Infant feeding

Infant feeding is an intrinsic part of parenthood. When it goes well it can be incredibly rewarding, but it's not always straightforward and many parents experience difficulties.

In this episode, Lynsey and Chrissy discuss the different factors that influence feeding decisions, the intricate relationship between infant feeding and mental health, and the challenges around medication and breastfeeding. 

References and resources:

• Supporting positive conversations about feeding choice and mental health (The Breastfeeding Network, 2017)
• Guilt, shame, and postpartum feeding outcomes: a systematic review (Jackson et al., 2021)
• The Breastfeeding Network
• First Steps Nutrition Trust
• GP Infant Feeding Network
• World Health Organisation factsheets
• The politics of breastfeeding - Gabriel Palmer
• Why formula feeding matters - Shel Banks
• Why breastfeeding matters - Charlotte Young

If you or someone you know is struggling with mental health difficulties, there is lots of help available. You can contact your primary care provider in the first instance, or if you are based in the UK the NHS perinatal mental health website will help you to find support in your local area.

Transcript

[00:00:11] Chrissy: hello everyone and welcome to our podcast Beyond Baby Blues. My name is Dr Chrissy Jayarajah. I'm a consultant perinatal psychiatrist in London.

[00:00:22] Lynsey: And I'm Dr. Lynsey McAlpine. I'm a trainee psychiatrist also based in London. 

So Chrissy today's episode is about infant feeding. Now most new parents will probably agree that feeding a baby takes up a vast amount of energy and attention wherever way you choose to do it. It's an incredibly nurturing act, but it can also be exhausting and stressful and sometimes quite an overwhelming responsibility. So it's not at all surprising that it comes up in our clinical work all the time. With that in mind, I was quite keen to use this episode to think about the relationship between infant feeding and maternal mental health. 

And look, it's a tricky topic to cover. There are lots of wider public health discussions about breastfeeding and bottle feeding. And understandably, it brings up a lot of really strong feelings for people. So for example, I know that we hear the phrase breast is best getting used a lot as a slogan to highlight the health benefits of breastfeeding. And then I've heard other people counter that by saying, well, fed is best. And I think that's mainly to make the point that we should be focusing less on the method of feeding and more on ensuring that the baby is getting enough to meet all of its energy and nutritional needs. 

And I think you agree with me here at Chrissy, where I tend to take the more pragmatic stance that really what's best is to support mothers to make informed and autonomous choices about what's right for their own physical and mental health, as well as the overall wellbeing of their baby. 

But for the purposes of this episode, I thought it would be helpful to focus more on the mental health considerations from our point of view, as perinatal psychiatrists.

[00:01:54] Chrissy: Yeah, absolutely And And and just as a kind of quick disclaimer, we're not advocating for any one type of feeding method against the other. It's really just having a think, about feeding in general and how that is a massive, massive part of the perinatal journey. 

[00:02:10] Lynsey: That's right. So when a baby is born, they need a huge amount of nutrition in order to grow and to thrive. We know that good nutrition in the first few years of life will affect that child's health over the course of their entire lifespan. So it is incredibly important to get it right. 

[00:02:27] Chrissy: It's something that is obviously really important, but when you're trying to get pregnant, your focus is on getting pregnant. And then you're focusing on the delivery and having a safe labor and a good labor experience. So you've got all these things. And by, by the time the baby comes, you're like, Oh, right. I've got to feed the baby.

[00:02:44] Lynsey: Yeah, it's um, it's a lot to think about. And there were a few different options. So perhaps we should just run through what the, what the options are. So first of all, breastfeeding is usually the recommended option. The world health organization recommends exclusive breastfeeding for at least the first six months. And then after that, they recommend continuing breastfeeding alongside the introduction of solids. 

And there's lots of reasons why it's recommended. There's a whole host of immune and nutritional benefits. And when it goes well, it can be an incredibly rewarding experience with a positive impact on bonding and attachment.

Another option is to express breast milk and give it via a bottle. Or in some cases, people are able to access donor breast milk, which can also be given by bottle. And then yet another option is to use infant formula which can either come as a powder that needs to be prepared in sterile bottles. Or as the more expensive, ready to drink liquid. 

As a bit of a side note. Um, I did want to point out the infant formula has a complicated and pretty problematic history. Historically formula was heavily marketed in developing countries where there was a lack of access to clean water and appropriate sterilizing equipment. And also a lack of sufficient safety standards and regulation. It's a pretty bad example of where capitalism, colonialism and structural racism have all worked together to drive health inequalities on a global scale. 

