does breastfeeding protect maternal mental health...

8/14/2019

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Does Breastfeeding Protect Maternal Mental Health?The Role of Oxytocin and Stress

Kathleen Kendall-Tackett, PhD, IBCLC, FAPA

Breastfeeding protects maternal mood

Depression is a direct threat to breastfeeding

• What does “breastfeeding” mean?

• Is it exclusive?

• Stress/oxytocin system

• Birth interventions

• Sleep

The Stress/Oxytocin System

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Paraventricular Nucleus

High oxytocin means mothers are highly suggestible and vulnerable to criticism

Epinephrine

Norepinephrine

Dopamine

Catacholamine

Hypothalamus• CRH/CRF

Pituitary • ACTH

Adrenal cortex• Cortisol

HPA Axis

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9 10

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• IL-1β

• IL-6

•TNF-α

Inflammation

• Proinflammatory cytokines rise in last trimester

• When women’s risk of depression is highest

Does breastfeeding protect women’s mental health?

• Prospective studies

• Physiological changes

• Regulation of sleep

Are breastfeeding mothers just healthier to begin with?

Are breastfeeding mothers healthier to begin with?

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Prospective study of 2,072 mothers 36-38 weeks gestation to 3 months postpartum, Sabah, Malaysia

Significantly lower EPDS scores at 3 months postpartum for EBF mothers

Yusuff et al. 2016, J Hum Lact, 32(2), 277-281

`Women who were breastfeeding at 3 months had significantly lower depression at 24 months

Prospective study, N=205, assessed 5 times prenatally, 3,6,12, & 24 mospostpartum

Hahn-Holbrook et al. 2013, Arch Women’s Ment Health, 16, 411-422

• Less depression for BF 9 times/day vs 4 times/day

• Mothers depressed during pregnancy are less likely to breastfeed and weaned 2.3 months earlier

Hahn-Holbrook et al. 2013, Arch Women’s Ment Health, 16, 411-422

Heinrichs et al. 2001, J Clin Endo Metabol, 86, 4798-4804

CortisolACTHResponse to

induced stressor

Short-term

lessening of the stress

response

Baby at the Breast Lowers Mothers’ Stress

• ACTH negatively correlated with suckling

• Longer skin to skin lowered cortisol

• Oxytocin lowered ACTH and cortisol

63 primips, 2 days postpartum

Handlin et al., 2009,Breastfeeding Med, 4(4), 207-220

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Schwartz et al. 2009, Obstet Gyn, 113, 974-982

Lifetime ProtectionFor Mothers

CV

D

Diab

ete

s

Hyp

erte

nsio

n

High

Triglyce

ride

s

139,681 post-menopausal women (Mean age=63)

1,372 Korean parous postmenopausal women (age >50)

Women who breastfed 47-432 months had 67% decreased risk of depression compared to those for breastfed 0-23 months• 29% decreased risk

for each additional infant

• 9% decreased risk for each additional year

Park & Cnoi 2019, J Affect Dis, 248(1), 13-17

What if there’s pain or other problems?

Birth Interventions

More breastfeeding problems at 3 months following forceps-assisted and unplanned cesarean births

5,332 mothers in the UK

Rowlands & Redshaw 2012, BMC Preg Childbirth, 12, 128

Bai et al., 2013, J Midwif Wom Health,

58(1), 25-32

1,280 mothers and infants from Hong Kong

Any Exclusive

InductionOpiods

Emergency cesarean

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Women who had Epidurals were more likely to:

• Partially breastfeed

• Have difficulties in the first week

• Stop breastfeeding by 24 weeks

Prospective study of 1280 Australian women, 1 to 24 weeks postpartum

Torvaldsen et al., 2006, Int Breastfeed J, 1:24

• Negative impact (N=12)

• No effect (N=10)

• Positive effect (N=1)

Review of 23 studies, epidurals and breastfeeding difficulties and earlier cessation

French et al. 2016, J Hum Lact, 32(3), 507-520

Survey of Mothers’ Sleep and Fatigue

Survey 6,410 mothers of infants 0-12 months, 59 countries

Feeding Method by Delivery Type

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71 69 70 69

15

2624

27 28

2 3

7

24

0102030405060708090

Vaginal Asst.Vaginal

Unplanned Planned Emergency

Breastfeeding Mixed Formula-Feeding

Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96

Epidural by Feeding Method

42

65 6858

35 32

0

10

20

30

40

50

60

70

80

Breastfeed Mixed Formula

Epidural No Epidural


Pain Medications by Feeding Method

24

3540

76

6560

0

10

20

30

40

50

60

70

80

Breastfeed Mixed Formula-Feed

Pain Meds No Pain Meds


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Depression and Birth

Interventions

25%-28% depression

30%-37% anxiety

Following elective cesarean

Kuo et al., 2014, PLoS ONE, 9, e86653

Depression by Birth Type

0.750.8

0.850.9

0.951

1.051.1


Retrospective study of peripartum synthetic oxytocin usen=9,684 exposed, n=37,048 unexposed

• For women with history of depression or anxiety, peripartum oxytocin increased the risk of postpartum depression or anxiety by 36%

