Monday, January 30, 2012

Feeding your infant: equipment costs

As someone who works a significant amount of time in labor and delivery, I see multiple mothers a day who struggle with the question of breastfeeding versus formula feeding. There are many blogs and articles dedicated to this debate. I intend on focusing on the price of your feeding choice - both in equipment and in opportunity costs.

Today's article is to discuss the actual cost of the equipment most people need to formula or breast feed and about how much time it will take up.  Rather than just repeat various prices, I'll discuss a few hypothetical scenarios and use a few assumptions in my calculations. 

Assumption #1: For simplicity's sake, I will assume it take 20 minutes to bottle feed or breast feed a baby and that it takes an additional 20 minutes pump then bottle feed your child breastmilk. I'll assume you feed the baby 7 times a day.

Assumption #2: Some cost are acknowledged but are considered 0 sum. The additional food you eat to breast feed is negligible (around 500 calories). Equally, I assume you purchase bottles for your infant regardless of your formula or breast milk use.  The additional water and electricity use for the additional infant differences is also negligible.

Assumption #3: Because you are reading this blog about frugality, you are buying the Walmart generic  economy size formula 36 ounces which makes 264 ounces per can for 18 dollars.  That is equal to about $0.07 per ounce.

Assumption #4: If you are going to freeze milk to store for later use, you already own a freezer, and its electricity use is stable. While you can use numerous different containers to store milk, I'll base my calculations on using 6 ounce breastmilk storage bags which are $10 for 50 bags. (Other containers are less reliable and less than ideal due to the relative amounts you need to thaw at a time.) Thus one set of full breastmilk bags will be 300 ounces at $0.03 per ounce.

Assumption #5: You deliver in a hospital and they supply you with a hand pump and a few bottles and nipples for free as part of your hospital stay.  All other supplies will be included in additional calculations. Disposable breast pads are $10 for 60, and we'll assume you use one a day. I know there are more reusable options available, but they are more expensive in the short term and don't always suit everyone.

Assumption #6: Feeding numbers. As an estimate, assume your child takes 42 ounces a day for the first 12 months of life. This is to average out the relative growth of your child which will vary with each child and their age and will equally affect both formula and breastfeeding . (If you are wondering, I assumed a 14 lb child drinking 6 ounces 7 times a day. I used the weight gain/fluid calculators hospitals use for growth).

Scenario #1: breastfeeding full time for 6 months, formula for 6 months
This mom is meeting the goal of 6 months of exclusive breastfeeding
6 month supply of disposable breastpads: $30
3 nursing bras $17 x 3 = $51
Formula needed for 6 months: $530 dollars
(42 ounce x 6 months x 30 days = 7560 ounces)
Hours spent feeding baby for 1 year=840 hours
    Total: $530 for 840 hours

Scenario #2: breastfeeding full time for 12 months
This mom is the 'ideal'
Hand pump provided by hospital: free
12 month supply of disposable breast pads: $60
3 nursing bras $17 x 3 = $51
Hours spent feeding baby for 1 year = 840 hours
    Total: $111 for 840 hours

Scenario #3: breastfeeding full time for 6 months, returning to work at 2 months
This is your typical mom trying to meet the goal and returning to work
6 month supply of disposable breast pads: $30
3 nursing bras $17 x 3 = $51
Medela twin breast pump with AC adaptor: $250
Formula needed for 6 months: $530 dollars
Hours spent feeding the baby for 1 year (includes pump sessons):920 hours
    Total: $861 for 920 hours

Scenario #4: breastfeeding via pump for 6 months, storing 2 additional months

This is the mom whose baby never latches but is determined to do it
6 month supply of disposable breast pads: $30
3 nursing bras $17 x 3 = $51
Medela twin breast pump with AC adaptor: $250
Formula needed for 4 months: $353
Storage bags 420 bags for 2520 oz: $84
Hours spent feeding baby for 1 year (includes pump sessions): 1120 hours
    Total: $768 for 1120 hours

Scenario #5: formula feeding 12 months
This is the mom who never breastfeeds
Formula needed for 12 months: $1030
Hours spent feeding baby for 1 year: 840 hours
    Total: $1030 for 840 hours