 I think it probably goes beyond the scope of today's episode, but, um, if you're interested, I would highly recommend a book called the politics of breastfeeding by, uh, by Gabrielle Palmer, Chrissy you're very welcome to borrow my copy and I'll put the details in the show notes for anyone else who is interested.

But, um, anyway, to get back to my point, nowadays, at least in the UK infant formula meets all of an infant's basic nutritional needs and it's safe as long as it's done properly. It's a more expensive option, but for some people it can be much more reliable than the breast milk supply. And it offers a certain amount of flexibility for parents as well, and I think it is important to say that formula feeding is completely compatible with bonding, attachment and good emotional health. 

So when people are weighing up the decision about how to feed their baby what sort of factors will influence that decision?

[00:04:54] Chrissy: I think there are loads of factors, Lynsey. Um, of course, the most obvious one was thinking about their own experiences, so how they were fed as a baby and what their family do, what their parents did or aunties or grandparents did, and also what their friends, what their current peer group are doing as well

[00:05:13] Lynsey: Yeah. And that's probably partly about cultural norms and about doing what's familiar. But also possibly about experiencing peer pressure. and wanting to fit in with the social group as well.

We also know the advice and information from healthcare professionals and public health messaging can play a big role. Um, so access to reliable advice and support can really influence that decision too.

[00:05:36] Chrissy: But also with that, I've certainly heard in clinic, lots of women feeling quite guilty if they choose to formula feed, but they're feeling that there's a certain push from public health to breastfeed. And we are aware that the UK has one of the lowest rates of breastfeeding actually in Europe. So. It's a kind of double edged sword, actually, because obviously we're trying to give a public health message, but at the same time, people are entitled to choose what works best for them, and try to feed without those feelings of guilt

another factor that affects the decision is of course the mother's own emotional well being and their mental health and how they feel about themselves and their body and that can also change during the perinatal period

[00:06:24] Lynsey: Yeah. And also how they feel about their identity as a parent. Um, I think we've talked before in the podcast about the concept of matrescence Which is the sort of biological and psychological and social process of becoming a mother. I think it's fair to say the infant feeding is often closely tied up with that new emerging identity as a mum. 

And sometimes there are external factors too, that affect the decision. So the choice of feeding method is sometimes dictated by the circumstances.

[00:06:53] Chrissy: Yeah It might be that mum and baby are separated. For example, if mum needs to be admitted to hospital for any reason and isn't able to continue breastfeeding their child, then bottles become a lifeline really. 

[00:07:04] Lynsey: Yeah. Or also when the baby is admitted to hospital. So as you know Chrissy, my amazing sister, Sarah is a pediatric nurse who works in neonatal intensive care. Which is an environment where parents can really struggle with infant feeding because of all the practical, as well as medical challenges. I was catching up with her ahead of recording this episode. 

And she was telling me about some of the incredible lengths that NICU staff will go to in order to support parents with feeding. I think as far as possible, NICU will try to support with breastfeeding and expressing if that's what the parents want to do.

But there are definitely some situations where they might recommend adding in formula milk, especially where the baby was very premature or had a very low birth weight or in situations where the baby's not gaining enough weight. 

And it's much less common, but there's also situations where the baby might have a specific medical condition. That means that they can't tolerate breast milk. So for example, babies with genetic conditions like galactosemia or phenylketonuria um, can't digest or metabolize some of the components of breast milk, so they will need a specialized formula in order to keep them healthy and well.

 So even once parents have made a decision about their method of feeding, it's not always straightforward. In the UK, for example, we know that feeding difficulties are one of the most common reasons for women to attend their GP or urgent care in the early postnatal period. 

[00:08:23] Chrissy: So some of the common challenges women experience with breastfeeding is things like painful nipples, difficulty with latching on, problems with milk supply, um, problems with the baby not gaining enough weight, also infections like mastitis, which is an infection of the breast, which can be extremely painful.

[00:08:46] Lynsey: Yeah. And most of the things that you've mentioned there are things that can potentially be treated or managed. So it's really important to make sure that women who are struggling with breastfeeding have access to timely, reliable advice from people like GPs uh, midwives health visitors, lactation specialists, or even breastfeeding peer support. All of those things can make a huge difference.

[00:09:07] Chrissy: there are other wider issues about, uh, breastfeeding, 

Um,

breastfeeding is physically very exhausting and tiring and particularly If your baby does what's called cluster feeding, which is where they just feed non stop for hours on end, that can be really difficult because you can feel like you're just a feeding machine essentially

but also breastfeeding in public can cause a lot of worry and concern, particularly to new mums. and Negotiating going back to work while you're still breastfeeding can be really, really tricky. 

