Postpartum depression (PPD) is a form of depression that develops following childbirth and impacts functioning to various degrees depending on severity. Onset is usually from the first few weeks postpartum up through the first year. Postpartum depression and a condition known as the “Baby Blues” may be confused. The differences between the “Baby Blues” and PPD are the duration, intensity, and severity of the symptoms. Approximately 80% of new mothers experience what is known as the “blues” (with symptoms such as lack of sleep, exhaustion, and a roller coaster of emotions), usually due to a hormonal imbalance. However, these symptoms typically peak around two weeks and then disappear. Some mothers react more strongly than others to the changes in hormone levels, be it post-partum or even post-weaning.
Unlike the blues, postpartum depression/anxiety symptoms persist and become more severe. Mothers often report feelings of worthlessness, guilt, despair, difficulty concentrating, or other similar feelings when depressed. Appetite and sleep patterns can be disrupted and a mother coping with postpartum depression may not be able to experience pleasure or interest in the baby or her family. Anxiety symptoms often accompany the depression. She may also have a difficult time adjusting to her new life as a mother while grieving the loss of her old identity and lifestyle. Many times, the mother may feel isolated due to lack of support. In some cases, a mother may have thoughts of wanting to hurt herself or her baby. Immediate help is required in these particular situations.
Multiple factors are believed to contribute to PPD. Medical issues, such as hormonal changes and/or a thyroid imbalance, play a role; psychosocial factors do, too. The latter may include a lack of social support, substance abuse issues, breastfeeding issues, birth defects, etc. A family history of anxiety or depression can also contribute. When doing an evaluation for postpartum depression, it is incumbent for the practitioner to assess for all of these factors. A spectrum of PPD exists (ranging from mild to severe), and if left untreated can become more severe. Approximately 20% of new mothers experience PPD, and it can affect any mother regardless of age, race, or income.
RISKS AND STIGMAS
It is unlikely that a mother will admit to depression and anxiety. Instead, she may say something like “I cry almost every day, I don’t see a way out, everything looks hopeless,” or “It feels like I am a bad mother--I should have never had this baby.” Many new mothers are ashamed or embarrassed to admit to feeling depressed and/or anxious for fear of judgment or for fear of an authoritative figure deeming her unfit and taking her baby away. Unfortunately, these fears leave the mother in a state of isolation and silence.
Postpartum depression is shrouded in myths and stigmas hindering the understanding, creation, and accessibility of resources. This is due, in large part, to the societal expectation that a new mother should be happy about her baby or that after a brief transition following the birth, she should be able to adjust fairly smoothly to her new role. The cultural expectation that motherhood will come naturally is personified and reinforced by media representations of the perky mom with her happy baby. Furthermore, the media’s portrayal of postpartum depression and other perinatal mood complications is usually negative. Media coverage is further intensified when there is a tragic outcome. For all these reasons, greater compassion, understanding, and support are crucial to break through the barriers of these stigmas. Isolation only exacerbates the depression and impairs the mother and family’s well being.
THE IMPACT OF POSTPARTUM DEPRESSION ON FAMILIES
A cycle of perpetual negative reinforcement and isolation exists which leads to a continued deterioration of coping skills and a likely increase of family conflict. Postpartum depression has a ripple effect influencing the mother’s ability to bond with her baby, as well as adversely affecting her relationship with her partner or other family members. Oftentimes, the partner feels bewildered by the mother’s symptoms, is unsure of what to do, and/or feels helpless. S/he, however well intentioned, may expect the mother to “just snap out of it,” unable to understand that what she is experiencing is out of her control. The impact of untreated postpartum depression on the child could include low birth weight, disruption of the bonding process, insecure attachments, and social/behavioral problems in the older child. Early intervention and treatment is crucial to improve the outcome of the entire family unit.
SCREENING AND TREATMENT
A mother experiencing postpartum depression needs to understand that she is not alone, it is not her fault, and (with help) she will get better. Screening for PPD is crucial for identifying risk factors as early as possible. Ideally, screening would begin during pregnancy and occur during regular intervals during the postpartum period. It is the hope that in the future every hospital and birth center will have a screening protocol in place. The Edinburgh Postnatal Depression Scale (EPDS)1 is an example of a widely used screening tool that is adaptable in many languages and is easy to administer and score. Please note that the EPDS is a screening tool only - it does not assess the severity of the symptoms, nor is it a diagnostic tool. Follow up with the clinician is necessary to make an accurate diagnosis. Also, if the mother answers anything other than a zero on question number 10 (harm-related question), an immediate referral for further assessment and intervention is mandated.
The good news is that effective treatment for postpartum depression is available. Treatment includes individual counseling, support groups (face to face or online), one-to-one peer support, medication, or a combination of these. Individual counseling provides a trusting, supportive atmosphere where the mother can open up about her experience, focus on her strengths, and work on solutions to improve coping skills. Support groups are very powerful in that the mother can identify with others experiencing similar circumstances. This is a powerful affirmation that she is not alone. Several online support groups are available, making it a cost effective option and allowing the mother to participate from home. One-to-one peer support involves individuals, such as postpartum doulas, parent mentors, or other volunteers, communicating with the mother on a regular basis.
Finally, medication may also be a very helpful option in reducing depression and anxiety symptoms, thus increasing coping skills. However, many mothers are hesitant to consider medication for fear of stigma or how it will affect them or their babies. The decision to take medication is a personal one, and the risks and benefits of medication for the mother and her baby need to be carefully considered. The mother will need to be referred to a physician for further information and a medication evaluation. Resources, such as Lactmed, are available to help mothers and physicians evaluate pharmaceutical options.
POSTPARTUM DEPRESSION AND BREASTFEEDING
Mothers with PPD may feel that this condition is a contraindication to breastfeeding. However, it may be a situation where the mother needs to understand issues such as the use of medication, getting enough sleep, and family interactions, then figure out a strategy to meld these factors with breastfeeding. The interplay of these factors may or may not impact an individual mother’s decision whether or not to begin or continue to nurse.
Mothers with PPD may ask the following:
- “Can I breastfeed while taking a particular antidepressant/anti-anxiety medication?”
- “How can I maximize the amount of sleep I am getting while continuing to breastfeed?”
- “I can’t/don’t wish to continue to breastfeed...am I a bad mother?”
The bottom line is the well being of the mother and child. In her article on breastfeeding and depression, Kathleen Kendall -Tackett points out the benefits of breastfeeding in a mother experiencing PPD. 2 Lactation consultants, Breastfeeding USA Counselors, and educators can be extremely helpful and supportive in helping the mother with breastfeeding questions and issues. This support is crucial if a mother wants to continue to nurse, especially if she is having problems. In cases of severe PPD, early intervention with medical consultation is important for the health and safety of mother and baby. The risks of untreated PPD to the infant are documented.
As Katherine Stone states,
“I know some mothers who suffered from PPD that felt incredible relief when they decided to stop breastfeeding, while others found their depression worsened. The decision to breastfeed (or not) is a very personal one. It is critical to recognize that breastfeeding is more important to some mothers than it is to others (whether that is biologically, intellectually, or emotionally determined). The relationship between PPD and sleep quality is critical. Unfragmented sleep is important in helping mothers to manage and overcome PPD. But if breastfeeding is highly valued to a particular mother (and to her mental health) and if the mother is breastfeeding successfully, then the sleep advice needs to be compatible with maintaining a healthy milk supply. Bad sleep advice could cause the mother’s milk supply to plummet and unnecessarily compromise her ability to breastfeed her baby.”3
Whatever decision the mother chooses needs to be respectfully accepted without judgment.
In summary, postpartum depression is an issue that needs to brought “out of the closet.” So many new mothers experience it, yet it is an issue that is shrouded in secrecy and shame. The good news is that more attention is being focused on PPD. Increasing services for advocacy, education and resources is crucial if we are able to encourage the many mothers and families who require help to receive it without shame or fear of repercussion. The new mother needs to understand that she is not alone, not to blame, and with help will get better.
1. Cox, J.L., Holden, J.M. Sagovsky R. (1997). Edinburgh Postnatal Depression Scale
2. Kendall-Tackett, K. A new paradigm of depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammation protects maternal mother health. International Journal of Breastfeeding 2007, 2:6
3. Stone, K. (2013, June 6) Sleep management, breastfeeding and postpartum depression. Postpartum Progress http://www.postpartumprogress.com/sleep-management-breastfeeding-postpar...
© Copyright Breastfeeding USA 2014. All rights are reserved.
For Aimee Teslaw, making time for cardio, Pilates, yoga, biking, dog walking, swimming, and playing outdoors with her children is important for a healthy lifestyle. So is breastfeeding. Aside from the occasional plugged duct, she says exercising hasn’t negatively impacted her milk supply. Teslaw, a Breastfeeding USA member in Barrington, IL, said she isn’t a lifelong athlete but began exercising in college and continues to work out both on her own and with her children. “I love exercising as much as I love breastfeeding!” she says. “It’s all part of my personal wellness plan.”
Research shows 1,2,3,4 that moderate exercise doesn’t affect milk supply, milk composition, or baby’s growth. Lactic acid levels have been shown to increase somewhat when a mother exercises to maximum intensity, described as exhaustive exercise, but there are no known harmful effects to the baby.5,6,7,8,9 A couple of small studies10,11 found no difference in immunologic factors after moderate exercise, but they showed a decrease in immune boosting proteins after exhaustive exercise. Levels return to normal within an hour, and the impact on baby is unlikely to be significant.
Most breastfeeding mothers naturally increase their calorie intake to adjust for those expended through exercise. While some moms anecdotally report difficulty consuming enough calories to compensate for increased exercise, an Australian study12 found no impact on infant growth. Researchers examined 587 mothers and found that for their babies age 6-12 months, exercise had not decreased breastfeeding duration. At a year, exercise had no significant impact on baby’s growth. The findings applied to both women exclusively breastfeeding and those who said they did “any” amount of breastfeeding.
Breastfeeding mothers would have to reach a high level of exercise and/or diet restriction to experience a drop-off in milk production. It depends, in part, on what the mother’s body was accustomed to before lactation. That’s why mothers who are calorie-restricted, such as in famine-stricken areas of Africa, are still able to produce adequate milk, whereas the average mother in America might have problems if her calorie intake was suddenly decreased to that degree. Mothers are urged to start slowly in any new diet or exercise program, and work up to their goal over a period of time.
Mothers who are overweight or obese before or during pregnancy, may find that they actually do need a combination of exercise and calorie restriction in order to lose weight while breastfeeding. They need to start slowly and work up to a comfortable pattern of weight loss.
Exercising tips for breastfeeding mothers(from KellyMom):
For your own comfort, you may wish to nurse before exercising and wear a good, supportive bra. Some babies object to breastfeeding after mom has been sweating due to the salt on mom’s skin. You may wish to take a shower before nursing. If you regularly lift weights or do other exercise involving repetitive arm movement and you develop plugged ducts, cut back and start again more slowly. Keep yourself hydrated.
Some mothers share their stories:
I am breastfeeding my 24 month old and 5 month old. I started walking 30 minutes to an hour a day with my family or just the babies. About 2 months ago, I started going to an hour of Zumba a week to get some “me” time, and it does wonders! I am happier, refreshed, and have more energy for my kids. Before this, I never worked out, except for high school PE and sports, almost 20 years ago! I have not had a problem with my supply, but I make sure to keep up on my calorie intake and stay well hydrated.
I do not "work out." I juggle regularly, dance 45-60 minutes a day in my living room with my kids and walk pretty much every day between 3-5 miles going to and from places by bus. Parenting activities are nowhere near the level of activity that I sustained before kids. Between clowning, performing on touring shows, city living, and never eating "real" meals, I have put on weight just because of the amount of calories I consume to maintain my milk production for tandem breastfeeding. I have no idea how my activity level affects my milk production because I don't really track feedings at this point. If I sit still long enough, some kid inevitably asks to nurse.
Staten Island NY Chapter
Around 6 months postpartum with my second child, I attempted to work out. I did a modified version of P90x. Within the first week, I dropped 9 lbs. and couldn't ever feel satisfied after eating. I couldn't keep up with the calories I needed, and my milk supply started waning. I never recovered the weight lost, and now, a year later, I am below my typical weight by 8 lbs. Prior to having children, I was an athlete in college and a very fit individual leading up to pregnancy. I have recently started working out again and am hungry constantly. My 21 month old has increased her nursing sessions from 2-3 per day to every few hours. I know this isn't typical but for me, working out has a big impact on my body while breastfeeding. Even simple workouts like Pilates and yoga wear me down.
