Guest Blog: Breast is Best...Really? Always?!

Dr. Harita Raja is the Founder and Medical Director at Bethesda Women’s Mental Health. She is a board certified psychiatrist specializing in reproductive psychiatry, which means that she understands the intricacies of psychiatric problems that occur before, during and after pregnancy, and their treatments. Dr. Raja completed her psychiatry residency at MedStar Georgetown University Hospital, where she serves as a clinical instructor in the Department of Psychiatry. She is the author of numerous articles and book chapters on women’s mental health. Dr. Raja lives with her husband and two children in Bethesda MD.

We often hear that “breast is best.” Is breastfeeding always best?

Dr. Raja: For many new mothers, breastfeeding is easy, natural, and a positive experience. However, for some women, breastfeeding can be challenging, painful, and/or undesirable. With the emphasis on “breast is best,” breastfeeding is often internalized and idealized by women, inadvertently putting undue pressure on new mothers for whom breastfeeding may not be ideal.

There is no doubt that breastfeeding has benefits: it is an ideal combination of nutrients for the baby, can be more cost effective, and supports mother-baby bonding. However, there are clear disadvantages to breastfeeding as well: it is time-consuming, puts the burden of nutrition solely on the mother, and can be a potential stressor on mental health.

It is imperative that we take a step back and recognize (like most things in life), that breastfeeding does not have to be all-or-nothing. The current recommendation from the American Academy of Pediatrics is exclusive breastfeeding for the first six months, but this is a RECOMMENDATION, not a rule. I know of too many women who latch (pun intended) onto this recommendation as the Holy Grail of motherhood. This can lead them to focus on exclusive breastfeeding at all costs, including potential negative impacts on their mental health.

Let’s face it: exclusive breastfeeding for six months can be hard! Data from the Centers for Disease Control and Prevention bears this out: the 2018 Breastfeeding Report Card shows that only 1 in 4 infants are exclusively breastfed at six months.

What is the impact of breastfeeding on an infant’s health?

Dr. Raja: Let’s start with the basics. In general, women who breastfeed tend to have higher education and higher socioeconomic status. In fact, data the Kaiser Family Foundation reports that women of low income are less likely to exclusively breastfeed for three months than women of higher income (see chart at right). Therefore, it can be challenging to separate the effects of breastfeeding on the infant from socio-economic considerations.

Studies from the 1980s and 1990s helped lead to the emphasis on exclusive breastfeeding. Research from this period showed that babies who were breastfed had a lesser likelihood of asthma, eczema, and earaches; lower rates of obesity; lower rates of necrotizing enterocolitis (though only in premature infants); and higher childhood IQs.

More accurate studies were performed in the 2000s, providing more nuanced information. For example, a sibling trial showed that obesity was not directly correlated with the extent of breastfeeding, and another study showed that many long-term effects may be related to selection bias, meaning that the study participants did not accurately reflect the larger population.

Can mental health issues, such as anxiety or depression, impact breastfeeding?

Dr. Raja: Absolutely! Mental illness can play a significant role in breastfeeding; it is a bidirectional relationship. While many studies show that breastfeeding can be protective against anxiety or depression, other studies indicate that perinatal mood and anxiety disorders predict a shorter breastfeeding duration. A recent study indicates that the mother’s mental health is most impacted when her desires, goals, or expectations about breastfeeding do not match reality. Women who experience more significant mental illness, such as bipolar disorder, need to consider their mental health as a significant factor in exclusive (round-the-clock) breastfeeding. When treating new mothers with bipolar disorder, I tell them that sleep and medication are essential to maintain their mental health, and I see the best results when they continue medication, prioritize sleep, and have someone else feed the baby at night. Many new mothers tell me they feel guilty for not exclusively breastfeeding, so it is really important to support them in their decisions.

Some women report feeling very emotional right before or right after initiating breastfeeding. Can you shed some light on this?

Dr. Raja: There is a phenomenon known as dysphoric milk ejection reflex (D-MER), which involves intense negative emotions that are elicited by milk letdown and which impacts about 10% of breastfeeding mothers. Emotions come on suddenly and last from seconds to minutes. These feelings have been described as “anxious, sad, irritable, panicky, agitate

d, oversensitive, and tearful.” D-MER is thought to be linked to the significant fluctuation of hormones during letdown (see the image at right which shows the changes in prolactin and oxytocin associated with lactation). There is no particular treatment for D-MER, though some anecdotal options are available to make it better, such as staying hydrated. Fortunately, these negative feelings often pass very quickly once the baby is latched and feeding.

Can women take antidepressant or antianxiety medication and breastfeed?

Dr. Raja: Taking medication – especially antidepressant or antianxiety medications — IS NOT a reason to stop breastfeeding. In fact, the risk of adverse outcomes is very low for infants whose mothers breastfeed while taking the most commonly-prescribed anti-depressant and antianxiety medication. Fortunately, there are safe and effective medications for women who are pregnant or breastfeeding.

There are several resources for both parents and providers about the impact of medications of all types on infant health, including:

• LactMed

• Mother to Baby

• Treating for Two.

Let’s say a new mother who has a history of significant depression took sertraline (brand name Zoloft) during pregnancy and maintained a positive state of mental health. She wants to continue her medication postpartum, but is concerned about the impact of the medication while breastfeeding.

• First, the baby has already been exposed to the medication in utero.

• Second, the amount of the medication passed through breastmilk is low, often undetectable in the plasma, and does not have any clinical significance on a healthy baby.

• Third, if she discontinues her medication, she is likely to experience symptoms of anxiety or depression, which then exposes her baby to potential negative impacts of her mental illness.

So what’s your bottom line on breastfeeding? Breast is best – except not always, and not everywhere, and not for every mother or infant. It is imperative to evaluate the benefits and risks of breastfeeding for each individual mother-baby dyad. Women should be educated, empowered, and supported in making breastfeeding choices that are right for them, their infants, and their situations. No judgment.

The bottom line: Happy, healthy mothers make happy, healthy babies.

The original interview can be found by clicking here

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