[00:09:41] Lynsey: Yeah, absolutely. And it's not just breastfeeding that can be hard. I know that plenty of women who are expressing can also find that really challenging. And that's particularly hard when they're doing combination of breastfeeding and expressing because in between breastfeeding, they have to find time to express and then clean all the equipment and store the milk which can be really draining when you're also looking after a little baby.

[00:10:02] Chrissy: Yeah, honestly, expressing and managing bottles is a full time job in On top of managing a baby, I remember those days well. And yeah, it just, it's Oh gosh, it's so grinding and um, it's really difficult and I think things have moved on a lot now, you can now get those express pumps that literally sit in your bra, you don't have to be connected to a machine anymore but still it's very demanding um, in terms of time but also effort as well.

[00:10:31] Lynsey: Difficulties can arise with formula feeding too. It's not necessarily the easy option. Um, one of the biggest issues I've come across is that it's just so much harder to find high quality evidence-based information and advice about formula feeding. So it can be really hard for parents to know which formula to choose or how to prepare feeds and sterilize bottles properly. 

There's just not as much information out there and that can be a real problem. One resource that, I like to recommend is the first step nutrition trust, which runs a website that's full of unbiased and very comprehensive info about every type of infant milk that's available on the UK market. And it includes a review of all the health claims made by milk manufacturers. I'll share the link to that in the episode description.

So, 

Okay, so let's move on and think about some of the issues that we encounter in our clinical work. There's a really complicated relationship between infant feeding and mental health. The two things are so closely intertwined, especially in those early days and weeks but there's a really wide range of different experiences. And that relationship between feeding and mental health can really change over time.

First of all, we know that when feeding is going well, it can have a positive and a protective effect on maternal mental health and this is particularly true for women who plan to breastfeed and then managed to do so successfully.

So in many cases, these positive experiences of breastfeeding can be a really validating experience as a parent. And it can help to counteract many of the feelings of guilt and shame and failure that are really common for new parents.

It's a great early opportunity to bond with the baby and to learn how to understand and respond to its needs. And of course, all of the psychological benefits are also boosted by the hormonal response. So breastfeeding in particular leads to the release of a hormone called oxytocin, which has a powerful effect on the maternal brain.

I read some really interesting research that explored breastfeeding experiences in women who've had a difficult or a traumatic birth experience. In these cases, it seems like successful breastfeeding can be a very cathartic and empowering experience. 

And these, um, these positive experiences are not exclusive to breastfeeding. So although most of the research focuses on breastfeeding there's also plenty of evidence to support the idea that successful bottle feeding can also promote oxytocin release and support bonding, and attachment. And protect against perinatal mental illness. And that positivity goes both ways. So the positive feeding experiences can promote good mental health, but also good mental health can facilitate good feeding experiences.

On the flip side, when perinatal mental illness does arise, this can increase the likelihood of feeding difficulties and then going the other way round, we know that feeding issues themselves can actually trigger or exacerbate existing mental health problems. And then when these two problems co-exist, they can fuel each other and it can be incredibly hard to unpick what came first.

[00:13:24] Chrissy: Yeah So they may start to become unwell after having their baby and the feeding could kind of get woven in to their feelings, um, around their mental health. So, for example, if they're experiencing postnatal depression, they might feel excessive feelings of guilt around their choice of feeding, or being unable to feed a certain way

[00:13:47] Lynsey: and of course depression will distort people's thinking patterns too. So all of those self-critical thoughts about not being good enough or those feelings of failure will just reinforce the depressive thinking patterns in a sort of self perpetuating cycle. 

And then another feature of depression is something that we call anhedonia which is the reduction or the complete loss of the ability to experience pleasure. And that can extend to things like feeding as well. So if a new mom is trying to feed her baby, but she's exhausted and she has no motivation and she's not actually feeling any happiness or any joy from the experience of feeding that can reinforce all of those feelings of guilt and shame and failure, which makes it harder to go home with a feeding and also just makes it harder to recover from the depression as well.

And it's not just about perinatal depression. I think feeding is relevant to lots of other perinatal mental disorders that we see in clinic all the time. One thing that has come up in the research is that women with severe mental illness, which includes things like schizophrenia and bipolar disorder, as well as postpartum psychosis. Uh, these women are much less likely to initiate breastfeeding and those who do start are less likely to maintain it. 