Note: When exercise (and thus calorie expenditure) is too overwhelming with very fast weight loss, the baby may be hungry and nurse more frequently to boost supply. While this is definitely not the norm, it does occasionally happen and shows that even experienced athletes may need to resume exercise more slowly or at a lower intensity after childbirth and during lactation. Our bodies and metabolism can change with the cycle of pregnancy, birth, and lactation. Going slowly, listening to your body, and watching your baby are the best ways to ease into a healthy program.
I (along with my friend and another Breastfeeding USA member) exercise 5-6 days a week. We run 10-15 miles/week and do strength training, kick boxing, etc. I haven't had any supply problems at all.
I am Mandy's friend and haven't noticed any major supply issues. My 17 month old still wakes 3+ times in the night to nurse and asks for breastmilk maybe 4-5 times throughout the day. I worked out while nursing with both of my babies, and I guess I notice a very, very slight decrease in production, but that is directly after a tough workout—I just feel empty (even though I know my breasts are never actually empty). The biggest thing I notice is it taking longer for my milk to let down, but since my baby is much older, I am not too concerned if she gets a couple of ounces less because she eats a ton of solids, as well. After a healthy snack and a big glass of water, I feel much less empty, and let down happens more quickly. Just my experience!
In conclusion, it seems from the research, and even from our own very small sampling of mothers’ stories, that for most moms, breastfeeding should not be seen as any kind of deterrent to a healthy exercise program. For each mother, the type and frequency of exercise may be different, but the fact is that our bodies are meant to be in motion. Healthy mothers - healthy babies. Go for it!
1. Daley AJ, Thomas A, Cooper H, et al. Maternal exercise and growth in breastfed infants: a meta-analysis of randomized controlled trials. Pediatrics 2012 Jul;130(1):108-14.
2. Dewey KG. Effects of maternal caloric restriction and exercise during lactation. J Nutr 1998 Feb;128:386S-389S.
3. Dewey KG, Lovelady CA, Nommsen-Rivers LA, McCrory MA, Lonnerdal B. A randomized study of the effects of aerobic exercise by lactating women on breast-milk volume and composition. N Engl J Med 1994 Feb 17;330:449-453.
4. Lovelady C. Balancing exercise and food intake with lactation to promote post-partum weight loss. Proc Nutr Soc. 2011 May;70(2):181-4. Epub 2011 Feb 24.
5. Quinn TJ, Carey GB. Does exercise intensity or diet influence lactic acid accumulation in breast milk? Med Sci Sports Exerc 1999 Jan;31(1):105-10.
6. Wallace JP, Ernsthausen GI. The influence of the fullness of milk in the breast on the concentration of lactic acid in postexercise breast milk. Int Jour of Sports Med 1992;13:395-398.
7. Wallace JP, Inbar G, Ernsthausen K. Infant acceptance of post-exercise breast milk. Pediatrics 1992 Jun;89(6 Pt 2):1245-7.
8. Wallace JP, Rabin J. The concentration of lactic acid in breast milk following maximal exercise. nt J Sports Med 1991 Jun;12:328-31.
9. Wright KS, Quinn TJ, Carey GB. Infant acceptance of breast milk after maternal exercise. Pediatrics. 2002 Apr;109(4):585-9.
10. Lovelady, CA, Hunter, CP, Geigerman, C. Effect of exercise on immunologic factors in breast milk. Pediatrics 2003;111;148-152.
11. R.L. Gregory, J.P. Wallace, L.E. Gfell, J. Marks, and B.A. King, Effects of exercise on milk immunoglobulin A. Med. Sci. Sports Exer 1997; 296–1601.
12. Dada Su, Yun Zhao, Colin Binns, Jane Scott and Wendy Oddy. Breastfeeding mothers can exercise: results of a cohort study. Public Health Nutrition,2007,10, pp 1089-1093.
© Copyright Breastfeeding USA 2014. All rights are reserved.
As you journey into motherhood, bonding with and caring for your new baby, the thought of another pregnancy may be distant. Whether or not you want more children in the future, the time to think about your fertility is before or soon after giving birth. Considering options and determining what best meets your personal circumstances can be overwhelming. This article discusses your fertility while breastfeeding and provides links to additional online resources. It is a starting point, which we hope will inspire you to continue this important conversation with your health-care provider and/or your partner.
After birth, when will my fertility return?
Fertility often returns in stages. You may first experience menstruation without ovulation or ovulation without luteal competency (when the uterine lining can support implantation). When you are both ovulating and have luteal competency, your fertility has fully returned. Most women will not start ovulating in the first six weeks after giving birth.1 Breastfeeding typically delays the onset of ovulation.2 Depending on the intensity of breastfeeding, it can be several months or over a year before you regain your fertility. Conversely, absence of breastfeeding may cause you to start ovulating as early as three weeks after giving birth.1
Why is it important to understand your fertility?
The World Health Organization recommends that women wait 24 months after giving birth before becoming pregnant again.3 Your health improves when you have a chance to recover, physically and emotionally, from giving birth and caring for your new baby. When you are healthy, your family benefits, too. Closely spaced pregnancies increase health risks, including preterm labor and low birth weight.4 Women also space childbearing for social and financial reasons. If your first menstruation is preceded by ovulation, you may become pregnant before you are aware that you are fertile again. The possibility of getting pregnant makes it important for women to make and act on decisions about their fertility before or soon after giving birth.
How can fertility be managed?
Contraception refers to methods (and devices and practices) used to reduce the risk of pregnancy. There are many different contraceptive methods, and a little later in this article we’ll look at many of them. First, let’s discuss some of the personal considerations that may influence you as a breastfeeding mother. The following steps can guide your decision-making process:
Establish your fertility goal: For how long do you want to avoid childbearing? How important is it for you to not get pregnant right now? What would you do if you experienced an unintended pregnancy?
Determine what your breastfeeding goal and actual patterns are: How old is your baby? Are you exclusively or partially breastfeeding right now? For how long do you want to breastfeed? How important is it to you that the contraceptive method you use is compatible with breastfeeding?
Consider what fits your personal circumstances and daily routines: How does your relationship status affect your contraceptive choices? How important is ease of use? Do you need a method which is long-acting? Discreet? If you have used certain methods in the past, what did you like and dislike about them?
Respect your own conscientious convictions: What methods are compatible with your personal values and religious beliefs?
Prioritize: Of all these considerations, which ones are more important to you and your family right now?
Consult your health-care provider and/or partner before starting or stopping a contraceptive method. There may be health considerations--such as your age, any illnesses, or smoking--which affect what contraceptive methods you can safely use. Your health-care provider will help you determine your clinical eligibility and identify whether there are methods you should avoid. Your health insurance may restrict what methods are covered under your plan. Talk to your provider about all of your options. Below are some useful questions that you can ask. If you have chosen a method, your provider should also explain or demonstrate how to use it correctly.
Questions to ask your health-care provider:
- How does this method prevent pregnancy?
- How effective is it in preventing pregnancy?
- How long is this method effective?
- How do I use it correctly?
- What are the side effects and risks of this method?
- What evidence exists about its effect on breastfeeding?
- Have any breastfeeding mothers in your practice had negative effects on their milk production?
- If I experience negative effects on milk production, what do you recommend?
- How easily reversible is the method? When do its effects wear off after I stop using it?
- If and when I want to have another child, how quickly will my fertility return after I stop using the method?
- Is there any medical reason why I should not use this method?
- What does it cost? Does my insurance cover it?
- What are comparable options?
This section looks at how different contraceptive methods prevent pregnancy, their efficacy, and compatibility with breastfeeding. When health professionals talk about efficacy, they usually refer to ‘perfect use’ and ‘typical use.’ Perfect use means that you always use the method correctly. Typical use refers to how most people actually use the method, including incorrect and inconsistent use. Because there are many factors and barriers that influence our use of contraceptives, the average person falls under ‘typical use.’ Failure rates for both perfect and typical use are reported in percentages. The data indicates how many women out of 100, who use the method for one year, will experience an unintended pregnancy.
Lactational Amenorrhea Method (LAM):
- Works by suppressing ovulation.2 Without an egg, pregnancy cannot happen.
- Depends on exclusive breastfeeding and breastfeeding on cue.5
- Is very effective in preventing pregnancy temporarily.6
For LAM to effectively reduce the risk of pregnancy, you need to meet three conditions:
- your menses have not returned;
- your baby is younger than six months and;
- you are exclusively breastfeeding and not allowing long periods of time between feedings.7
The last condition means that your baby does not get supplements of foods or liquids, does not use a pacifier frequently, and does not go longer than approximately four hours during the day and six hours during the night without breastfeeding.
With perfect use, the failure rate of LAM is 0.45% for six months after birth. With typical use, it is 2%.2, 8 LAM may not be as effective for mothers who are separated from their babies and rely heavily on expressing milk, including mothers who are employed outside the home or are full-time students.9 LAM requires that you evaluate and re-evaluate your situation on an ongoing basis to make sure that the three conditions are still met. Whenever one of the conditions is no longer met, the failure rate may be increased, and an alternative contraceptive method would be recommended.5
Other natural methods:
- Work by avoiding contact between sperm and the vagina, constantly or periodically, when you are at risk for pregnancy.
- Are fully compatible with breastfeeding.
- Are very to somewhat effective in preventing pregnancy.6
Abstinence means refraining from shared sexual activity that can result in pregnancy and sexually transmitted infections. To be effective abstinence needs to be practiced constantly. If you decide to have sex, another method is necessary to prevent pregnancy.
There are different fertility awareness-based methods that can help you identify when you are fertile. The symptothermal method requires you to 1) check your cervical mucus daily; 2) take your temperature each morning at the same time and before voiding, and; 3) chart your ovulation symptoms. 10 It can be used once your menstrual cycle has started and become regular again.11 During days when you are at risk for pregnancy, you can practice periodic abstinence, withdrawal, or use a barrier method (discussed below).
Withdrawal (or the ‘pull out’ method) requires your partner to completely remove the penis from the vagina before ejaculation to prevent sperm from entering the vagina. If a man ejaculates on the vulva or near the vaginal opening, sperm can still enter the vagina. After an ejaculation, small amounts of sperm may be left in the man's urethra. There is inconclusive evidence whether the amount of sperm in pre-ejaculatory fluid (precum) can cause pregnancy, and research shows that this is likely to vary greatly between individual men. While withdrawal is more effective in preventing pregnancy than unprotected sex, it is not recommended if avoiding pregnancy is critical for you.
With perfect use, natural methods have very low failure rates (constant abstinence: 0%; symptothermal method: 0.4%; withdrawal: 4%).6 These methods are accessible to all women at no or low cost. Their main disadvantage, however, is that they are often used incorrectly and inconsistently. They require user knowledge, significant self-control, and good communication between partners. Failure rates increase exponentially with typical use: (no method: 85%; fertility awareness-based methods: 24%; withdrawal: 22%).6
- Work by blocking sperm from passing through the cervix.11 Without sperm, pregnancy cannot happen.
- Are fully compatible with breastfeeding.2
- Are effective in reducing the risk of pregnancy.6
The most common barrier method is the condom. There are female and male condoms. They are relatively inexpensive and usually easy to acquire. With perfect use, the failure rate for male condoms is 2%, and for female condoms it is 5%.6 Many people use condoms incorrectly and inconsistently. With typical use, the failure rate for male condoms is 18%, and for female condoms it is 21%.6 Condoms also reduce the risk of sexually transmitted infections. They can be used simultaneously with other contraceptive methods, thus offering ‘dual protection.’ Other barrier methods, such as the cervical cap, diaphragms, and the sponge, are less effective than condoms, especially for women who have given birth. Diaphragms need to be refitted after childbirth or with large weight swings. Diaphragms and cervical caps are more effective when used in conjunction with spermicides.
- Work both by suppressing ovulation and making cervical mucus thicker, which blocks sperm from passing through the cervix.11, 12, 13, 14 If there is neither an egg nor sperm, fertilization cannot happen. Some of these methods also suppress growth of the uterine lining (details in listing below).11, 13
- Are compatible with breastfeeding15 but are not recommended as the first choice for breastfeeding mothers.2, 16
- Are very effective in preventing pregnancy.2, 6, 11, 17
Note: Since this article was published the Academy of Breastfeeding Medicine has changed its recommendations regarding hormonal contraceptive use for lactating women.