Scenario #6: breastfeeding for 8 months with pumping 7 times a week for 5 oz/day, which would use 240 bags, and buying the most expensive products possible. 
This is the mom that spends top dollar for everything and can really spend money. (I used the Babies R Us website for pricing information)
5 high end nursing bras 5 x $40:
Medela freestyle double pump: $370
Medela bottle system/feeding set: $30
Nursing pads for 8 months: $40
Balboa nursing pillow: $46
Medela quick clean bags 240 uses 5 x $15:
Pump and go bags (50 bags) 5 x $15: $75
Organic nursing cover by BeBe: $50
Similac organic formula x 4 months (at $28/170 oz): $831
Hours spent feeding baby for 1 year (includes pumping): 920 hours
    Total:  $1392 for 920 hours

I did not include these other costs, but I wanted to mention the other items I located on Babies R Us website: Milk screen testing ($25 for 20 tests) to screen your milk in case you have been drinking, UV sensitive nursing bracelet ($20) that you can wear instead of a watch to keep track of your nursing (not sure why anyone needs that), and a bottle warmer/cooler/sterilizer ranging $70-$130.  There were so many more random products out there like 'night time formula.'

(In case you were wondering, despite claims, almost all formulas have almost the same added ingredients and vitamin content. The minor differences are all marketing gimmicks. This includes newborn versus 'step 1' and so forth. 'Sensitive/gentalease/early shield/immune shield' are not proven to bear out scientifically either. Soy formula should never be fed to premature babies and babies should not be on specialty formulas like Alimentum unless it has been prescribed by your doctor. I promise to discuss formula in another post. )

As you can see, I tried to hit the low, middle, and extremes of breastfeeding. Mothers end up in different scenarios and their expenses reflect those situations. You cannot just assume that breastfeeding is 'cheaper' because if you may need a pump, which includes accessories and time hassle, it may not be - or your choices will make it so. There are ways to decrease this cost - renting a hospital pump, buying/borrowing a used pump, using the same pump for multiple children, and so forth.

Food for the thought . . .

Next post: Why don't you cut 'x' out of your budget?

Sunday, January 22, 2012

Debt Repayment Part 2: Loan expenses

Now that I have established how we live on my current salary, let's talk about what our repayment plan is currently. In short - use all of Hubby JD's salary to pay things off.

Anticipated monthly repayment for 260K of student loans
Hubby JD salary $4700 in January
Hubby JD mandatory loan payment $650 (started October 2011)
Jane MD mandatory loan payment $1050 (starts January 2012)
Emergency fund/condo fund $1300
Extra loan payment $1700

Repayments already complete as of January 2012
Starting loan total $260K
-$12K on 8.5% loan from emergency fund in October
-$8K of extra savings from Jane MD's job (includes October mandatory payment)
- $1.3K total for November and December mandatory payment
Total loan remaining at start of January 2012 $238.5K

Wait! Where did you get a 12K emergency fund?
We had been building an emergency fund in case we needed to cover a 20% down payment on our out-of-state condo, which would be in the 20-30K range. Our condo monthly payment is mostly covered by a renter, but our first time homebuyer loan is not for rental/income properties and gets reassessed for renewal yearly. While Hubby JD took care of Child#1 before his job started, Jane MD's extra salary and all extra student loan money went into the emergency fund - pulling it from $11K to $22K over 5 months.

Fortunately, we got the extension,and then had to decide what to do with $22K.  Investing was not a short term solution; CDs have lower interest rates than our student loans. Voluntarily paying off 20% on the condo was not worth while with the much higher student loan interest rates. We went ahead and paid off the highest interest loan ASAP in October and then made extra loan payments to hit the other higher interest loans.

That worked fine, and our emergency fund is down to around 10K again - which would be around 3 months of money if both of us lost our jobs. As we will get reassessed again next year, we need to build back up to the previous emergency fund level. If we get another extension, we'll put another lump sum into the highest remaining loan. We've signed up for one of the autosaving plans from our bank where they move an extra dollar per transaction into a savings account - now up to $1.5K. We also will continue to put that extra $500-1000 per month to the student loan with the left-overs from JaneMD's salary.
Accoring to the debt repayment calculator at "" we can expect to pay off our loans in about 6 years.

Next up: Breastfeeding Economics: Part 1

Saturday, January 14, 2012

Pros and cons of probiotics and prebiotics

"I'm so confused about prebiotics and probiotics. Am I bad if I just buy my kid yogurt?"