And although there are lots of different reasons for this. One of the really important factors that has come up in the research is that these women are much less likely to be able to access high quality professional support around feeding. So that's, um, that's quite an important structural barrier that I think we need to be more conscious of as healthcare professionals.

[00:15:21] Chrissy: One of the things that I think we often forget, is that it can be quite anxiety provoking, particularly breastfeeding in public. There's a lot of women who may feel worried or anxious about, um, feeding in public or feeling that they have to go and hide in the toilets to feed their baby, or worried about unsolicited comments from other people who may be observing them. I remember one time for myself where I was determined to go out for decaf coffee with my six week old baby, um, and prove to myself that I can do it. And I went to Starbucks and then my baby needed to be fed. And I didn't know what to do because I haven't been outside and fed my baby yet in public . And I have the, you know, I have the kind of muslin cloth and everything, and I ended up getting tangled in my muslin cloth over my head. With this baby and I thought I was in the corner of a coffee shop in, in kind of in my privacy. I didn't realize I was in front of this glass window.

And I think just the aspect, you know, whether you're having a bottle or breast or expressing and putting that into a bottle, just kind of, getting out and about with a baby and having all the paraphernalia of bottles and feeding we've talked about anxiety before on the podcast it can really be quite stifling and it can cause many women to just not bother to go out because it's just too much, uh, too much overwhelm, too much uncertainty

[00:16:47] Lynsey: Yeah. And then related to those sorts of anxiety spectrum disorders another related issue that we've both seen a lot is with obsessive compulsive disorder. Where feeding can become a sort of focal point for obsessional thoughts and compulsive behaviors. Especially obsessive thoughts about contamination which can be incredibly distressing. I've seen lots of examples where the compulsion to sterilize bottles and then re-sterilize them over and over and over again. Those compulsion's can completely take over to the extent that parents are not able to focus on the task of actually feeding the baby.

[00:17:19] Chrissy: Another way that it can present is just, um, postnatal psychosis, which we talked about in the podcast before, and one of the things they might say is they're worried that the milk has been Spoiled or poisoned in some way or contaminated, um, by people trying to harm their baby. So feeding and milk can become a real focus of concern

[00:17:40] Lynsey: Yeah. And that can happen in other psychotic illnesses too. So, um, new mothers with things like schizophrenia or Schizoaffective disorder, might also develop unusual beliefs around feeding. And also, I think when people become thought disordered, which can happen with things like psychosis, But also with delirium or, um, with mania. That can also lead to challenges. So if someone's thoughts are muddled up, then that can affect their ability to plan ahead or keep track of lots of information, or even have an accurate sense of how much time has passed. And all of those things can make it even harder to keep track of feeding and do in a safe way.

 Another issue that sometimes comes up is where people have a current or a past history of an eating disorder. The process of feeding a baby or even weaning further down the line can bring up a lot of really difficult feelings. 

And we sometimes find that that intense focus on feeding, you know, the constant conversations and planning and thinking about when the next feed is due. I can mean that eating disorders symptoms might re-emerge in the postnatal period.

[00:18:40] Chrissy: We also know actually that stopping breastfeeding, that has a hormonal impact on women and that can precipitate or trigger um, experiences of postnatal anxiety and postnatal depression because of the hormonal changes that occur during that time.

[00:18:56] Lynsey: That's right. So we sometimes see women who are recovering from an episode of perinatal mental illness, be that depression or anxiety, or even postnatal psychosis. Sometimes they're recovering really well. And then the experience of relapse in their symptoms around about the time that they stopped breastfeeding. So that's something to be mindful of in clinical practice.

[00:19:15] Chrissy: So, one of the things, I guess the, the biggest concern for many women is around medication use um, many women are really worried about taking medication, for anything, but particularly for their mental health, whilst breastfeeding.

And unfortunately, we see this. Time and time again, we see women feeling they have to choose one or the other. So either I stay mentally well and take my medication or I'm going to breastfeed, but that means I'm going to stop taking the medication that's been prescribed.

[00:19:46] Lynsey: In reality, it doesn't necessarily have to be one or the other. A lot of the medication that we use for perinatal mental illness is compatible with breastfeeding. Um, when we're helping our patients to weigh up this decision about taking medication in breastfeeding. We use a measure called the relative infant dose. Which is a way of looking at how much of the drug actually crosses into the breast milk and then estimating the relative amount that the baby is actually exposed to.

As a general rule for healthy babies who are born at term. We say that a relative infant dose of 10% or lower is compatible with breastfeeding and many of the medications that we use in perinatal psychiatry, you have a relative infant dose below 10%.