"A Cochrane review indicated that evidence from randomized controlled trials on the effect of hormonal contraceptives during lactation is limited and of poor quality: ‘‘The evidence is inadequate to make evidence-based recommendations regarding hormonal contraceptive use for lactating women.’’
Until better evidence exists, it is prudent to advise women that hormonal contraceptive methods may decrease milk supply especially in the early postpartum period. Hormonal methods should be discouraged in some circumstances (III):
- existing low milk supply or history of lactation failure
- history of breast surgery
- multiple birth (twins, triplets)
- preterm birth
- compromised health of mother and/or baby
Hormonal methods can be divided into different sub-categories, including short-acting and long-acting, and combined hormonal and progestin-only contraceptives. Combined hormonal methods, such as the ‘pill,’ the patch, and the vaginal ring, contain both estrogen and progestin. Estrogen may decrease milk production and negatively affect breastfeeding duration.2, 16 The World Health Organization recommends that breastfeeding mothers avoid combined hormonal contraceptives in the first six months after birth unless other methods are not available or acceptable.18 The Academy of Breastfeeding Medicine recommends alternative methods until after the baby has weaned.2
If you are breastfeeding, progestin-only methods are preferred over combined hormonal ones.2, 19 Progestin-only contraceptives include the ‘mini pill,’ the implant, injectables, and the intrauterine system (IUS). The earliest recommended use of progestin-only methods by breastfeeding women, who are clinically eligible to use them, is usually six weeks after birth, if milk production is well-established.2, 16, 19 There are anecdotal clinical reports that progestin-only contraceptives can decrease milk production, too.2, 16
The possible negative effects on milk production can sometimes be difficult or impossible to fully reverse with either combined hormonal or progestin-only methods, especially with methods that cannot be stopped quickly. A nursing mother needs to carefully consider whether to use any of the hormone-based contraceptives while the baby is dependent on breastmilk for the majority of his nutrition. The importance of pregnancy prevention versus maintaining optimal milk supply is something that only the mother can assess.
The following information is based on evidence current as of the date of publication and is not meant as an endorsement of any particular method or as being compatible with breastfeeding.
Select progestin-only contraceptives2, 6, 11, 12, 13, 14, 19
Progestin-only pill (also called the ‘mini pill’)
- Perfect use: 0.3%
- Typical use: 5%
- Requires taking the pill daily and at the same time. Can be stopped at first sign of adverse effects on milk production.
- Perfect use: 0.05%
- Typical use: 0.05%
- Requires no daily routine and works for three or five years depending on the brand. Like other hormonal methods, the implant suppresses ovulation and makes cervical mucus thicker, which prevents fertilization. It may also suppress growth of the uterine lining.
- Perfect use: 0.2%
- Typical use: 6%
- Should be administered every 12 weeks. It takes longer for the hormone from the injectable to leave your system compared to other hormonal methods. If it has adverse effects on breastfeeding, the method cannot be quickly reversed. It must wear off on its own.
- Perfect use: 0.2%
- Typical use: 0.2%
- Requires no daily routine and works for up to five years. The hormone is released locally in the uterus, and it typically has little to no effect on milk production. Like other hormonal methods, the IUS suppresses ovulation and makes cervical mucus thicker, which prevents fertilization. The IUS also suppresses growth of the uterine lining.
If I choose a hormonal method, will hormones in my breastmilk affect my baby?
Hormonal contraceptives have been used by breastfeeding mothers for decades without any reported adverse outcomes for their babies due to ingestion of hormones in the breastmilk.16 The level of estrogen that transfers to human milk is low. It does not exceed the level that occurs naturally when a woman ovulates.20 Natural progesterone is poorly absorbed by the infant via milk.20 Changes observed in milk composition of breastfeeding mothers who are using hormonal contraceptives are within normal variations.5
Copper-bearing intrauterine device (IUD):
- Works by releasing copper ions, which change the chemical environment in the uterus and destroys the function of sperm before they can fertilize the egg.13
- Is fully compatible with breastfeeding.2
- Is very effective in preventing pregnancy.6
The copper-bearing IUD is available for breastfeeding mothers who want long-acting, reversible contraception without hormones. After the IUD is placed by a trained provider, there is no daily routine, and it can be used for at least 10 years. In the first year, the typical failure rate is 0.8%.6 Over the course of 10 years, the typical failure rate is 2%.11 The copper-bearing IUD can also be used as emergency contraception for up to five days after unprotected sex.21 When placed after unprotected sex, the copper-bearing IUD prevents fertilization and may also prevent implantation.22
- Tubal ligation works by blocking the egg in the fallopian tube. Vasectomy works by keeping sperm out of semen.11
- Are fully compatible with breastfeeding. Medications used during the tubal ligation procedure may temporarily affect breastfeeding.2
- Are very effective in preventing pregnancy.6
If you are positively certain that you have completed childbearing, permanent contraceptive methods may be for you (or your partner). With tubal ligation, the fallopian tubes are surgically cut or blocked. If you want to have the procedure done immediately after childbirth, you have the right to give informed consent before giving birth.11, 23 In the first year after the procedure, the typical failure rate is 0.5%.6 Over the course of 10 years, the typical failure rate is 2%, and a small risk of pregnancy remains until you reach menopause.11
Vasectomy is also a surgical procedure. The vas deferens that carry sperm to the penis are blocked. It takes up to three months after the procedure until it is effective in preventing pregnancy. After three months, the man can have his semen analyzed to see whether it contains sperm.11 In the first year, the typical failure rate is 0.15%.6 If the semen is not analyzed, the failure rate in the first year may be as high as 3%.11 Vasectomy is simpler, safer, and less expensive than tubal ligation.2, 11
Even if you take great care to manage your fertility, you may find yourself in a situation where you are at risk of pregnancy. It takes several days after sex before a pregnancy is established.24 Emergency contraception is a safe and effective way of preventing pregnancy for up to five days after unprotected sex. It is not intended to be used as an ongoing contraceptive method. There are two options, including ‘morning after’ pills and the copper-bearing IUD (discussed above). ‘Morning after’ pills work by disrupting ovulation and preventing fertilization. 11, 28 Progestin-only ‘morning after’ pills are generally considered compatible with breastfeeding,26, 27 and breastfeeding can continue uninterrupted.16 Their failure rate is around 10-15% in the first three days after unprotected sex. 28 They become less effective as time passes. Although the ulipristal acetate-containing ‘morning after’ pill has a lower failure rate than the progestin-only ‘morning after’ pill,28 its possible effect on breastfeeding has not been adequately evaluated. Recent research shows that ‘morning after’ pills may also be less effective for obese women.
If you experience an unintended pregnancy while breastfeeding, you are not alone! About half of all pregnancies in the United States are unintended. As with any pregnancy, you have options, including continuing the pregnancy or having an abortion.
Continuing the pregnancy:
When you breastfeed, the hormone oxytocin is released, and it can cause uterine contractions. These contractions are usually very mild and undetectable. With a healthy pregnancy, continued breastfeeding is considered safe and unlikely to increase the risk for preterm labor.36 Pregnancy, itself, can have a negative effect on milk production. This will have a greater impact on a younger infant who is more dependent on your breastmilk as the primary source of nutrition.
Breastfeeding USA does not take a position on abortion; rather, we are committed to providing evidence-based information.
Three in 10 American women will have an induced abortion in their lifetime. 29 The majority (61%) already have children29 and may still be breastfeeding. In the first trimester, abortion can be done using vacuum aspiration or medicines. If you have decided to terminate a pregnancy and are considering an aspiration abortion, you can discuss pain management options with your health-care provider. Together you can agree on a pain management plan that has no or low adverse effects on breastfeeding.
Medical abortion can be done with a combined regimen of mifepristone and misoprostol.30 Mifepristone passes into breastmilk, and there are no known adverse effects on the breastfed infant.30, 31 One small study found that levels of mifepristone in milk samples taken 6-12 hours after maternal intake ranged from undetectable to low, depending on the dose. The study concluded that with the low dose of mifepristone, “breastfeeding can be safely continued in an uninterrupted manner during medical abortion.”32 Alternatively, you can opt to express and discard milk for two days after taking mifepristone.31 Misoprostol is used for a range of reproductive health indications, including management of postpartum bleeding.33 It passes into breastmilk, and drug levels rise and fall quickly. Misoprostol may temporarily cause infant diarrhea.20, 31 Within five hours, there are no detectable traces left in breastmilk.34
About one in five confirmed pregnancies end in spontaneous abortion (miscarriage). If you experience an incomplete miscarriage (when some pregnancy tissue remains in the uterus) or a missed miscarriage (when fetal death has occurred but the body does not expel the pregnancy), vacuum aspiration or a misoprostol-only regimen may be used as part of your treatment.
Understanding your fertility is an important aspect of life as a new mother. There are many options available for breastfeeding mothers who want or need to manage their fertility. This article is an introduction to this important subject, and we encourage you to continue the conversation with your health-care provider and/or your partner. Remember, you have the right to decide how to manage your fertility. Only you can decide which option is right for you. Being an active, informed health-care consumer can help you achieve your goal.
Information about contraceptive methods:
Information about contraception and breastfeeding:
 Jackson, E. & Glasier, A. (2011). Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstetrics and Gynecology, 117(3), 657-62.
 The Academy of Breastfeeding Medicine. (2005). Clinical Protocol Number 13: Contraception during breastfeeding. (Author’s note: This document cannot be retrived online because it is out of date. As of May 12, 2014, the Academy had not released its revised version.)
 World Health Organization, Department of Reproductive Health and Research. (2007). Report of a WHO technical consultation on birth spacing. Geneva, Switzerland: World Health Organization.
 Zhu, B. P. (2005). The effect of interpregnancy interval on birth outcomes: findings from three recent US studies. International Journal of Gynecology and Obstetrics, 89 (Supplement 1), 25–33.
 Labbok, M. H. (2007). Breastfeeding, birth spacing, and family planning. Hale & Hartmann’s textbook of human lactation. Eds. Hale, T. W. & Hartmann, P. F. Amarillo, Texas: Hale Publishing
 Trussell, J. (2011). Contraceptive Efficacy. Contraceptive Technology, Twentieth Revised Edition. Eds. Hatcher, R. A. et al. New York, NY: Ardent Media.
 The Breastfeeding Answer Book. (2012). Retrived on April 23, 2014, from http://www.llli.org/docs/0_babupdate/04babupdatecontraception.pdf
 Labbok, M. H. et al. (1997). Multicenter study of the Lactation Amenorrhea Method (LAM): Efficacy, duration and implications for clinical applications. Contraception, 55, 327-36.
 Valdéz, V. et al. (2000). The efficacy of the lactational amenorrhea method (LAM) among working women. Contraception, 62, 217-9.
 Weschler, T. (2006). Taking Charge of Your Fertility, the Definitive Guide to Natural Birth Control, Pregnancy Achievement and Reproductive Health, Tenth edition. New York, NY: HarperCollins Publishers.
 Johns Hopkins Bloomberg School of Public Health/ Center for Communication Programs & World Health Organization. (2011). Family planning: a global handbook for providers, 2011 Update. Geneva, Switzerland: World Health Organization.
 Jonsson, B., Landgren, B-M. & Eneroth, P. (1991). Effects of various IUDs on the composition of cervical mucus. Contraception, 43, 447-58.
 Ortiz, M. E. & Croxatto, H. B. (2007). Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Contraception, 75 (Supplement 6), S16-30.
 Health Matters Fact Sheets, Implant. (2010). Retrived on April 23, 2014 from http://www.arhp.org/Publications-and-Resources/Patient-Resources/fact-sh...
 American Academy of Pediatrics. (2001). Transfer of drugs and other chemicals into human milk. Pediatrics, 108(3), 776-789.
 Mohrbacher, N. (2010). Breastfeeding Answers Made Simple, a Guide for Helping Mothers. Amarillo, Texas: Hale Publishing.
 Interventions Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy: RHL commentary. (2008). Retrived on May 12, 2014 from http://apps.who.int/rhl/fertility/contraception/CD001326_bahamondesl_com...
 World Health Organization. (2010). Combined hormonal contraceptive use during the post-partum period. Geneva, Switzerland: World Health Organization.