I can see why that is confusing. In the past 5 years or so, the idea of probiotics and prebiotics has become a hot topic. They are listed on so many items, formula, honey, vegetables, herbal supplements, nature food stores, breastmilk. What exactly are they supposed to do?  How do they work? Should I be buying more of them?
We'll start with defining the terms
Probiotic: this is a type of bacteria or yeast that, in theory, gives some type of benefit to the person who consumes it. The theoretical benefits include recovery of intestinal bacteria after antibiotics or diarrheal illness, prevention of allergies, improvement of eczema, preventing yeast infections, curing urinary tract infections, decreasing flares of Crohns disease or ulcerative colitis, preventing cancer, and MANY other claims. These microrganisms are specifically grown as a certain strains (genetically identical and grown in the same manner each time) and there are multiple different strains available for purchase. Common strains are called things like "Lactobacillus acidophilus XXX###" to differentiate it from "Lactobacillus acidophilus YYY###." Any food item that has live bacteria/yeast cultures in it contains probiotics - specifically many yogurts, buttermilk, certain pickled vegetables. They can also be purchased in capsule form or multi-strain combinations.

There is also an active fraudulant internet market of fake and/or unsafe products for the naive.

Prebiotic: any substance that can encourage the growth of the 'healthy' probiotics when consumed.  That seems like a very broad area also, but in most cases, science is referring to a sugar-fiber combination that humans will have difficulty truly digesting, but could encourage growth of 'healthy' bacteria. Generally, the issue that is important is how much of this sugar-fiber each item contains. Almost any food can be claimed to have it, but there is not any real regulation to know which foods have alot of it. This is the list of the top ten foods starting from the top: raw chicory root (64.6%), raw Jerusalem artichoke, raw dandelion greens, raw garlic, raw leek, raw onions, cooked onion, raw asparagus, raw wheat bran, and cooked whole wheat flour (4.8%). The next highest food with prebiotic is raw banana at 1%.

Please explain the theory behind them.
The theory is that some type of illness occurs that alters the appropriate combination of microorganisms in the intestine. If you eat probiotics/prebiotics, you will be helping return to the appropriate balance with these healthy microorganisms. That is why diarrheal/stomach illnesses are such big targets and it seems like it would make sense.

But, unfortunately, the science is not on the side for this one. First of all, the stomach has a very low pH. It is actually around 2, which nears the bone dissolving strength of hydrochloric acid. Most bacteria cannot survive at this pH so probiotics probably do not reach the intestine where they are supposed to work. Also, your gut has a huge number of different types of microorganisms in it, so you won't be able to reach the 'normal' composition of bacteria anyway. For example, after antibiotics, it only takes a few days for a normal person to reachieve their previous gut microorganisms.

How are people testing the health claims?
The ideal way to study this type of thing is to do a double blind randomized placebo controlled study. You have 150 9 year old kids with diarrhea.  You give 75 kids Probiotic#1 and the other 75 kids PretendProbiotic#1.  You record how fast each group recovers from diarrhea when they return to your office in 1 week.  To keep your results bias free, you don't know if you gave the child the real one or pretend one and neither does the parent. Instead, someone else who never sees the kid knows who got what and that person collects the information. That is the strongest and best way to prove something works or doesn't. It prevents expectations and biases from affecting the results.

Sadly, most of the time something more like this happens. Company #1 offers free probiotic to families of healthy children and tells the family all about the theory of fixing diarrhea/stomach problems.  The company contacts the family three months later and asks the parents how many times they had diarrhea in the family.  The company compares the reported amount of diarrhea by the family to the three month average of diarrhea in households in the United States.  If it is lower, they advertise their probiotic 'prevents diarrhea.' This is considered very biased data, altered by multiple factors, and scientifically unsound.

So should I be buying them or not?
That entirely depends on what you believe is going to happen when you use them. The actual health benefits proven in head to head, randomized placebo controlled studies for probiotics have been VERY modest, if any. There may be some small use in diarrhea or post antibiotic diarrhea. Other avenues are being explored, but they are definitely not recommended for immunocompromised children, chronicly debilitated children, or children with indwelling medical devices as the microorganisms have caused serious infections.

Prebiotics also have no proven benefit.  They are being studied particularly for preventing allergies and eczema, but nothing has been proven to be effective yet. Besides, many foods falsly claim that they contain large amounts of prebiotics, when, as discussed above, they do not.  Also the European Food Safety Authority has rejected almost all pre/probiotic health claims as not enough evidence to be proven as of November 2011.

