Breastfeeding and Postnatal Depression

What is Postnatal Depression?

Postnatal depression, or PND, is a depression that starts within the first 12 months after giving birth. In the UK it is estimated that 1 in 10 women suffers from PND at some point during the first 12 months of their baby’s life (1). The symptoms of PND include low mood, lack of pleasure and interest in doing things, withdrawal from social activities, difficulties falling asleep or sleeping too much, lack of energy, problems concentrating, and frightening thoughts such as of hurting yourself or your baby (1). A woman with PND may experience some or all of these symptoms.

How does PND impact on breastfeeding?

It is important to remember that suffering from PND does not mean you are a bad mother or that you do not love your baby. However, sometimes PND can make it difficult for a mother to bond with her new baby. This is no one’s fault, and it is not surprising if we consider the symptoms of PND and the amount of energy and effort it takes to look after a newborn. Coping with PND symptoms and caring for a new baby can be very hard. Some women may also struggle with breastfeeding during PND. Because successful breastfeeding in the early days depends on things such as being close to your baby and nursing often, a woman who is too low in mood or too tired to spend time with her baby might find it difficult to keep breastfeeding going. This does not have to be the case for all mothers with PND.

Breastfeeding protects against PND

The relationship between PND and breastfeeding is very complex. Whilst PND can make it difficult to breastfeed sometimes, research suggests that breastfeeding can actually positively impact both the outcome and risk of developing PND. Wo men who breastfeed are at much lower risk of developing PND in the first place than women who do not breastfeed (2). For those women with PND, breastfeeding has been linked to fewer depressive symptoms (3, 4). A higher frequency of breastfeeding at three months has also been linked to a greater decline in depressive symptoms (5).

“I had postnatal depression with my daughter. Then due to losing a number of babies in pregnancy, I had antenatal depression with my son which developed into postnatal depression after he was born. I really struggled to cope. Everything seemed such a struggle and my friends seemed to melt away so I felt very alone. I felt like there was a glass barrier between me and the world. But breastfeeding meant there was a chink in that barrier. My baby straddled both worlds and I was able to connect with him through it.”
Emma

Lack of sleep is associated with a higher risk of developing PND

The relationship between PND and sleep quality is important to understand since undisturbed sleep can play a huge role in recovering from PND. Sometimes mothers with PND are advised to wean off the breast in order to achieve more sleep. Such advice can be worrying if you are struggling with PND but want to carry on breastfeeding. What evidence is this advice based on? There is research suggesting that mothers who breastfeed are woken up more frequently at night (6). Total fewer hours of sleep are also linked to a higher risk of PND (7).

Breastfeeding mothers get more sleep overall

It can be easy to assume that discontinuing breastfeeding would make it more likely to recover from PND by improving sleep. Society often considers weaning off the breast at night the main way for exhausted mothers to get more sleep. This advice can be distressing if you are feeling desperate for sleep, but still want to breastfeed. Evidence suggests that night weaning is not necessarily the solution. Breastfeeding your child doesn’t mean you will get less sleep than if you had chosen to bottle feed. Research in this area actually points towards breastfeeding mothers spending less time awake overall, as compared to mothers who don’t breastfeed (7, 8). This means breastfeeding mothers may overall get more sleep, in particular those who exclusively breastfeed (8). Not exclusively breastfeeding has actually been linked to an increased risk of developing PND (9). Research has even found that night weaning can prolong PND in those affected (10).

Night weaning might not mean more sleep

To add to this, night weaning doesn’t actually mean your baby will sleep more or better. Breastfeeding can be an amazing way to help your baby go back to sleep. Since babies wake up for all sorts of reasons and not only because they are hungry for milk, breastfeeding at night can serve multiple purposes. Just like during the day, it can provide nutrition to a thirsty or hungry baby, but it can also give the comfort and love your baby needs to go back to sleep. Some women find that night weaning before the baby is ready doesn’t mean fewer awakenings. In fact, night weaning can actually cause babies to wake up more frequently. After night weaning you may no longer possess the tool to get your baby back to sleep easily (11). Finally, night weaning too early may affect a woman’s milk supply and have serious effects on breastfeeding.

More sleep without night weaning

Where do these research findings leave you if you are struggling with PND and exhaustion? Sleep can play an important role in improving PND symptoms and if you feel that you need it, there are some creative ways of getting more sleep without stopping breastfeeding. This means thinking about alternative ways to catch up on sleep. You may want to try napping with your baby (whenever possible), co-sleeping (using safe practice guidelines), and letting a trusted friend or family member take your baby for a short walk during the day so you can get some undisturbed rest. Offering the breast more frequently during the day may result in your baby filling up on milk during the daytime and minimising night feeds, although all babies are different, so there are no guarantees here. You could also try keeping your baby close to you in the evening to encourage cluster feeding before bedtime.

“The bottom of the PND hole is pretty lonely. At 3am, alone with my son for the fourth time that night I had only the sounds of the milk float for company. My eyes burned from tiredness and crying myself back to sleep. My son was unaware of it all. He was close to his mother, warming his tummy with her milk and so peaceful. I learned to function on 4hrs sleep and on the good days I appreciated what I was doing for my child. Those nights feel endless but there is an end. Once PND subsided (even though the sleepless nights did not) in its place was the most incredible love from this little boy. That bond and that love are the rewards for your selflessness, even on your worst day all your baby knows is warmth and love, a full tummy and mammy’s heartbeat next to theirs.”
Emma

Minimising PND risk through breastfeeding support

Inflammation, stress and fatigue can increase the risk of developing PND. Sleep disturbances are only one of the reasons why new mothers are especially vulnerable; postpartum pain, experiencing breastfeeding difficulties such as nipple pain, or psychological trauma all act as stressors which cause their inflammatory levels to rise. When things are going smoothly, breastfeeding protects mothers against the risk of developing PND by reducing stress and attenuating the inflammatory response (12). This is one of the reasons why it is particularly important to address breastfeeding difficulties promptly by seeking help and support. Depressed mothers are at high risk of quitting breastfeeding, especially when they are experiencing pain, but research has found that breastfeeding decreases negative mood (13) and it protects the infants of depressed mothers from the harmful effects of depression. This is because mothers do not disengage from their babies and continue to look at, touch and stroke them (14).