 World Health Organization. (2008). Progestogen-only contraceptive use during lactation and its effects on the neonate. Geneva, Switzerland: World Health Organization.
 Hale, T. W. (2008). Medications and Mothers’ Milk, Thirteenth edition. Amarillo, Texas: Pharmasoft Medical Publishing.
 International Consortium for Emergency Contraception. (2012). The Intrauterine Device (IUD) for Emergency Contraception. New York, NY: Family Care International.
 Schwarz, E. B. & Trussell, J. (2011). Emergency Contraception. Contraceptive Technology, Twentieth Revised Edition. Eds. Hatcher, R. A. et al. New York, NY: Ardent Media.
 The American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women. (2012). Committee Opinion Number 530: Access to Postpartum Sterilization. Obstetrics and Gynecology, 120, 212-215.
 International Planned Parenthood Federation. (2004). Medical and Service Delivery Guidelines for Sexual and Reproductive Health Services, Third Edition. London, United Kingdom, International Planned Parenthood Federation.
 The difference between medical abortion and emergency contraceptive pills. (2010). Retrived on April 23, 2014 from http://www.arhp.org/publications-andresources/clinical-fact-sheets/mifep...
 Gainer, E. et al. (2007). Levonorgestrel pharmacokinetics in plasma and milk of lactating women who take 1.5 mg for emergency contraception. Human Reproduction, 22(6), 1578–1584.
 Polakow-Farkash, S. et al. (2013). Levonorgestrel used for emergency contraception during lactation, a prospective observational cohort study on maternal and infant safety. Journal of Maternal, Fetal and Neonatal Medicine, 26(3), 219-221.
 International Consortium for Emergency Contraception. (2013). Clinical Summary: Emergency contraceptive pills. New York, NY: Family Care International.
 Guttmacher Institute. (2014). Induced Abortion in the United States. New York, NY: Guttmacher Institute.
 Ipas. (2009). Medical Abortion Study Guide. Chapel Hill, North Carolina: Ipas.
 My bpas Guide. (2012). Retrived on April 23, 2014 from http://www.bpas.org/js/filemanager/files/my_bpas_guide_jul_12.pdf
 Saav, I. et al. 2010. Medical abortion in lactating women: low levels of mifepristone in breast milk. Acta Obstetricia et Gynecologica Scandinavica, 89(5), 618-622.
 Allen, R. & O’Brien, B. M. (2009). Uses of Misoprostol in Obstetrics and Gynecology. Reviews in Obstetrics and Gynecology, 2(3), 159-168.
 Vogel, D. et al. (2004). Misoprostol versus methylergometrine: Pharmacokinetics in human milk. American Journal of Obstetrics and Gynecology, 191(6), 2168-73.
 Abdel-Aleem, H., et al. (2003). The pharmacokinetics of the prostaglandin E1 analogue misoprostol in plasma and colostrum after postpartum oral administration. European Journal of Obstetrics and Gynecology and Reproductive Biology, 108, 25-8.
 Ayrim, A., Gunduz S., Akcal B., Kafali, H. (2014). Breastfeeding Throughout Pregnancy in Turkish Women. Breastfeed Med, 9(3), 157-160.
© Copyright Breastfeeding USA 2014. All rights are reserved. Revised August 2015.
How can something that is so small hurt so much? That is the question I asked myself when I developed a bleb on my right nipple. Then asked again when the next one developed in the exact same spot. And again. And again. I asked myself this question eight times for a total of eight recurrent blebs. Ouch!
Blebs made it hurt to breastfeed and also to not breastfeed. Any pressure, even the slightest, on my nipple made me cringe. That included wearing a bra or top. I remember lying in bed with an open nipple pore (after I had wiped away a bleb) trying to sleep and feeling excruciating pain. I remember being confused by that because I had expected the pain to go away once the bleb had been removed. A lactation consultant told me the pain was nerves responding to air entering the nipple pore. True? I don’t know. I just know that until I developed my first bleb, I had never experienced pain like this before.
So what is a bleb? A bleb (also called a milk blister or blocked nipple pore) is what forms when a little bit of skin grows over a nipple pore (milk duct opening), and breast milk backs up behind it. According to kellymom.com, “A milk blister usually shows up as a painful white, clear or yellow dot on the nipple or areola, and the pain tends to be focused at that spot and just behind it. If you compress the breast so that milk is forced down the ducts, the blister will typically bulge outward. Milk blisters can be persistent and very painful during feeding, and may remain for several days or weeks and then spontaneously heal when the skin peels away from the affected area.” 1
Why do some breastfeeding women develop milk blebs? There are a variety of possibilities, such as oversupply, wearing a tight bra or something that puts pressure on that area of the breast, and latch or suck problems.
I dealt with oversupply for the first several months after my second baby was born. She had a posterior tongue tie and upper lip tie, which created latch problems. These eight blebs occurred during her first twelve weeks while I was on maternity leave. I remember vividly the relief I felt each time they disappeared, followed by dread each time they reoccurred.
How can we get rid of blebs and better yet, how can we prevent them? Before breastfeeding, soak the breast in warm water or apply a warm, wet compress. This may make it easier for the baby to remove the bleb while nursing. If that works, go ahead and treat the area to assist in healing (e.g. saline rinse, application of expressed breastmilk, application of an antibiotic ointment that is compatible with breastfeeding). If the bleb remains in place after breastfeeding, however, there are other steps that can be taken to eliminate it. Some sources suggest applying olive oil to a cotton ball and wearing it in the bra so that the oil softens the skin where the bleb is located 2. Afterward, try to remove the bleb by rubbing it gently with a warm, wet washcloth. If the bleb still remains, see a health-care provider, who can open the bleb with a sterile needle so that the milk can flow out.
If blebs recur, consider eliminating saturated fat from your diet and taking lecithin in either liquid (one tablespoon three times per day) or capsule (one or two 1,200 mg three or four times per day) 2,3 . Be aware that lecithin is often a soy-based product; check the label for the source. Identifying and resolving the underlying cause for recurrent blebs goes a long way toward preventing more of them.
My own story went like this: As I wrote at the beginning of this article, I had eight blebs back to back to back to….you get the idea. I soaked my breast in warm water before every feeding. I often started each feeding with the unaffected breast because my daughter’s hunger would be somewhat satisfied when she got to my right breast. Consequently, her sucking wasn't as vigorous. After each feeding, I sprayed my breasts with a homemade saline solution. Breastfeeding, however, was not enough to open up the blebs. The only way I could remove them was to rub them with a washcloth in the shower. During, in between, and even for months after the blebs went away (for fear they would return), every evening after my daughter was asleep I put an olive oil-soaked cotton ball in my (underwire-free) nursing bra. I kept it in my bra for at least 15 minutes and then hand expressed so that more milk didn't back up behind the nipple pore. Thankfully after the blebs stopped forming, the nipple pore remained open. Even today, almost three years later, that one spot still has a wide, visible opening.
I hope you never get a bleb. If you do, I hope the information presented here helps you find resolution quickly.
- Mohrbacher, N. (2010). Breastfeeding Answers Made Simple. Hale Publishing, L.P. 658-659.
- Mohrbacher, N. (2013). Breastfeeding Solutions: Quick Tips for the Most Common Nursing Challenges. New Harbinger Publications, 90-91.
Published June 2014
© Copyright Breastfeeding USA 2014. All rights are reserved.
After having overcome some breastfeeding challenges with my first daughter, I was looking forward to an easier experience the second time around. Finding out that my second daughter, Miriam, would be born with a unilateral cleft lip and palate was a cold shower - the first of many. I didn't know exactly how it would affect breastfeeding, but I knew deep down that my dreams of a carefree breastfeeding experience were no longer going to come true. When I got home, I took my breastfeeding reference book off the shelf and discovered that breastfeeding (as I then imagined it - exclusive breastfeeding at the breast), with a cleft lip and palate, may not have even been possible. I was thoroughly devastated.
I managed to muddle through my daughter’s first seven months, patching together information from different sources, feeding her expressed breast milk and partially breastfeeding at the breast as she got older, until her palate operation (at 6 ½ months) after which she learnt to breastfeed unaided. In the seven years since, I have spoken with a multitude of parents whose babies have clefts, who have recounted their difficulties with breastfeeding. From their experiences and my own research, I have come to the conclusion that many difficulties faced by the parent and baby are management issues -- lack of support, lack of information, and lack of practical help. Instead of receiving the best breastfeeding support available (i.e. the red carpet treatment), these mother-baby dyads and their families are often forgotten, or their difficulties are underestimated.
In the US, a cleft lip and/or palate affect approximately 1 in 600 live births 1. Frequency of the conditions varies from country to country. Despite the incidence of clefts, there is very little in the breastfeeding literature about breastfeeding with a cleft lip and palate, and very few breastfeeding counselors and lactation consultants seem to have direct and repeated experience with it. Even my family doctor knew very little about the condition; we had to do quite a bit of research before finding my daughter’s future cleft repair team. Now, with the number of Internet parent support groups 1, 2, finding information is a little more straightforward. There is still a long way to go in many countries, however, before a positive diagnosis of cleft lip and/or palate is followed by relevant and reliable information on what to do next.
Cleft lip and/or palate are umbrella terms for various presentations of a facial cleft 3. A cleft lip can affect the lip only, lip and gum (alveolar ridge), and may possibly include a submucosal cleft palate. A solitary cleft palate can be submucosal (not seen by the eye and frequently missed during postnatal checks), or involve the soft palate, or both hard and soft palates. A cleft lip and palate will include lip, gum (alveolar ridge), and hard and soft palates. The size of the cleft can vary from a few millimeters to a centimeter or more.
Different clefts will impact breastfeeding in different ways 4, 5. The recently revised Academy of Breastfeeding Medicine guidelines for breastfeeding with a cleft lip and/or palates, note that the “literature describing breastfeeding outcomes is limited, and the evidence is anecdotal and contradictory.” The guidelines state that both suction and compression (pressing breast between tongue and jaw) are necessary for milk transfer during breastfeeding and that the amount of oral pressure generated during feeding will depend on the size and type of cleft and the maturity of the baby. For this reason, babies with a cleft lip only are more likely to breastfeed than those with a cleft palate or a cleft lip and palate. Some babies with small clefts of the soft palate generate suction, but others with larger clefts of the soft and/or hard palate may not. Older babies generate more suction than newborns and premature babies.
Anecdotally, many mothers recount that they have been successful at breastfeeding exclusively when their baby presents with a cleft lip only (even when bilateral, and even including the alveolar ridge or gum). There is some discussion over whether a baby with a cleft of the soft palate can manage to breastfeed exclusively. I have come across four different personal accounts of mothers who have successfully breastfed (at the breast) a baby with a cleft of the soft palate 6, 7, 8, 9. Breastfeeding an infant with both a cleft lip and palate appears to be more elusive, although one medical study in Thailand9 recounts success with exclusive breastfeeding. Hopefully, more studies will be forthcoming.
From my experience, I believe that with optimal breastfeeding support immediately after birth and in the following days, babies with clefts will be able to show their true breastfeeding potential. I call this “the red carpet treatment.” Expert support in the very early days after birth should help parents to avoid most of the more common breastfeeding difficulties, especially problems associated with low milk production. What we parents often don’t receive is help getting our babies to latch on in the first hours after birth, evaluation of breastfeeding and milk transfer, and determining whether supplementing is necessary and how that should be done. This “red carpet treatment” would help ensure that we maximize our milk production, whether the baby is receiving milk at the breast or via other means. When milk production is insufficient, we also need to know what our options are when exclusive breastfeeding is not possible.
The “red carpet treatment” of breastfeeding support for a cleft-affected infant might include:
- Early skin-to-skin contact and help with latching within the first hour after birth 10
- Early evaluation of breastfeeding, positioning, and milk transfer
- When milk transfer at the breast is insufficient, or baby is unable to latch, help with colostrum expression, within first hour after birth and at least every three hours after that 11
- Assistance with and instruction of optimal expression techniques (hand expression, or combination of hand expression/double electric pumping, in first 48 hours or until copious milk production begins, double electric pumping combined with ‘hands-on’ techniques subsequently) 12
- When milk production is insufficient, help with implementing strategies for maximizing milk transfer 13 and supply, such as hot compresses before a feed/pumping session; breast massages before or during feed/pumping session; breast compressions; breast massage and reverse pressure softening 14 to encourage milk let down; expressing after breastfeeds to build supply; and the use of galactogogues 13
- Evaluation of whether and how to supplement – via bottle, syringe, spoon, or an at-the-breast supplementer; and full information about options including donor milk and formula
- Psychological support
- Practical support – a feeding/pumping plan and how to find the time to manage that along with family/home responsibilities and time for looking after one's self
Some parents are concerned about knowing the exact presentation of their child's cleft prior to birth. Knowledge of the cleft can facilitate preparation for breastfeeding and researching and choosing a cleft surgeon or team, but is not necessary. Currently, in the United Kingdom, it is encouraged to express colostrum prenatally 15. when expecting a baby affected by cleft lip or palate, in case a supplement is required after birth. This colostrum is a great backup, although it is important that using this backup not take the place of early breastfeeding initiation and/or frequent postnatal expression, vital for establishing good milk production.