There is also no recommended dose at this time. Each product often contains a different strain of microorganism at a different amount because, technically, these are not medications. There are not strict controls over their contents for that reason. Most companies have their own 'patented' strain they use and market, often as 'better than so and so's product.'

At this point, there is not proof that probiotics will make your normal child more healthy. We have very little evidence they do anything or reach their targeted site easily. Will you harm your child by using them? In most cases, no, particularly if you buy them in the United States in the form of yogurt, and you have no other medical issues except possibly a recent stomach bug that is getting better.

If you do have a child with chronic gastrointestinal issues like Crohns, ulcerative collitis, cancer associated colitis, you should be discussing your individual case with your GI or Hematology/Oncology Specialist.

What will it cost?
A single container of yogurt, made with live microorganism cultures, cost somewhere between $0.25 to $1.25 if you get it with mix ins. There is no proven benefit to buy any that claims to have 'more' probiotics than others.

You can buy 30 'Culturelle' probiotic tablets at Walmart for $16-19, which claim to be lactose free, contain 10 billion cells and have 'more probiotics than yogurt.' 10 billion cells is NOTHING from the relative standpoint of number of cells you are colonized, FYI, so that doesn't mean much. The package also claims to boost the immune system and add healthy bacteria to your intestines.  Each tablet would cost somewhere between $0.53 to $0.63 and contains no calories or protein.

Keep your expectations low that probiotics may help a little with slowing diarrhea after antibiotics or a stomach bug. The best buy is probably yogurt, but buying the more expensive capsules may be an option if your child has lactose toleration issues. Most food does not contain enough prebiotics except those listed above which will prevent you from buying something will a false claim.

Definitely do not buy anything that has bigger claims than we've discussed or you can purchase from a 'Secret European Lab Doctors are trying to hide from you' that you found on google or in your spam filter.

Thursday, January 12, 2012

Debt Repayment Part 1: Living expenses

My husband and I have an electronic bank account that I stare at obsessively. I desperately hope that the numbers will some how add up differently, and I'll see the light at the end of the tunnel sooner.  We definitely do not want to wait 30 years to pay off our loans and decided to do something more drastic. Our goal is to live on one salary as long as it takes to pay off our loans.

Household salary after taxes and benefits:
Jane MD 5,100
Husband JD 4,700

Fixed monthly expenses

Rent $1,000
Daycare $670-770
Cell Phone plan $125
Internet $35
Insurance car/home $125
Car lease $190
House cleaning $100
Gym $88
Total $2333-2433

Variable monthly expenses, estimated
Utilities $160
Gasoline $150
Groceries/ toiletries $800-1000
Personal expenses $500
Charity/religious $400
Onetime expenses $300
Total $2310-2510

Total monthly budgeted expenses $4643-4943

There are a few questions you are probably wondering about our listed expenses. We rent an 850 sq foot apartment, our day care is $150-175 a week depending on number of days attended. Our cell phone plan is unlimited and Hubby JD's work reimburses it for $60 a month. We have the lowest grade internet possible. The gym has free babysitting for up to two hours any day we go. Our cleaning service comes every other week and cleans the house except the kitchen for $50 just to keep the peace. We lease a car because our family keeps growing, and we will need to trade up.

Utilities vary based on the month since we pay electric and gas, worse in the hotter summer months.  We have two cars that get 25-40 mpg, and our total driving time with daycare is 100 minutes a day.  We fill up about 4 times a month. Our grocery bill is primarily at Walmart where we buy almost everything, including dog food, diapers, tolietries. We try to eat as cheaply and healthily as possible, but Hubby JD has the metabolism of a 15 year old boy and consumes something like 3,000-4,000 calories a day. (Yet he still has a six pack and weights 173 lbs, so unfair)

Personal expenses includes clothing, babysitting, haircuts, dry cleaning, medical/vet bills, and unrelated car bills.  We recognize that wear and tear is going to occur no matter what we do and have budgeted accordingly. Similarly, our onetime expenses are used to plan for the presents, special occasions, holiday gifts, big purchases like glasses or procedures. We have a monthly dues to our synagogue and since we both have jobs, we feel obligated to give every charity/fundraiser that solicits us at least a $10 token donation. Invariably some elementary school student wants to sell us a raffle ticket or buy cookies for their bake sale.  This category appears particularly large at this time because of our end of the year donations. 

