost the ability to self-calm at night, probably thanks to all the coughing. He now reliably needs attention and usually a feeding around 3am. Over the last two weeks that’s often been accompanied by a coughing fit.
• loves a good saline nasal rinse. Yes, really.
• still smiles easily, although with the ongoing cold symptoms, has been looking a bit worn out, and doesn’t laugh much. This is in contrast to Grant who never seemed to look sick, even when he clearly was.
• easily rolls from back to tummy when playing, and often at night as well.
• loves to watch us all eat -- especially Grant. Seth is probably going to start on “solid” food (rice cereal) as soon as he recovers from his cold.
• has 7 oz. feedings twice a day when Mommy is at work.
• is starting to establish a schedule. It still changes some from day to day but goes roughly like this: 6am, wake up hungry and eat breakfast. 6:30-8:30am, nap. 8:30am, snack (sometimes). 9-10am, play. 10am-noon, nap. Noon: lunch. 1-4pm: nap. 4-5pm: play. 5pm: dinner. 5:30-8:30pm: play. 8:30pm: bedtime snack. 9pm-3am: sleep. 3am: midnight snack. 3:30am-6am: sleep.
• has moved his crib and bathtub into Grant’s room. We aim for twice a week for baths for Seth, but have not established a schedule yet like we have for Grant (who gets a bath every other day, with shampoo on the weekend day).
• loves to grab his toes when they are available.
• will gnaw on his fist or lip if he’s starting to get hungry.
• loves to stand on his feet, holding onto a person or a piece of furniture. In this way he is very much like Grant at the same age. He does not crawl.
• can hold himself sitting up for a minute if you put him in a sitting position and help him catch his balance.
• grabs for toys (and pages of books you are reading, and so on), and sometimes cries if you take away a favorite.
• has amazing timing for when Mommy is about to eat dinner. He always seems to save up his dinnertime hunger attack for the moment she sits down.
• can spin himself around on his tummy easily, on any surface -- wood floors and rugs and his crib included.
• has grown out of the bassinet attachment for his Pack-n-Play.

As for Grant, we have been very impressed by his maturity and politeness lately. For example, he always thanks whoever made dinner, very clearly and without prompting, as soon as he takes a bite. “Mmmmm!” he says, loudly. Then, “Thank you for making this bake bazitti, Mommy and Daddy!” (He really latched on to the subtle “d” sound in “baked ziti” for some reason.) He also wrote his own name for the first time the other day.

For Easter, all the kids in the garden court got together to dye eggs and we’ll have a hunt tomorrow morning. Should be a blast!

-Scot & Anita