“Breastfeeding provided me with the only connection to my son when all emotional ones were absent. Breastfeeding gave me a sense of purpose and strength to face each day waiting for things to get better. It was the only barrier from me running away forever, and proof my body and mind were not permanently and completely broken.”
Sarah

Breastfeeding and antidepressant medication

If you have PND and are breastfeeding you may also face the decision of whether or not to take antidepressant medication. This decision is an individual one, but it might be reassuring to know that you can continue to breastfeed whilst taking antidepressants. A review of the research on this topic found that breastfeeding does not need to be discontinued during antidepressants, but that some medications are better researched than others (15). SRIs (Serotonin Reuptake Inhibitors) are the most commonly used antidepressants and also the most well researched in their use during breastfeeding (16). Infant exposure to antidepressants through breastmilk is generally low to very low, and women who wish to take antidepressants do not need to discontinue breastfeeding (17). Your GP will be able to give you accurate information on the most suitable medication for you, as well as the safest one for your baby.

If you would like to have more information on breastfeeding and PND you can read the following articles posted on the LLLGB website:

Breastfeeding and Postnatal Depression

New Study: Breastfeeding linked to lower risk of postnatal depression

Written by Matilda Rizzo and first published in Breastfeeding Matters issue 222 (November/December 2017). Matilda Rizzo holds a MSc in Clinical Psychology and has worked in mental health for the last six years. She is currently working as a Psychological Wellbeing Practitioner and also runs the Tameside and Oldham branch of Attachment Parenting UK.

References:

1. NHS Choices. 11 February 2016. Postnatal depression. Available from: http://www.nhs.uk/Conditions/Postnataldepression/Pages/Introduction.aspx
2. Borra, C., Iacovou, M., Sevilla, A. 2015. New evidence on breastfeeding and postpartum depression: the importance of understanding women’s intentions. Maternal and Child Health Journal, 19, pp. 887-907.
3. Dennis, C.L., McQueen, K. 2009. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics, 123, pp. 736-751.
4. Skrundz, M., Bolten, M., Nash, I., Hellhammer, D.H., Meinlschmidt, G. 2011. Plasma oxytocin concentration during pregnancy is associated with development of postpartum depression. Neuropsychopharmacology, 36, pp. 1886-1893.
5. Hahn-Holbrook, J., Haselton, M.G., Dunkel Scheltr, C.J., Glynn, L.M. 2013. Does breastfeeding offer protection against maternal depressive symptomatology?: A prospective study from pregnancy to 2 years after birth. Archives of Women’s Health, 16, pp. 411-422.
6. Galbally, M., Lewis, A.J., McEgan, K., Scalzo, K., Islam, F.A. 2013. Breastfeeding and infant sleep patterns: an Australian population study. Journal of Pediatric Child Health, 2-2, pp. 147-152.
7. Kendall-Tackett, K., Cong, Z., Hale, T.W. 2011. The Effect of Feeding Method on Sleep Duration, Maternal Well-Being and Postpartum Depression. Clinical Lactation, 2-2, pp. 22-26.
8. Doan, T., Gardier, A., Gay, C.L., Lee, K.A. 2007. Breast-feeding increases sleep duration of new parents. The Journal of Perinatal and Neonatal Nursing, 21, pp. 200-206.
9. Dorheim, S.K., Bondevik, G.T., Eberhard-Gran, M., Bjorvatn, B. 2009. Sleep and depression in postpartum women: a population-based study. Sleep, 32, pp. 847-855.
10. Kendall-Tackett, K. 2010. Four research findings that will change what we think about perinatal depression. Journal of Perinatal Education, 19, pp. 7-9.
11. Ockwell-Smith, S. 10 August 2014. How to gently night wean a breastfed baby or toddler. Available from: https://sarahockwell-smith.com/2014/08/10/how-to-gently-night-wean-a-breastfed-baby-or-toddler/
12. Kendall-Tackett, K. 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. Available from: https://doi.org/10.1186/1746-4358-2-6
13. Mezzacappa, E.S., Katkin, E.S. 2002. Breast-feeding is associated with reduced perceived stress and negative mood in mothers. Health Psychology, 21(2), pp. 187-193.
14. Jones, N.A., McFall, B.A., Diego, M.A. 2004. Patterns of brain electrical activity in infants of depressed mothers who breastfeed and bottle feed: the mediating role of infant temperament. Biological Psychology, 67, pp. 103-124.
15. Di Scalea, T.L., Wisner, K.L. 2009. Antidepressant Medication Use during Breastfeeding. Clinical Obstetrics and Gynecology, 52, pp. 488-497.
16. Weissman, A.M., Levy, B.T., Hartz, A.J. et al. 2004. Pooled analysis of antidepressant levels in lactacting mothers, breast milk, and nursing infants. American Journal of Psychiatry, 161, pp. 1066-1078.
17. Berle, J.O., Spigset, O. 2011. Antidepressants Use During Breastfeeding. Current Women’s Health Reviews, 7, pp. 28-34.