Some of you will notice that we are missing cable and have no restaurant or entertainment budget. We eat out so rarely we spend less than $30 a month. We do not use credit cards and the only card burning a hole in my wallet is my library card. There is no home phone. Hubby JD contributes to an FSA which covers some medical expenses, but not everything. We only pay for babysitting because Hubby JD donates his time teaching a free martial arts class.  Our date night involves geeking out on the couch after the baby is asleep watching Star Trek TNG over microwave popcorn.

The key to making this work is budgeting for those little expenses that happen every month despite your best frugal efforts. We did holiday cards and Child#1 portraits in December as part of personal expenses. We used a free portrait sitting coupon, bought some electronic copies for much cheaper than a package price, and went on Shutterfly during their holiday sale for all our cards and larger portraits with free shipping. The month before we needed new car tires and had to pay for it.

At the end of the month, we are often 500-1000 below available budget.  What happens to that money will be covered in a future post.

Next up a medical post: Prebiotic, probiotic, or yogurt.

Tuesday, January 10, 2012

Taking your infant home with JaneMD - equipment

We were having our first child and we decided to register at the local Babies R Us. I had never personally entered Babies R Us because when all of my friends/family had babies, I typically did it all online.  My husband and I were greeted by an overly chipper saleswoman, given a laser gun, and a list of 'essentials.'

The list of essentials was over 300 items!  It was in four columns and many of the items listed on it were completely unnecessary and, in some cases, completely unsafe and associated with SIDS. The list included sleep positioners and sheet set with bumpers. They also listed bassinet, armoire, changing table, baby dresser, crib, toddler bed, rocking chair, carseat, travel system, snap and go, jogging stroller, umbrella stroller, swing, baby bath tub, bouncy chair, high chair, portable high chair, bumbo, wipe warmer, bottle warmer . . . I let my husband handle the laser gun, took a pen, and crossed out almost EVERYTHING on the list.

Listen carefully to this: Your baby does not care about any of that. Your new infant cares about three things. 1) eating 2) sleeping 3) being clean. Your job as a parent is to provide those 3 things in a safe manner for at least the first month of his/her life. 

It's not just Babies R Us that embraces this overly consumer driven birth of your child. Open any baby magazine and every page is full of ads.  Each ad exists to make you feel like a bad parent if you don't chose a nursery theme and buy each matching piece of bedding/toy/furniture that is shown in the picture. 3/4 of what they advertise is not even age appropriate for your first month. Your house will be overcrowded with that stuff while waiting to use it. Worse, when your child is old enough to show some preferences, it is possible he/she won't like certain objects that you so lovingly put together, let alone use three different baby swings.

Here is what you actually need to survive your first two weeks.
1) Diapers and wipes: newborn or size 1 depending on your baby's size. Knock yourself out if you want organic/cloth diapers. No data exists for the significant advantage of either. The hospital often sends you home with a few days supply.  You'll be able to tell if your energy level allows you to try to save money by washing cloth diapers in a few days.

2) Carseat: you must have this.  Make sure it is at an appropriate weight for your child. Get it installed by the fire department ahead of time to make sure it is at the correct angle and most ideal placement in your vehicle. Used carseats are not okay except in very defined circumstances (will discuss in future post) If you buy it at reputable store, the expensive 'safety' features are not that important. How it works in your stroller system is important though.

3) Bassinet/cosleeper:  It is recommended that the baby sleep in the room with you for at least 4 months.  He/she is going to need to feed every few hours so you might as well be close. Co-sleeper refers to the bassinet type thing you can strap/connect to the bed, not actually having the child sleep in bed with you. (BAD idea, will discuss bed safety in future post) A pack-n-play works great too.

4) Snap and go stroller: this is the cheapest stroller you can buy as your infant carseat snaps into it. No need for a jogger right now. You shouldn't be going far from home till the baby is around 6 weeks. His/her head control is pretty bad so nothing too high energy for travel. Check online to see which ones are interchangable. (My graco carseat fit just fine with my baby-trend snap and go)

5) Newborn/0-3 month clothes (prewashed): Your overjoyed family and friends have already purchased these for you. You probably won't need more than 2-3 outfits per day to deal with spitting up/pooping. Avoid overly complicated outfits with bells and whistles and remember your infant needs to be kept a 'one layer' warmer than you.  In other words, long sleeved rompers with covered feet are in, that cute newborn bikini you saw at The Children's Place is out.