So in the UK, the breastfeeding network runs a fantastic advice service called the drugs in breast milk information service- it's led by pharmacists and it provides unbiased evidence-based information about the safety of specific physical and mental health medication in breastfeeding. Their service has shared some really interesting statistics saying that about 15% of the requests that come through to their service are from women who have received inconsistent or negative advice about taking psychiatric medication during breastfeeding. And that's something that reflects what I've seen in my own practice. 

Many women stop their medication quite suddenly due to inaccurate or conflicting or overly cautious advice from healthcare professionals. And of course that can be quite risky. Um, we know that the postnatal period as a time of increased vulnerability So if someone stops their medication suddenly without any planning or any monitoring that can lead to quite a rapid deterioration in their mental health.

[00:21:23] Chrissy: Um, but we really would urge if you are in that situation where you're not sure, um, or you feel really conflicted or torn, please do speak to your GP or even consider asking for a referral to a perinatal service because we'd be more than happy to support, with information in making those decisions.

[00:21:41] Lynsey: Yeah. And even if you ultimately weight it up and decide that you don't want to take the medication while you're breastfeeding, the perinatal team can provide other types of supports um, while you're off the medication.

Actually, while we're on the subject of medication Chrissy, I wanted to talk about some drugs that are used to influence milk production either to stop it or to increase the breast milk supply. It's not stuff that we would prescribe as psychiatrists, obviously. But they do get used sometimes. And I think they have quite important implications for mental health. So I think it is worth talking about them briefly.

Firstly, sometimes clinicians will use a group of medications called dopamine agonists to try and stop breast milk supply. This can be done in quite understandable situations, like where there's been a stillbirth, where it would be absolutely heartbreaking to continue with lactation. And they're also occasionally used in other situations where the mum can't breastfeed so for example, if she's on chemotherapy or she needs high-dose opiate medication, or she's taking lithium, and these drugs act by activating dopamine receptors in the brain. Um, we know that these dopaminergic pathways are really significant in the development of psychotic illnesses. So although there's only kind of case report level evidence on this, I think speaking as a perinatal psychiatrist, we would tend to advise against these drugs, especially in women who are at high risk of postpartum psychosis, because of the risk that it might trigger a psychotic episode.

The second group of medication are called dopamine antagonists and they have pretty much the opposite effect. So there are sometimes used to try and encourage milk production when there's issues with supply. These drugs act by blocking the dopamine receptors in the brain, which in theory encourages the production of more prolactin one of the hormones responsible for breast milk supply.

 I think the most common dopamine antagonist that's used for this indication is one called dom It's an off-label prescription and again, it's not something that we would prescribe a psychiatrists, but I think it's really important to highlight that actually there's emerging evidence that drugs like domperidone can cause quite severe rebound psychiatric symptoms when the mother tries to stop this medication and these symptoms can be very sudden and very severe. So I would encourage everyone to be really cautious if they're considering using either of these medications.

So Chrissy, I think we should finish up with a few take home points from today's episode. For me, the most important thing that I want people to take away and this is for parents and healthcare professionals. Is to approach infant feeding with compassion and kindness. 

I would love to find more opportunities for collaborative working between perinatal mental health services and the professionals and organizations who work to support infant feeding. So that we can create spaces where women can get all of that support and information in a way that's tailored to their personal situation and to their mental state at the time. And I think the key to that is to listen to women and to respect their choices and to try and support them to have a positive feeding experience however they end up doing it.

[00:24:37] Chrissy: Absolutely, and I remember when I had my babies and I was thinking about the difference between bottle feeding or breastfeeding, and I remember the midwife that visited me at home, she said to me, you know what, whatever you choose, whether you choose to bottle feed, breast feed, or mix feed, your baby will still love you as their mum regardless. 

[00:24:58] Lynsey: Yeah, that's so true. And I think that's a nice note to end things on. 

So that's all we've got for today. It was a very brief overview of quite a complicated subject, but I hope that we've been able to shine a bit of light on some of the things that we think about as perinatal psychiatrists.

We've put lots of resources in the show notes. So if you'd like to learn more about this subject, please check them out. 

[00:25:19] Chrissy: Thanks everyone for listening to our podcast. Please do leave us a comment if you've enjoyed it. 

[00:25:24] Lynsey: Yeah, we love getting comments and feedback. And if you'd like to hear more about upcoming episodes, you can follow us on social media, we're on Instagram and X and blue sky at, beyond baby blues podcast. And of course, all of our previous episodes are available on all the major podcast platforms. So do check them out.