Mothers, who have been successful with at-the-breast feeding, recount techniques that they have found useful, including:
- Closing lip with fingers to help make a seal
- Experimenting with different positions to enable baby to maintain suck and swallow, such as using the breast tissue to close the cleft
- Dealing with early signs of engorgement due to inefficient or incomplete drainage of all areas of the breast such as rotating the position of the baby's mouth/latch around the breast, reverse pressure softening, hand expression and pumping
- Maintaining an abundant milk supply
- Assisting milk letdown via hand expression, breast compressions, and visualization of the milk flowing
Timing of cleft surgery and surgical protocols vary enormously from country to country and from surgeon to surgeon. There are various programs in force attempting to standardize cleft protocols 16, 17. The cleft may be repaired in one surgery or multiple stages - the palate and lip together or separately. The lip may be repaired as early as two months or as late as a year and a half. The palate may be repaired in the early weeks, at around six months, or after the first birthday. Some surgical teams will allow breastfeeding/bottle feeding immediately after surgery, while others will require temporary weaning from breast/bottle for some weeks. Breastfeeding is usually possible because the breast is soft and pliable, conforming to the baby's mouth.
Exclusively breastfed babies will often find comfort in breastfeeding immediately after surgery, although some babies may refuse the breast for hours or days. Babies who have undergone palate surgery are often reluctant to feed at all in the early days after repair, and this can be challenging. A baby may be more willing to feed with a cup or spoon because lip suction is not needed. It is important to maintain milk production during this transitional period.
Transitioning to the Breast
After palate repair, there is a chance that the baby will transition to the breast almost fully (palate repair generally occurs from five/six months onwards and solids may also be introduced). This can be a delicate time as many factors occur simultaneously. The baby may be reluctant to feed at all either at the breast, via bottle, or spoon-fed solids as the palate surgery involves the incisioning and redirection of the palatal muscles. A decrease in milk production may occur due to fatigue and stress post-surgery. Transitioning to the breast 20 requires extra time and effort.
Transitioning to the breast after palate surgery is the last great challenge in breastfeeding a cleft-affected child - 'the last hump' in the difficult breastfeeding journey. When my own daughter was recovering from palate surgery (age six months), she went on an all out 'nursing strike' and would scream every time I attempted to latch her onto the breast. I decided to put in one last major effort, dedicating myself entirely to pumping AND nursing. It was a very intense time. In the end, thanks to a silicone nipple shield taped over a supplementing device, Miriam accepted the breast again. Within a couple of days, she was breastfeeding solo without bottles and pumped milk. It was a huge relief, and each time we sat down to nurse after that was a celebration. Many other mothers recount similar experiences.
However, not every baby does go on to breastfeed unaided at the breast. One mother recounts that her son breastfed unaided for around a month before a fistule opened in his palate; he lost suction and ceased breastfeeding. Others have found the process of transitioning to the breast too stressful for both mother and baby. Some babies are more intent on learning to breastfeed, while others are not. Transitioning to the breast should not be our only goal.
One mother of triplets (all three with a cleft!) recounts that she 'raised the white flag' when her sons reached six months. It is important to keep that white flag handy. Sometimes it is breastfeeding and/or pumping that will be let go, or it could be something else in our everyday routine and family organization. Evaluating priorities is an ongoing process, and it can be useful to discuss this with a Breastfeeding USA Counselor or a Lactation Consultant (IBCLC).
We all need to feel that we are doing the best for our children. When breastfeeding is harder than we expect, it helps to be reminded that we are doing our best, even if our best is less than we would like. Breastfeeding does not have to be limited to exclusive breastfeeding. The World Health Organization defines breastfeeding 18 as an infant being fed human milk, whether from the breast or expressed (including donor milk), and other foods - we shouldn't lose sight of that. Every drop of breast milk that we provide is a cause for celebration.
Over the years that have followed my own breastfeeding experience, I have sought out other breastfeeding families, both to offer support, but also to learn more about what exactly makes breastfeeding a baby with a cleft lip and/or palate difficult. The more I hear, the more I realize that we don’t have enough expert support. Parents often arrive at birth very well informed, but lack hands-on help and an expert eye. Sometimes parents encounter criticism and discouragement. I encourage other parents to tell their stories – whether they have attempted breastfeeding and if so, whether they have breastfed partially or fully. Doing so helps to increase the body of knowledge on breastfeeding with a cleft lip and/or palate. I continue to seek out resources, both print and video, and have created a website 19 so that parents and health-care workers have a starting point for their own research.
It takes more than the efforts of one parent to breastfeed a cleft-affected child. It takes not only the patience and support of the whole family, but also the community, especially the health-care community that surrounds us. What we need is more than just encouragement and information; we also need the right support - "the red carpet treatment."
- PR1. Cleft Palate Foundation, For parents of newborn babies with cleft lip/cleft palate (accessed october, 2013) http://www.cleftline.org/parents-individuals/publications/fact-sheets/
- PR2. Cleft Advocate http://www.cleftadvocate.org/
- PR3. Cleft Lip and Palate Foundation of Smiles www.cleftsmile.org/
- PR4. Cleft Lip and Palate Breastfeeding Discussion Group https://www.facebook.com/groups/339242706210018/
- PR5. Baby centre cleft moms https://www.facebook.com/groups/425825524141451/
- PR6. Exclusive expressing/pumping https://www.facebook.com/groups/19128555821/
- Farrow, A, 2013, One cleft is not like another, (accessed October 2013) http://cleftlipandpalatebreastfeeding.com/2013/08/one-cleft-is-not-like-...
- Reilly, S., et al., revised 2013, ABM Clinical protocol #17: guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate, revised 2013, Academy of Breastfeeding Medicine
- Farrow, A., What to expect, http://cleftlipandpalatebreastfeeding.com/2013/07/what-to-expect/ (accessed October 2013)
- Grady,E,. 1983, Nursing my baby with a cleft of the soft palate, Schaumburg, Illinois, La Leche League International, 1983 (out of print)
- Cleft palate breastfeeding (video) http://www.youtube.com/watch?v=BpqqYQlKDeA (accessed October 2013)
- Cwir, J. (ed), 2013, I wish I’d known….how much I’d love you!’, CreateSpace Independent Publishing Platform
- Pathumwiwatana P, et al. The promotion of exclusive breastfeeding in infants with complete cleft lip and palate during the first 6 months after childbirth at Srinagarind Hospital, Khon Kaen Province, Thailand. J Med Assoc Thai 2010; 93. Suppl 4; S71-77
- WHO Breastfeeding – early initiation e-Library of Evidence for Nutrition Actions (eLENA) http://www.who.int/elena/titles/early_breastfeeding/en/index.html (accessed October 2013)
- West, D., Maximizing a Mother’s Milk Production Capability, http://www.breastfeedingconferences.com.au/search_results.php?cx=0074617... (accessed October 2013)
- West, D. and Marasco, L., (2009). The Breastfeeding Mother's Guide to Making More Milk. New York, NY: McGraw Hill.
- Cotterman, J., Reverse Pressure Softening http://www.breastfeedingmadesimple.com/SimplerRPSsheet2.doc (accessed October 2013)
- Soper, D., Expressing Milk Before Birth: A Tool for Use in Special Circumstances
https://breastfeedingusa.org/content/article/expressing-milk-birth-tool-... (accessed October 2013)V
- The Americleft Outcomes Project http://www.acpa-cpf.org/research/the_americleft_outcomes_project/
- Eurocleft Journal of Cranio-Maxillofacial Surgery (2001) 29,(3):131-40; discussion 141-2
# 2001 European Association for Cranio-Maxillofacial Surgery
doi:10.1054/jcms.2001.0217, available online at http://www.idealibrary.com on (accessed October 2013)
- The World Health Organization's infant feeding recommendation http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/
- Australian Breastfeeding Association: Breastfeeding babies with clefts of lip and/or palate https://www.breastfeeding.asn.au/bfinfo/cleftpalate.html
© Copyright Breastfeeding USA 2014. All rights are reserved.
When I was pregnant, there were many decisions to be made about how to balance the needs of a new baby while continuing an earth-friendly lifestyle. From cloth diapers to organic cotton baby clothes and non-toxic toys, many small choices were made with the bigger picture in mind. For many reasons, I chose to breastfeed — a decision that impacted me, my baby, and Mother Earth!
Packaging: Human milk is ready to serve in its original container and is already at the perfect temperature! If every child in America were bottle-fed, almost 86,000 tons of tin would be needed to produce the 550 million cans required for a year’s worth of artificial formula. Plus, bottles and nipples are made from glass, rubber, plastic, and silicon; most are not recyclable.
Waste: Formula packaging and shipping boxes contribute to the waste in landfills. If a baby goes through eight 12-ounce cans of formula per month, 96 empty containers are thrown away before his first birthday. Plus, when breastfeeding, there’s no worry about BPA-lined bottles and cans, or formula recalls for contaminants.
Production: Manufacturing formula requires huge dairy farms, milking machines, cattle feed, manure disposal, factories, packaging, and shipping with all the associated costs. Breastfeeding requires none of these, and is free. Substituting cow’s milk for human milk destroys the water, land, and air. Waste from cattle farms pollutes rivers and groundwater. Cow flatulence releases methane, which may contribute to the destruction of the ozone layer. It would take 135 million lactating cows to substitute the breast milk just of the women of India.2 That many cows would require 43% of the surface of India to be devoted to pasture.
Fewer tampons and diapers: Women who practice total, unrestricted breastfeeding average 14 months without menstruating. This helps with child spacing, and reduces the need for sanitary products. And because formula is absorbed slowly and inefficiently, babies receiving formula excrete more and require more diapers.
Breastfeeding is a natural, renewable resource making it the perfect environmentally-friendly choice.
1. Happy Earth Day http://normaritter.blogspot.com/2009_04_01_archive.html
2. The Ecological Impact of Bottle Feeding, by Andrew Radford, Baby Milk Action http://www.reducepackaging.com/impact-bottlefeeding.html
3. Breastfeeding; The Eco-Friendly Way to Feed Your Baby www.gogreenstreet.com/%20breastfeeding-the-eco-friendly-way-to-feed-your...
4. Breastmilk: the perfect renewable resource http://www.infactcanada.ca/ren_res.htm
© Copyright Breastfeeding USA 2013. All rights are reserved.
The season of sneezes and sniffles is upon us, and many moms and babies are likely to catch colds or the flu. Evidence shows that breastfed babies have considerable protection from such illnesses, and when they do become ill, relief can come directly from mother’s milk.
Colostrum, the early milk a breastfed newborn receives for a few days after birth, contains highly concentrated antibodies that protect against many diseases. Mature milk continues to protect infants from many diseases and strengthens the immune system. Babies who are not breastfed have a higher risk of contracting bacterial infections, such as E. coli and salmonella; viral infections, such as influenza and rotavirus; as well as parasites.
One of the most amazing qualities of human milk is how it adapts. As mother and baby are exposed to bacteria and viruses, milk includes antibodies specific to those antigens. It also contains more general disease-fighting substances that provide help in preventing many common illnesses. A mother will pass antibodies to her baby through her milk, which can actually destroy bacteria in the infant’s gastrointestinal tract before they have a chance to make baby sick. Ear infections and allergies occur more commonly in babies who are not breastfed.
When baby does get sick, one of the best things a mother can do is keep breastfeeding. Babies who are ill need to keep up their fluid intake, especially if there is vomiting or diarrhea. Breastfeeding should continue as usual, and there is rarely a need to replace or supplement human milk with water, juice, or Pedialyte. If the baby is too sick to breastfeed, expressed breast milk can be given from a cup, bottle, syringe, or eyedropper.