6) Swaddle blanket and sheets: You only need 2 or 3 blankets to use as your swaddle for the baby to sleep in its back. Sleep sacks are fine too. Many bassinets/pack-n-plays don't come with sheets. Buy whichever cheap version is closest. Say no to the bumper, the large quilt, the handknitted personalized afgan blanket that looked so cute. Just keep the only thing in the crib to be the swaddled baby and NOTHING else. No cute plush stuffed animal.

7) Formula or breast feeding supplies with bottle brush: You will have to feed the baby, but you don't need anything more than 4 ounce size.  Most infants are taking 1-2 ounces at most. If your breastfeeding and are thinking about pumping, rent a hospital pump to see if it is for you. Don't get stuck with a $350 pump that you never use again.  Rentals are $40-70 a month.

8) Diaper bag with diaper pad: This will allow you to change your baby on any flat surface without feeling too gross. We changed our baby on an old dresser, never bought a changing table or a different pad. As long as the dirty tush is on the pad, it really is fine.

9) Vaseline: for the baby bottom, often given to you by the hospital. No need to buy eight different butt creams. If you want to purchase something with a zinc oxide base, go ahead.

Notice a few things that are NOT on the list. Baby monitor - how far away do you anticipate being in these first two weeks?  Bathtub/clothes - can't wash till cord falls off and a towel is a towel no matter what. Baby lotion - totally unnecessary and you are courting a skin reaction. Dry skin is normal. Any type of chair/bumbo/feeding apparatus - your child is too young for this. Pop your car seat out of the car if you want.

Really doctor? Yep. We bought a $30 bassinet from Walmart and he slept in it for 6 months in our room. Then he moved into a pack-n-play in our second bedroom that is essentially a walk-in closet. His changing table/dresser is in our office. He had breastmilk for 7.5 months, met all his milestones, and his mother fanatically followed the American Academy of Pediatrics recommendations for everything.

So when you go to register, ask for alot of gift cards and a few essential items. Don't get trapped in buying everything all at once and keep it age/stage appropriate as you figure out how you are going to survive some severe sleep deprivation.

Next up: Debt repayment budget and plan.

Starting out 400K in debt

Welcome to Expensive Medical Education, Cheap Life.  We'll be talking about frugality and pediatrics in this blog and how the two meet.  First however, I need to be upfront about my own load of crushing debt.

Ummm, your profile says you are a doctor married to a lawyer.  What do you have to worry about?

Excellent question.  This is a great time to let you in on a little secret.  We don't make the money you imagine, and our debt is easily greater than our combined salaries.  Here it is, rounded for simplicity.

Jane's Medical School Debt: $175,000 (150,000 principal + 25,000 interest)
Husband's Law School Debt: $95,000 (90,000 principal + 5,000 interest)
Out of state condo: $130,000 (bought 4 years ago in housing boom at 0% down)
Total debt: $400,000

So you may be wondering how we ended up with that combination? I was able to get through undergrad on scholarships and a summer job without debt. No such scholarships existed for medical school, so I had to take on loans. These loans went into deferment/forebearance during my residency.  Residency required 80 hours a week for $41-45K a year. At my current repayment rate, it is expected that I will pay them over 30 years and 250,000 in interest. 

My husband worked in insurance, had a decent salary and decided after putting in for his 401k that he had enough money for a condo. He went to a public college where his mom taught and had free tuition, graduating debt free. He was single, employed, and imagined living in one place for at least 5-10 years. So in 2007 at the height of the boom, he bought a condo with 0% down and a first time homebuyer loan. Then he met a medical student, fell for her, decided to go to law school, and moved out of state. She paid the couple's living expenses and he took out loans with higher interest rates than hers. At his projected repayment rate, it will take 30 years and 140,000 in interest.

That total 790,000 is the price of a VERY nice house or six children's college education at a four year university. We haven't really touched the principal on the condo yet and we may have to come up with 20 percent of its current value if the government doesn't grant us extensions since we don't make the residency requirement to continue the original loan.

Here was the situation the day before my husband graduated from law school.  My salary was 3,300 a month after taxes for a family of 3 and we owed 400,000.

So yes, we had plenty to worry about.