• Among those with no history, oxytocin increased the risk by 32%

Kroll-Desrosiers et al. 2017, Depress Anxiety, 34(2), 137-146

Epidurals 214 mothers from China

• 15 depressed with epidural

• 37 depressed without epidural

Ding et al., 2014, Anesthes Analges, 119, 383-392

Impact of Epidural on PPD

0.75

0.8

0.85

0.9

0.95

1

Yes No


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Controlled for • All other birth

interventions

• Primip v multip

• Number of hours in labor

• Income

• Education

• History of depression

• History of sexual assault

• Current anxiety

• Current anger/irritability

Interventions still related to depression• Postpartum

hemorrhage• Postpartum

surgery• Epidurals


Parasympathetic Activation

Sympathetic Activation

Epidural

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Depression and Breastfeeding Cessation

Intended to breastfeed and did

Intended to breastfeed and did not

ALSPAC sample, Avon UK, 14,541 pregnancies

Borra et al, 2015, Matern Child Health J, 19(4), 897-907

PPD

PPD

d

Anxiety at 3 months

reduced odds of exclusive

breastfeeding by 11% at 6

months

Adedinsewo et al. 2014, J Hum Lact, 30(1), 102-109

Reasons for breastfeeding cessation (EPDS >9)

• Too many household duties

• Breastfeeding was too painful or tiring

• Sore or cracked nipples

• Breasts were engorged

Infant Feeding Practices Study II (N=4,902)

Bascom & Napolitano, 2016, J Hum Lact, 32(2), 282-291

Women with complex

pregnancies had 30% lower odds of

EBF

2400 births in U.S.Supportive

hospital practices increased any or

exclusive breastfeeding 2

to 4 times

Kozhimannil et al. 2014. PLoS One, 9(8), e104820

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Increase oxytocin

• Skin-to-skin contact

• Touch

• Positive social interaction

• Safety

• Warmth

Mother-infant sleep

Poor sleep was an independent risk factor for depression

Dorheim et al. 2009, Sleep, 32, 847-855

Study of 2,830 women at 7 weeks postpartum Factors associated with

poor sleep• Depression

• Previous sleep problems

• Primiparity

• Younger or male infant

• Not exclusively breastfeeding

Dorheim et al. 2009, Sleep, 32, 847-855

6.61

6.41

6.3

6.26.36.46.56.66.7

Breastfeeding Mixed Formula

Hours Mothers Sleep N=6,410, Survey of Mothers’ Sleep and Fatigue

3.03

2.722.79

2.4

2.6

2.8

3

3.2


Mothers’ Daily Energy

Kendall-Tackett et al. 2011, Clin Lactation, 2(2), 22-26

N=6,410, Survey of Mothers’ Sleep and Fatigue

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Mothers’ Depression

0.5

1

1.5


Kendall-Tackett et al. 2011, Clin Lactation, 2(2), 22-26

N=6,410, Survey of Mothers’ Sleep and Fatigue

Sleep Location and Feeding Method

6.72

6.43

6.13

6.55

5.8

6

6.2

6.4

6.6

6.8

Bedshare Non-Bedshare

Ho

urs

of

Sle

ep

Sleep Location

Total Hours Mother Sleeps

EBF Non-EBF

0.94 0.98

1.21.08

0.40

0.70

1.00

1.30

Bedshare Non-Bedshare

Ho

w O

fte

n A

nxi

ou

s

Sleep Location

Anxious or Afraid

EBF Non-EBF

1.5

1.45

1.62

1.54

1.35

1.4

1.45

1.5

1.55

1.6

1.65

Bedshare Non-bedshare

Ho

w O

fte

n A

ngr

y

Sleep Location

Anger and Irritability

EBF Non-EBF

0.84 0.87

1.02

1.18

0.60

0.80

1.00

1.20

1.40

Bedshare Non-bedshare

De

pre

ssiv

e S

ymp

tom

s

Sleep Location

Postpartum Depression

EBF non-EBF

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What About Sexual Assault Survivors?

Percentage who are Breastfeeding

78.6 78.9

70

80

No Sexual Assault Sexual Assault

Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22

N=6,410, 994 sexual assault survivors

0.853

1.11

0

0.2

0.4

0.6

0.8

1

1.2

Current Depression

No Sexual Assault Sexual Assault


N=6,410, 994 sexual assault survivors 6.63

6.52

6.44

6.16

6

6.1

6.2

6.3

6.4

6.5

6.6

6.7

No assault Sexual assault

Hours Mothers Sleep

Breastfeeding

Mixed/Formula


18.73

23.87

22.07

27.01

18

20

22

24

26

28

No assault Sexual assault

Minutes to Get to Sleep

Breastfeeding

Mixed-/Formula


0.8

1.071.03

1.25

0.7

0.8

0.9

1

1.1

1.2

1.3

No Assault Sexual Assault

Depression

Breastfeeding

Mixed/Formula


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1.491.51

1.53

1.69

1.35

1.4

1.45

1.5

1.55

1.6

1.65

1.7

1.75

No Assault Sexual Assault

Angry or Irritable

Breastfeeding

Mixed/Formula


What can we conclude?

Breastfeeding protects maternal mood

• Best protection is from for exclusivebreastfeeding

• Breastfeeding problems can cause depression

Apparent contradictions in data disappear when we understand the underlying physiology

Birth interventions impact both breastfeeding and maternal mental health

• Depressed mothers can breastfeed

• Don’t give up on mothers, even when they have risk factors

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Increase oxytocin!

Increase oxytocin!

New edition from

Routledge

Praeclarus Press.com

Find Me on Social Media

Kathleen Kendall-TackettKathy Kendall-Tackett

@UptySciChick

Kathleen Kendall-Tackett

Email: [email protected]

• www.PraeclarusPress.com

• www.UppityScienceChick.com

• www.KathleenKendall-Tackett.com

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