does breastfeeding protect maternal mental health...
TRANSCRIPT
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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
83
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
Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
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
Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
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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
Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
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
Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
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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
Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
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
Breastfeeding Mixed Formula
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
Breastfeeding Mixed Formula
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
Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
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
Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
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
Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
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
Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
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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
Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
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!
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Kathleen Kendall-TackettKathy Kendall-Tackett
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Kathleen Kendall-Tackett
Email: [email protected]
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