If baby’s nose is too stuffy to breastfeed, suggestions include:1,2
- Run a cool mist vaporizer near where baby sleeps.
- Take baby into the bathroom after you have filled the room with steam from the shower.
- Add a pinch of salt to a cup of warm tap water and squirt a few drops into baby’s nostrils using an eyedropper (or use a commercial saline nose spray).
- Use a nasal aspirator to suction mucus from baby’s nostrils. Squeeze the bulb first, insert the tip into baby’s nose, and then slowly release the bulb so the suction gently pulls out excess mucus. Mom’s health-care provider can show her how to use a nose spray or do nasal suctioning, if she hasn't already been instructed in these techniques.
Here is a video demonstrating nasal suctioning.
When mother is sick, there are a few steps she can take to reduce the chance of passing the illness to her baby, such as washing her hands frequently, and trying not to cough or sneeze on the baby while nursing or whenever baby is close.
Nursing mothers should be cautious of taking over-the-counter medications while breastfeeding. Decongestants can cause babies to be irritable, and antihistamines can make them drowsy.1 Pseudoephedrine has been shown to suppress milk supply. 2 For more information about medications for use in breastfeeding mothers, visit LactMed.
1. Gaskin, Ina May. Ina May's Guide to Breastfeeding. NYC: Bantam, 2009.
2. Lauwers, Judith, and Anna Swisher. Counseling the Nursing Mother. Sudbury. MA: Jones and Bartlett, 2011.
© Copyright Breastfeeding USA 2014. All rights are reserved.
“I can’t believe she’s doing THAT in public!” could be a comment on a multitude of situations. Unfortunately, it’s often used when a mother is seen nursing her child outside of the home. Breastfeeding in public is a top concern of many nursing mothers - they are worried about what people will say, whether they will be asked to leave a public place, or afraid they’ll become a headline news story! Why and when did breastfeeding in public become cause for public outcry? What is all the fuss about?
Nursing in public seemed to be a non-issue in colonial America. Our foremothers were expected to maintain a busy household, which included feeding the baby, and breastfeeding in the market or other public areas was not a cause for uproar. At that time, breastfeeding was the only way to feed a baby, either by the natural mother or a wet-nurse. The Puritans believed breasts were created for the nourishment of children and strongly encouraged women to nurse their own babies. 1 Breastfeeding in public was commonplace for colonial women because they lived in a society that supported breastfeeding.
What happened to change American society's views on nursing in public? Society’s outlook on breastfeeding began to change as the modern feeding bottle and nipple were invented, and commercially-created infant formulas became more accepted in the early 20th century. Scientists began analyzing components of human milk; this data also spurred the search for a chemically-modified animal milk that would closely resemble human milk. 2
Breastfeeding was dealt a double whammy in the early 20th century. As World War II raged on, women were needed to fill jobs left empty by men going off to war. Breast pumps were primitive in design, there were no laws that allowed women time to express milk while at work, and wet nursing went out of style. What was a mother to do? At this same time, large-scale manufacturing made infant formula easier for mothers to access.3 Formula manufacturers cultivated relationships with physicians, which led to physicians promoting formula use as a safe and accepted way to feed baby. With so many factors suppressing breastfeeding, it isn't surprising that breastfeeding rates began to decline sharply after World War II.
As infant formulas became more accepted in society, they became more popular, and bottles became commonplace. Breastfeeding rates declined steadily until the 1970s. With fewer women breastfeeding, even fewer were seen breastfeeding outside their homes. The sight of a woman nursing her child lost its normalcy and was replaced by bottle feeding. Consequently, when a woman is now seen nursing her baby, it feels alien and creates discomfort in many people. The rise of direct-to-consumer marketing and the use of women and breasts to sell products also contributed to this unfamiliarity with breastfeeding. In our society, breasts are often used to sell cars and beer; when they are seen being used for their biological purpose, it creates conflict for some people.
One major conflict is the so-called “Mommy Wars,” of which breastfeeding versus formula feeding is a major battleground. Influenced by the formula companies’ devotion to shareholder profit instead of mother support, the Mommy Wars play on a mother’s insecurity and fear that she is “ruining her child” or “doing it wrong.” If a woman had a prior negative breastfeeding experience, seeing a woman breastfeed in public might trigger upsetting emotions.
Today, nursing in public, or NIP, has become a hot-button issue. Women are told to cover up, feed in a bathroom, feed somewhere else, or are subjected to the stares of an uninformed public. Concerned breastfeeding supporters descend on businesses to hold nurse-ins. There is a NIP hotline sponsored by the nonprofit organization, Best for Babes, that collects stories of women being harassed while nursing in public and offers support and encouragement.4 Women can even take a 7-day e-course on how to nurse in public.5 Nursing in public is a popular topic of discussion at Breastfeeding USA Chapter meetings.
In many aspects, the law is on the side of a breastfeeding mother when nursing in public. At the federal government level, Public Law 106-58, Section 647 states: “Notwithstanding any other provision of law, a woman may breastfeed her child at any location in a Federal building or on Federal property, if the woman and her child are otherwise authorized to be present at the location.”6 Laws vary by state and most states have have laws that specifically allow women to breastfeed in any public or private location. Find up-to-date information about the breastfeeding laws in your state at the National Conference of State Legislatures: Breastfeeding Laws
Knowing all this, how can we normalize breastfeeding in public? Here are some ideas:
- Know the breastfeeding laws in your state and educate your staff.
- If a staff member treats a breastfeeding mother inappropriately, promptly apologize to the mother and give that staff member the training they need.
- If possible, have available areas where breastfeeding mothers can feed privately, if they desire. A bathroom does not qualify as a nursing area, but a dressing room might!
- When you see a breastfeeding mother, offer a smile, a thumbs up, or some words of encouragement; remember that staring might make her uncomfortable.
- If seeing breastfeeding makes you uncomfortable, look the other way.
- Some people are concerned about children seeing babies breastfeed. If your child sees a baby at the breast and asks you about it, simply say, “That mommy is feeding her baby.” Children generally don’t need or want a long explanation when a short one will suffice.
- Find what is comfortable for you. Pamela prefers to cover and be somewhat discreet, while Katie pops her baby in the carrier to feed and goes on with her day. The point is, figure out your nursing-in-public style: Cover or no cover? Park bench or your car? Dressing room or front of the store? Feeding in the carrier/sling? There are many ways to customize breastfeeding in public to fit your comfort level.
- Practice at home in front of a mirror or a supportive person before you go out! This will help you gain the confidence you need to feed your baby when you are away from home.
- Find support. If you’re nervous the first few times you go out, take an encouraging friend. Talk to your partner about your commitment to breastfeeding and how to help you in public.
- Know your rights. It may be helpful to carry a copy of your state’s breastfeeding laws to help educate anyone who questions you about nursing in public.
- Support other mothers. One way to normalize breastfeeding in public is to stop buying into the idea that mothers are in competition with each other. Instead of criticizing a woman for “having her breasts out,” realize that she is just trying to feed her baby, who otherwise could be screaming. Public breastfeeding isn’t meant to “show off” breastfeeding skills; it’s simply the reality of daily life and nourishment for your baby.
1. Mays, D A (2004). Women in Early America: Struggle, Survival, and Freedom in a New World. Santa Barbara, CA: ABC-CLIO.
2. Stevens, E. E., Patrick, T. E., and Pickler, R. (2009). A History of Infant Feeding. Journal of Perinatal Education, 18, 32–39. doi: 10.1624/105812409X426314
3. Weimer, J.P. (2001). The Economic Benefits of Breastfeeding: A Review and Analysis. Washington, D.C.: U.S. Department of Agriculture. http://www.ers.usda.gov/media/329098/fanrr13_1_.pdf
4. Hickman, M. (2011). Announcing 1-855-NIP-FREE: the Best for Babes “Nursing In Public” Harassment Hotline. Retrieved March 11, 2013 from http://www.bestforbabes.org/announcing-1-855-nip-free-the-best-for-babes....
5. Theuring, A, 2012. Become a Badass Public Breastfeeder in 7 Days. Retrieved January 27, 2013 from http://web.archive.org/web/20130516015708/http://gentleparentinfo.com/Ba... .
6. United States Breastfeeding Committee. (n.d.). Existing Legislation. Retrieved March 11, 2013 from http://www.usbreastfeeding.org/LegislationPolicy/ExistingLegislation/tab....
© Copyright Breastfeeding USA 2014. All rights are reserved.
When breastfeeding, inevitably the topic of weaning comes up. “How long will you go for?” “What’s your goal?” “Are you going to nurse until baby is ready to stop?” “You’ll stop before he goes to college, right?” The answers to these questions (except the last one!) are not so simple. Breastfeeding is a relationship between two people - mother and baby. As both evolve and grow throughout the relationship, so do ideas about weaning.
There is usually a time frame involved when discussing the duration of breastfeeding: exclusively at least until about six months of age, then combined with complementary foods to one year and beyond(1) or to two years and beyond (World Health Organization (2). Right from the start, the idea of an end date is planted in the minds of mothers. Often, once mothers reach these scheduled milestones, they find they enjoy breastfeeding too much to stop and decide to keep going. Rarely does a mother say, “I’ll breastfeed until I’m ready to stop.” When this situation arises – that mom is ready to stop breastfeeding but baby isn’t quite there yet – complicated emotions may develop.
What is weaning?
Depending on culture, weaning may be defined as introducing foods other than human milk to a baby or stopping breastfeeding entirely(3). For the purposes of this article, we will discuss weaning as ending all feeding at the breast.
Natural weaning, sometimes called child-led weaning, occurs when the child no longer has an emotional or nutritive need to breastfeed.(4) This usually doesn't occur before 18-24 months of age. Letting the child set the pace for weaning allows him to reach the developmental milestone of weaning on his own timeline. Though the child may ultimately decide when the breastfeeding relationship is over, this does not mean the mother sits by passively. As with any relationship, there is an element of give-and-take in the breastfeeding relationship. Mothers can set limits as the child grows older, such as only nursing at certain times of the day or asking the child to wait until mom is finished with a meal or task. Natural weaning is an intricate dance between mother and child that can take months or sometimes even a year or more to play out.
Mother-led weaning happens when a mother actively encourages weaning before a child is naturally ready. This may be done by increasing the use of a bottle or cup, offering food/drink besides human milk, or limiting nursing.
When NOT to wean
It’s important to note that there are several common reasons mothers give for weaning that may not be in the best interests of both mother and child. These include:
- Pressure from others: Friends and family will have their own opinions about when a mother should wean her baby. They are not a part of the nursing relationship and shouldn't be given power in this decision. If you’re finding it difficult to handle the opinions of friends and family, you may be able to find mother-to-mother support through a Breastfeeding USA Counselor.
- Misinformation: Some women are told their milk isn't nutritional after the baby reaches a certain age. Does broccoli stop being healthy after a certain age? No, and neither does your milk. Other myths told to mothers include that she’s only doing it for herself; the child doesn't need breastfeeding after a certain age; breastfeeding past a certain age is bad for the child; or that breastfeeding is the reason she is [insert problem/ailment here]. Talking to a breastfeeding counselor about nursing concerns can help women from prematurely weaning due to faulty information.
- Pregnancy: It is generally considered to be safe to breastfeed while pregnant. According to Dr. Bob Sears, breastfeeding during pregnancy may not be safe for “moms who have a history of miscarriages or preterm labor (labor beginning before 37 weeks gestation) with previous pregnancies (5).”
- Nursing strike:Children who self-wean rarely stop abruptly. If your child suddenly refuses to nurse, chances are it is a nursing strike, rather than weaning.
- Distractibility: Older babies and toddlers become fascinated with the world around them and will sometimes be too distracted to nurse. This does not mean they don’t need the breast anymore – it just means they may need some help focusing on the task of nursing for a while. Moms can help their babies focus by nursing in a quiet, darkened room; trying a new position; or wearing a “nursing necklace” that gives baby something to play with while nursing.
- Going back to work or school: Even if you aren't able to express milk while away from your child, this does not have to mean the end of breastfeeding! You can still breastfeed during the times you are with the child. When mom is away during the day, some babies do what is called reverse cycle breastfeeding: nursing frequently at night and less frequently during the day. Continuing to breastfeed during those times may help both you and baby reconnect after you have been separated. For more information on how to express at work or school, check out the “Expressing Your Milk” section of Breastfeeding USA at https://breastfeedingusa.org/breastfeeding-information.
