by Elizabeth Kirts, MPH, ICCE, IBCLC, RLC

In my role as the manager of the perinatal education department, and the lactation staff, I have the opportunity to have input and impact from pregnancy through postpartum. I am the Baby Friendly Coordinator at my hospital and I am on the executive committee for our local Postpartum Support International Chapter. Being in both roles, I hear both “sides;” on the one hand I hear about how breastfeeding is protective against postpartum depression and I hear how breastfeeding can exacerbate the symptoms. On one occasion, I was on a national call about a postpartum depression program where they would not even talk about breastfeeding because that group had such a stigma against breastfeeding when any perinatal mood disorders were present. As with any topic, I try to find the balance and work with the individual family. Breastfeeding can work and can be therapeutic while dealing with mood and anxiety disorders. It’s a matter of delving into the family dynamics and figuring out what is going to work; what is best for the situation. Breast is Best is the slogan that came out many years ago in response to low breastfeeding rates, subversive/subliminal marketing, and unethical practices in third world countries. It was and is critical to keep that message in the forefront. Breastfeeding is biologically normal, decreases morbidity and mortality, is ecologically better, and economically better. With that, people frequently talk about how this message encourages guilt in new moms. Keeping the balance that breastfeeding is normal and healthy along with supporting families when it isn’t going to work needs to be the goal. Going back to biologically normal, breastfeeding is what the body and the brain plan to have happen after the birth of a baby. The hormones are set up to move from birth to breastfeeding to weaning and a disruption in that cycle causes a disruption to the hormones. For baby, breastfeeding is biologically normal and the way that he or she receives appropriate nutrition, comfort, and it supports development. If for any reason breastfeeding isn’t going well, or temporarily can’t happen, we need to remember the Golden Rule of Lactation and that is “Feed the Baby, Maintain the Lactation.” If we can keep the lactation moving forward through hand expression and/or pumping then there are options to getting baby to breast. For some, pumping and bottle feeding may be the long term solution. Perinatal mood and anxiety disorders are on the rise (or better reported). Past statistics found that 10-20% of women experienced postpartum depression. Currently, we are seeing statistics of 15-25%. Additionally there is better categorization and depression, OCD, anxiety, and other mood disorders are being described. In the past the way to treat depression was typically to tell mom to wean the baby and get some sleep. The hormonal relationship and the benefits to both mom and baby were dismissed. Women were told that medication wasn’t safe with breastfeeding so it was better to quit and get treated. This approach was a huge disservice to mom’s, babies, and families. Many women reported that breastfeeding was the only thing going well and by weaning they lost the last thing they had hoped for in their new role. Luckily over time, the thinking began to shift. The medical community began to look at the risks and effects of medication during lactation. Complimentary approaches were explored to enhance other treatments. Support for our mom’s began to improve. There is still need to keep looking at best practice and we must remember that breastfeeding/lactation is both an art and a science. The science behind lactation shows that there is an association between pregnancy, high risk pregnancy, past trauma, and other risks on the HPA Axis. Kathleen Kendall Tackett has multiple webinars where she eloquently describes this relationship. There is a positive feedback loop between increased inflammation, increased risk of pre-term birth, and then an increased amount of stress. This cycle which leads to more inflammation often times results in depression and anxiety. However, breastfeeding is anti-inflammatory!  It down-regulates the stress response. Cortisol, ACTH, epinephrine and norepinephrine are decreased. Depression and other bad health responses are decreased. Breastfeeding also increases amount and quality of sleep. This is something that can be hard to convince people is true. The even harder part to help people understand is that exclusive breastfeeding has the biggest impact on sleep amount and quality. The thought that using supplementation as a strategy to help mom sleep and alleviate her PMAD symptoms, can actually have an impact on prolactin production and secretion which in term compromises deep restorative sleep. With all this information, we still find that moms with mood and anxiety disorders are more likely to supplement, wean, and/or report negative emotions around breastfeeding. So where do we go from here? This is where the challenge comes in and we need to approach this from an individualized perspective. I used to frequently hear that if a mom was pumping she needed to do it every two to three hours. But we know that a baby doesn’t eat on that schedule. They eat 8-12 times / 24 hours. We now modify this advice and tell moms to get a bigger chunk of sleep at night and pump more frequently during the day. This has worked so much better for mom’s whose babies are in an intensive care/separation situation. Partner/family support is critical. We need to help moms to not only have support but to accept help. In a society where we teach women that anything is possible and that we can do it all, we forget to teach them (us) that we can also ask for and accept help and support. There is no “one size fits all” solution for breastfeeding and PMAD but we now have an increase in support, research, recognition, and understanding. Moving forward, it is important that we don’t lose this momentum. That we continue to look at ways to build a circle of care for new families and be protective of this critical time in their life.

References

Borra C, Iacovou M, Sevilla A. New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions. Matern Child Health J. 2014 Aug 21 Dennis CL & McQueen K  2009 The Relationship Between Infant-Feeding Outcomes and Pospartum Depression: A Qualitative Systematic Review Doan, T., Gardiner, A., Gay, C., & Lee, K.A. 2007 Breastfeeding Increases Sleep Duration of New Parents.  Journal of Perinatal and Neonatal Nursing 21 (3) 847-855 Heise, A M 2019 DMER: Before the Letdown  Webinar purchased through Praeclarus Press Kendall-Tackett, K. A. Cong, Z., Hale, T. 2013 Depression, Sleep Quality, and Maternal Well-Being in Postpartum Women with a History of Sexual Assault: A Comparison of Breastfeeding, mixed-Feeding, and Formula-Feeding Mothers Breastfeeding Medicine Vol 8 No 1 Kendall-Tackett, K. , Cong Z, Hale, T 2011 The Effect of Feeding Method on Sleep Duration, Maternal Well-being, and Postpartum Depression Clinical Lactation Vol 2-2, 22-26 Kendall-Tackett, K. A. (2010). Breastfeeding beats the blues. Mothering, Sept/Oct, 60-69. Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2010). Mother-infant sleep locations and nighttime feeding behavior: U.S. data from the Survey of Mothers’ Sleep and Fatigue. Clinical Lactation, 1(1), 27-30. Kendall Tackett, K. A. 2007 A New Paradigm for Depression in New Mothers: The Central Role of Inflammation and How Breastfeeding and Anti-inflammatory Treatments Protect Maternal Mental Health International Breastfeeding Journal 2:6 La Leche League International 2019 Why Breastfeeding is Good for Mothers’ Mental Health www.llli.org/why-breastfeeding-is-good-for-mothers-mental-health/ accessed 4/2019