One important reason that a mother might begin the weaning process is that her feelings about breastfeeding have changed. Amber recalls, “One day I realized that I wasn't enjoying breastfeeding anymore. My nipples had become very sensitive, which made sex difficult to enjoy; I wanted to lose weight but was fearful that dieting or exercising too much would affect my milk; I was tired of only being touched when someone wanted something from me; I was tired of being woken up in the night and early in the morning; I was tired of having to sleep with a bra on . . . but I was determined to finish out my daughter’s first year and avoid putting her on formula.”
Brandie notes that when she reached her goal of one year, she was “just plain ready” to wean, but that “it was an emotional time and a long process that dragged on for months. I think I was ready to wean before my son was, but it was a two-person effort. We didn't successfully wean until he was ready.”
If a mother starts to have negative feelings about breastfeeding, it’s important to explore them. Many women will try to stuff them away, afraid of being labeled selfish or a bad mother. However, keeping those feelings in the dark only allows them to grow stronger.
Amber continues: “I pushed through my growing aversion to being touched and continued to breastfeed my daughter. I started to feel some resentment towards her, especially when she would prolong the experience by looking around like she was done, then fussing if I put my breast away, and I hated when she would reach her little hand over to my other nipple and remind me that she needed her nails cut. My resentment eventually turned to fear: would this experience affect my desire to breastfeed other children?”
The complicated emotions of weaning
The decision to wean is not an easy one. It can help if a mother can identify what she is feeling and then accept those feelings without judgment. Disliking or resenting breastfeeding does not make a woman a bad mother. Next, it might be helpful to talk about these emotions with a breastfeeding counselor or a trusted health-care professional. The decision to wean isn't one that should be made lightly, and talking about it with someone knowledgeable about breastfeeding can help a mother make an informed decision. It’s much easier to continue breastfeeding when you are unsure, than it is to stop and then try to relactate later.
When a woman decides to stop breastfeeding, she needs to know about the physical aspects to watch out for: engorgement with an increased risk of clogged ducts/mastitis. But many mothers are surprised at the intense emotions that can accompany this change. Some mothers, like April, report a mixture of emotions when their child doesn’t need to nurse anymore. A woman may feel nostalgic, sad, or depressed when breastfeeding ends, even if she is the one who made the choice to stop.
Hormonal changes play a part in this. Breastfeeding increases the levels of both prolactin and oxytocin, hormones that create feelings of well-being, calmness, and relaxation in most women. As weaning occurs, these hormone levels will drop, often producing emotional effects. Gradual weaning will help prevent a sudden drop in levels. Oxytocin levels increase during cuddling, hugging, and kissing - all activities that should be encouraged during the weaning process.(6)
In addition to hormonal influences, mothers may feel sadness because weaning marks a change in the mother-child relationship. Breastfeeding is one thing that only the mother can offer, and weaning is an end to that part of mothering. It’s common to miss the connection that breastfeeding provided. Sometimes, if mother-led weaning goes “too easy,” a mother can feel hurt by the child’s lack of concern for stopping nursing. Lisa shares, “I wanted to wean but still felt so guilty and sad. The first full two days that he didn't nurse, I cried all day!” Weaning may trigger a depressive episode in some women, especially if there is prior or underlying depression.(7)
Along with sadness comes the guilt. When a mother decides to stop breastfeeding, she knows she is taking something important from her child. There are two people in a breastfeeding relationship, but it is extremely difficult for most mothers to put their needs ahead of the needs of their baby. The importance of breastfeeding cannot be overstated, but if it is beginning to contribute to negative emotions in the mother-child relationship, then a mother must be empowered to explore these emotions without fear of judgment.
Tips for healthy weaning
If you are thinking about weaning, be prepared for the mélange of emotions that may occur. There are ways you can make this a smoother transition for both you and your child.
- Wean gradually. Drop one feed at a time, with plenty of time in between. Sara estimates that her weaning process took about 4 months. Weaning gradually will protect mother from physical problems, as well as give the child ample time to adjust to the change. Also, if you start dropping feeds and then decide you aren’t ready to fully wean, you’ll be able to continue breastfeeding more easily.
- Find new ways to comfort your child. Your child needs emotional support from you; nursing was one way to provide that. Without nursing, you’ll need to find other ways to comfort your child. Cuddling, hugs, and singing are all good ways to offer comfort without the breast. Enlist the help of your partner or family member, if available, to give your child more attention and skin-to-skin contact.
- Talk to someone. If you are struggling with depression, sadness, anxiety or other strong emotions, find a trusted confidant such as your partner, another family member, a close friend, or a Breastfeeding USA Counselor. If your symptoms persist, consider seeing a health-care professional for additional support.
- Take care of yourself. Eat a healthy, well-balanced diet. Try to get enough sleep. Get outside to enjoy nature. Physical activity is a great way to improve mood through the release of endorphins. Do something special and fun with your child, such as taking walks, going to the park, or another activity your child enjoys.
- Commemorate your breastfeeding experience, especially with an older child, through a weaning ceremony. The Leaky Boob, a popular breastfeeding blog, has some great examples of weaning ceremonies. Writing your nursing story, getting body art, buying/making a special piece of jewelry, and performing ceremonies/rituals are all ways mothers have honored the end of their breastfeeding relationship.
No matter how weaning begins and ends, child-led, or mother-led, or a natural combination of both, it is often a process of great significance for all involved, including other family members. Every child weans at some point. For a fulfilling breastfeeding relationship, weaning needs careful thought, consideration of needs, open discussion, and caring responses.
1. American Academy of Pediatrics. (2012). AAP Reaffirms Breastfeeding Guidelines. Retrieved from http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Reaffirm...
2. World Health Organization. (2013). WHO | Breastfeeding. Retrieved from http://www.who.int/topics/breastfeeding/en/
3. Greiner, T. (1996). The Concept of Weaning: Definitions and Their Implications. Journal of Human Lactation, 12, 123-128.
4. Bonyata, K. (2011). Do Babies Under 12 Months Self-wean? Retrieved from http://kellymom.com/bf/normal/babyselfwean/
5. Sears, Bob. (2013). Breastfeeding While Pregnant. Retrieved from http://www.askdrsears.com/topics/breastfeeding/special-situations/breast...
6. Bonyata, K. (2011). Comfort Measures for Mom During Weaning. Retrieved from http://kellymom.com/ages/weaning/wean-how/weaning_mom/
7. Sharma, V. and Corpse, C. S. (2008) Case Study Revisiting the Association Between Breastfeeding and Postpartum Depression. Journal of Human Lactation,24(1),77-79.
© Copyright Breastfeeding USA 2013. All rights are reserved.
One of the most common health concerns for women of childbearing age is an autoimmune disorder. According to the American Autoimmune Related Disorders Association1, authorities estimate that around one in five people—two thirds of them women—are living with an autoimmune disorder in the United States. Unfortunately, autoimmune disorders are not as rare today as in previous generations1. The reason for the increase in frequency of autoimmune disorders is unknown. Mothers with autoimmune disorders face unique challenges with regard to pregnancy and breastfeeding. This subset of mothers is often overlooked in standard parenting literature. This is a brief introduction to autoimmune disorders to give a better understanding of the issues surrounding the intersection of autoimmune disorders and motherhood.
What is an autoimmune disorder?
The immune system is responsible for fighting off infections as well as identifying and destroying abnormal cells, like cancer cells2. The ability to correctly identify normal “self” cells and invading microorganisms or abnormal cells as “non-self” cells is crucial to normal, correct functioning of the immune system. In an autoimmune disorder, the immune system gets ‘confused’ and is not able to tell the difference between normal and abnormal “self” cells2. This confusion means that the body begins to attack itself, causing an astonishing array of symptoms and diseases, ranging from relatively mild to life-threatening. In fact, autoimmune diseases are counted in the top ten causes of death for women under 651. No one knows what causes this confusion, except that these disorders are caused by a combination of genetic influence and environmental, not any one trigger2.
What are some examples of an autoimmune disorder?
There are over 100 different kinds of autoimmune disease1. Here are some examples:
- Type 1 diabetes: the immune system attacks the pancreas or insulin receptors (sometimes both), resulting in the inability to make and use insulin3.
- Hashimoto’s thyroiditis and Graves’ disease: conditions in which the immune system attacks the thyroid gland, resulting in under or overproduction of thyroid hormone2. Thyroid hormone is responsible for a whole host of functions, including metabolism and neurological development in the fetus and newborn.
- Ulcerative colitis and Crohn’s disease: collectively referred to as “inflammatory bowel disease”. The immune system mistakenly attacks the digestive system, causing painful abdominal cramps, digestive problems, and sometimes nutritional deficiencies4.
- Multiple sclerosis: the target is the nervous system. Interruptions in nerve transmissions result in a variety of symptoms, including numbness, pain and paralysis1. It is usually intermittent at first and often progresses to permanent disability5.
- Rheumatoid arthritis: generally results in the body attacking the joints, causing joint deformation, debilitating pain, and stiffness,2.
- Systemic lupus erythematosus (lupus): any system of the body may be attacked, from the heart and lungs to kidneys, skin, digestive or nervous system, causing damage and malfunction to that system2.
How does life change with an immune disorder?
Life with an autoimmune disorder varies with the disorder. Usually, a woman who looks perfectly healthy will start having vague symptoms that come and go and are hard to describe1. Often, she will have an idea that something is wrong, but because it is hard to describe the symptoms, she will put off talking to her doctor about it until they start to affect her everyday living. Thus begins the diagnostic odyssey.
Diagnosis with an autoimmune disease can be a long, difficult process. While some are able to get a diagnosis within weeks of the onset of symptoms, for others the process takes years of frustrating visits to numerous doctors. It isn't uncommon for sufferers of some diseases to be incorrectly labeled as drug seekers, chronic complainers, or worse, told that the disease is “all in the head”1. Treating the disease is not always easy, either. Some diseases simply require replacement of hormones that aren't being produced, like autoimmune hypothyroidism. Others, like lupus, may require life-long suppression of the immune system, along with management of the many symptoms that result from organ damage2. Finding the right medications to manage symptoms is an adventure in and of itself, with scary-sounding side effects like the possibility of cancer or heart problems. It is not uncommon for people with autoimmune disorders to go months or years at a time with minimal or no symptoms, followed by what’s called a “flare up,” an exacerbation of the disorder when the symptoms get very difficult to deal with and may keep a person bed or house-bound until it recedes. Others may not get a break, causing them to be unable to keep a job or manage around the house without help.
My own journey with autoimmune disease began as a postnasal drip and headaches when my first daughter was around a year old. Then a few months later, a vague, aching pain began, deep in my leg muscles at night. Sometimes I would get tingling nerve pain and my arms or legs would “fall asleep.” At first, the symptoms weren't too bad, and I passed it off as aches from exercising, bad posture, and allergies. By the time she was two, I realized that not only were the symptoms getting worse, keeping me from being able to sleep at night, but the symptoms didn't correlate with exercise or anything else. They were also starting to affect my day-to-day living, interfering with my ability to attend school, go to social engagements, and even interact with my family. Over the counter medications didn’t help, so I sought treatment, but was unable to find a doctor who would help. After many doctors visits, trials with different drugs and nasal sprays were ineffective. I just learned to cope. Eventually, when my daughter was four, I found a rheumatologist who diagnosed me with “undifferentiated connective tissue disorder” because although my lab results indicated something autoimmune, my symptoms didn't fit anything on his list. My symptoms finally became manageable with the drugs he prescribed. Because my disease wasn't “bad enough” to affect anything vital, however, getting a precise diagnosis was not a priority.
In contrast to my years-long (and still incomplete) journey toward diagnosis, a friend of mine, Joanna, started having symptoms one November and was diagnosed by the next month with ulcerative colitis. This disease is particularly difficult to deal with when it flares. Joanna describes what it’s like: “I get lots of pain, cramping and bloody stool, with times of flare ups which can keep me on the toilet for over an hour at a time and many times through the day and night. I get very tired because of dealing with the pain and being on the toilet, and I worry about taking care of my daughter and getting her to school on time and being able to pick her up. Leaving the house can be scary just for things like grocery shopping; it can take me much longer than everyone else because I may have to use the restroom 2-5 times while in the store. The pain can be very severe. There were times when I was in so much pain I was trying not to scream; it was like giving birth multiple times a day, where [her husband] was threatening to call 911 and send me to the hospital.”
What do these changes mean for women of childbearing age?
The hormonal activity inherent in menstrual cycles is believed to be the reason women of childbearing age are at increased risk of autoimmune disease7, 8, 9. Years ago, women with autoimmune conditions were simply advised not to get pregnant (5, 11). With modern medicine, doctors and researchers are finding that this advice is outdated5-7, 10, 11. Unfortunately, many women are still incorrectly advised that their condition is a complete contraindication to pregnancy and breastfeeding.
When women with autoimmune disorders want to get pregnant, they are advised to plan pregnancies carefully. They are told to wait until they are on a pregnancy-safe medication, or to wait a certain number of months after stopping a medication that is expected to cause birth defects. They may be told to wait until their disorder has been in remission, and they can find a good team of doctors to take care of them10.
Can a woman with an autoimmune disorder safely carry her baby to term and breastfeed?
Although many doctors mistakenly tell women that it is not safe to get pregnant or breastfeed simply because of their diagnosis, this is not evidence-based advice. Some doctors insinuate or outright tell mothers that if they breastfeed, the antibodies in their system will get into the baby and cause an autoimmune disease in the breastfed infant; this is not true12. Other health-care workers may incorrectly tell women that they won’t be able to continue taking the drugs that control their disorder if they choose to get pregnant or breastfeed. Some women with advanced disease states may be counseled against pregnancy due to symptoms such as uncontrollable high blood pressure or kidney damage. According to experts well-versed in current research, a diagnosis of an autoimmune disorder in and of itself is never a contraindication to pregnancy or breastfeeding10. In addition, current research indicates that many drugs previously believed to be unsafe for pregnant or nursing mothers are, in fact, no more likely to cause birth defects than other drugs considered safe5-7, 11, 13, 15. Most women with autoimmune disorders can have a baby without serious side effects, though some diseases require careful monitoring,7-10. In fact, for some disorders, like multiple sclerosis, rheumatoid arthritis, and inflammatory bowel disease, the progression of symptoms can be slowed or stalled by pregnancy and exclusive breastfeeding6,8,9,15,16. This is thought to be associated with the hormonal shift that accompanies lactational amenorrhea7,8,9,15. While there are some risks to the fetus, including the risk of prematurity and low birth weight, most risks can be managed quite well6,7,10,11,13. Risks from medication can be managed during breastfeeding, as well5, 10, 13, 14, 15, 17. Some autoimmune diseases—those relating to hormonal function—may interfere with milk supply, however 19, 20. This occurs when a mother’s disease interferes with normal levels of thyroid or insulin, for example. This should be managed by correcting the hormone to its normal levels, but many women are unaware of this possibility, especially with diabetes or pre-diabetes20.
One often-repeated concern regarding breastfeeding has been made which deserves special attention. Early studies of the hormone prolactin on nursing mice and in women with rheumatoid arthritis indicated that prolactin, and therefore breastfeeding, increased the severity and number of flares postpartum for women with rheumatoid arthritis who were having their first child18. This finding was often quoted by later researchers without much discussion6, 15. Frustratingly, not a single one of these studies controlled for partial breastfeeding versus exclusive breastfeeding, although they did divide breastfeeding mothers into those breastfeeding their first child versus those breastfeeding subsequent children. There was some acknowledgement that the sensitivity to prolactin may be genetic. In patients with multiple sclerosis, partial and exclusive breastfeeding mothers had different outcomes5, 8, 9.
Additionally, many women who chose to breastfeed in these earlier studies discontinued their medications in order to do so, making it difficult to distinguish between symptoms linked to breastfeeding and those due to the lack of medication. In studies of women with inflammatory bowel disease, breastfeeding was first believed to be associated with increased disease activity postpartum, but further analysis showed that when medication use was taken into account, the difference in disease activity was negligible15, 16. This underscores the importance of critically examining studies relating to disease activity and breastfeeding. Unfortunately, there are very few well-done studies to date relating to disease activity and breastfeeding specifically. Research in this area is starting to increase, but may not be available for several years. The reality is that the hormonal interplay of postpartum and breastfeeding with the immune system is so complex that we are just barely beginning to scratch the surface.
During my second pregnancy, my symptoms improved so much that I was able to stop taking daily medications. In fact, thanks to the hormonal influence of breastfeeding, I have not yet needed to start taking them again, even though my daughter is now 14 months old. Breastfeeding has actually proved to be pain-relieving for me. I often come home from school fatigued and in pain, to flop into my bed with my baby girl and nurse, only to find my energy increased and my pain gone. I tried finding an explanation for this phenomenon, but research in this area is scarce, at least as far as mothers are concerned. Joanna was able to control her symptoms throughout her pregnancy with the medication she was taking, but she suffered a very bad flare immediately postpartum, necessitating some creative thinking in order to breastfeed her child. She is now on a different medication.
What are a mom's major concerns when she is dealing with an immune disorder and an infant?
Dealing with symptoms and worries about the side effects of medication are probably the top two concerns of mothers with autoimmune disorders. Getting accurate, evidence-based information is a challenge because many doctors are not well-versed in current research in these areas. Despite the ameliorating effect breastfeeding has on my pain, I don’t always have time to breastfeed the pain away. As a busy mom, I still have to weigh my symptoms against taking medication occasionally. I know that at some point, the hormonal influence which keeps the majority of symptoms at bay will decline and I will need to decide whether to discontinue breastfeeding, find a breastfeeding compatible medication, or take my chances continuing to breastfeed with a poorly researched medication.
Joanna, on the other hand, had to deal with her symptoms much sooner. Immediately postpartum, she suffered such a severe flare-up that she had to get a doctor’s permission to nurse her one-day-old baby on the hospital toilet. Joanna decided that it would help her mental state to give an occasional bottle of formula as she dealt with her symptoms postpartum. However, by taking medication safe to use during pregnancy and beyond, she was able to continue breastfeeding her daughter for a year. Her doctors’ support was very important as they encouraged her desire to breastfeed. Her daughter is now a vibrant, healthy six year old.
Many mothers with inflammatory bowel disease are hesitant to try breastfeeding. Joanna has this to say: “Don’t be afraid to breastfeed. As long as you can find a medication that is compatible with breastfeeding, the medication will keep you healthy, and then your baby will get what he or she needs and be able to thrive. But don’t let yourself feel guilty if you are breastfeeding and need to supplement with an occasional bottle of formula. And if you need a stronger medication that is not compatible with breastfeeding, remember that it is better to have a healthy mother whose baby is on formula. You are doing the best that you can with the body you have been given.”
How can a Breastfeeding USA Counselor be of help?
Breastfeeding USA Counselors offer encouragement and share evidence-based information. They listen to and empathize with mothers’ concerns. They discuss problems that arise or might potentially arise and think of ways to mitigate them ahead of time. For example, if a mother has concerns that she might not always be available to breastfeed as needed, a Breastfeeding Counselor can provide information about pumping, both to increase and maintain the mother’s milk production, and to ensure that there is extra milk in the freezer so baby can be supplemented when necessary. If a mother is in pain, a Breastfeeding Counselor can help her find alternative nursing positions so that she can comfortably breastfeed. Breastfeeding Counselors reassure mothers that even if they do need to supplement with formula, as long as they are continuing to breastfeed, their babies will be getting important immunological and nutritional support. They can also help mothers to find ways to make sure that occasional supplementation does not begin to interfere with milk production.
"Breastfeeding USA Counselors”) are often the first line of support and are aware that some autoimmune diseases may lead to decreased milk production. They cannot diagnose an autoimmune condition or hormonal imbalance, but they are able, for example, to refer a mother to her doctor when she has unexplained low milk production to rule these out possible causes, even if she does not have a previous history of these disorders.
In addition, Breastfeeding USA Counselors help mothers find vital information about medications from sources such as Medications and Mothers’ Milk, the Infant Risk Hotline, and LactMed. This information can help mothers talk to their doctors about finding the right medications to both control their symptoms and safely continue breastfeeding. There is support available for mothers with autoimmune diseases.
1. American Autoimmune Related Disorders Association. (2013). Autoimmune Information: Questions and answers. Retrieved from https://www.aarda.org/q_and_a.php
2. Copstead, L. E. & Banaski, J. (2010). Pathophysiology (4th ed). St. Louis, MO: Elsevier.
3. Paddock, C. (2011). Is Type 2 diabetes an autoimmune disease? Retrieved from http://www.medicalnewstoday.com/articles/222766.php
4. Crohn’s and Colitis Foundation of America. (2013). What are Crohn’s and Colitis? Retrieved from http://www.ccfa.org/what-are-crohns-and-colitis/what-is-ulcerative-colitis/
5. Houtchens, M. (2013). Multiple sclerosis and pregnancy. Clinical Obstetrics & Gynecology, 56(2), 342-349. doi:10.1097/GRF.0b013e31828f272b
6. Elliott, A., & Chakravarty, E. (2010). Management of rheumatic diseases during pregnancy. Postgraduate Medicine, 122(3), 213-221. doi:10.3810/pgm.2010.05.2160
7. Østensen, M., Brucato, A., Carp, H., et al. (2011). Pregnancy and reproduction in autoimmune rheumatic diseases. Rheumatology, 50(4), 657-664.
8. Langer-Gould A, Huang SM, Gupta R, et al. (2009). Exclusive Breastfeeding and the Risk of Postpartum Relapses in Women with Multiple Sclerosis. Archives of Neurology. 66(8):958-963. doi:10.1001/archneurol.2009.132.
9. Langer-Gould, A., Gupta, R., Huang, S. et al. (2010). Interferon-gamma-producing T cells, pregnancy, and postpartum relapses of multiple sclerosis. Archives of Neurology, 67(1), 51-57. doi:10.1001/archneurol.2009.304
10. Levy, D. (2007) Clinical Feature: Autoimmune diseases complicate pregnancy. http://www.clinicaladvisor.com/autoimmune-disorders-complicate-pregnancy...
11. Borisow, N., Döring, A., Pfueller, C., Paul, F., Dörr, J., & Hellwig, K. (2012). Expert recommendations to personalization of medical approaches in treatment of multiple sclerosis: an overview of family planning and pregnancy. The EPMA Journal, 3(1), 9. doi:10.1186/1878-5085-3-9
12. Newman, J. (2009). Breastfeeding and illness. Retrieved from http://www.breastfeedinginc.ca/content.php?pagename=doc-B-I
13. Keeling, S. O., & Oswald, A. E. (2009). Pregnancy and rheumatic disease: “by the book” or “by the doc”. Clinical Rheumatology, 28(1), 1-9. doi:10.1007/s10067-008-1031-9
14. Makol, A., Wright, K., & Amin, S. (2011). Rheumatoid Arthritis and Pregnancy: Safety Considerations in Pharmacological Management. Drugs, 71(15), 1973-1987.
15. Moffatt, D., Ilnyckyj, A., & Bernstein, C. (2009). A Population-Based Study of Breastfeeding in Inflammatory Bowel Disease: Initiation, Duration, and Effect on Disease in the Postpartum Period. American Journal Of Gastroenterology, 104(10), 2517-2523. doi:10.1038/ajg.2009.362
16. van der Woude, C., Kolacek, S., Dotan, I., Oresland, T., Vermeire, S., Munkholm, P., & ... Dignass, A. (2010). European evidenced-based consensus on reproduction in inflammatory bowel disease. Journal Of Crohn's & Colitis,4(5), 493-510. doi:10.1016/j.crohns.2010.07.004
17. Wallace, D., Gudsoorkar, V., Weisman, M., & Venuturupalli, S. (2012). New insights into mechanisms of therapeutic effects of antimalarial agents in SLE. Nature Reviews. Rheumatology, 8(9), 522-533. doi:10.1038/nrrheum.2012.106
18. Brennan, P., & Silman, A. (1994). Breast-feeding and the onset of rheumatoid arthritis. Arthritis And Rheumatism, 37(6), 808-813.
19. Marasco, L. (2006). The impact of thyroid dysfunction on lactation. Retrieved from http://www.lalecheleague.org/ba/feb06.html
20. Nordqvist, C. (2013). Insulin’s role in making breast milk. Retrieved from http://www.medicalnewstoday.com/articles/262981.php
Published February 2014.
© Copyright Breastfeeding USA 2014. All rights are reserved.