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It is now recommended that breastfeeding mothers take vitamin D supplements. Here is a helpful article on the topic.

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In recent years, amongst health professionals and scientists, there has been growing interest in vitamin D.

This is mainly due to increasing rates of rickets in developed countries.

Vitamin D's role in bone metabolism has been known for a long time.

More recently, it has been discovered that vitamin D might have many other functions in the human body, and could play an important role in the prevention of many chronic diseases.

Because vitamin D is so important, it's essential we get enough of it right from the time we are born.

So, are any particular babies at risk of vitamin D deficiency? Are breastfed babies at risk? And if so, what should be done about it?

Here are 7 facts you need to know about vitamin D and the breastfed baby.

#1: Breastmilk Is Not 'Deficient' In Vitamin D

Much of the literature written about vitamin D and babies will make comments about breastmilk being deficient in vitamin D.

However, it's not a fluke that breastmilk is the way it is. It's the biologically normal way to feed babies, and so if there is 'a lot' or 'a little' of something in breastmilk, there are good reasons for that.

Breastmilk is not deficient in vitamin D. It's true that levels of vitamin D are very low in breastmilk, but it's not a fault of nature; there are physiological reasons for it.

So why does breastmilk have very low levels of vitamin D?

#2: We Are Designed To Get Vitamin D From Sun Exposure

When looking more deeply into why breastmilk has very little vitamin D, we discover we're meant to get vitamin D from sun exposure rather than from our diet. If we get sufficient vitamin D from sun exposure, then there is no need for breastmilk to have much of it at all.

However, in countries like Australia, there are high rates of skin cancer. For that reason, many of us have certainly taken notice of the public health messages about being 'sun-smart'. This, combined with our technologically driven lifestyles, means many of us get less sun exposure than previous generations did. While less sun exposure is important in reducing the risk of skin cancer, it increases our risk of vitamin D deficiency.

But how much sun exposure is enough for us to get enough vitamin D?

#3: Safe Sun Exposure Time For Children Is Unknown

Regular sun exposure can help prevent vitamin D deficiency, but the safe exposure time for children is unknown. The benefits of sun exposure need to be weighed up against the risks. If you have your baby out in the sun, perhaps limited exposure, in the early morning or evening might be best. The length of time needed for adequate vitamin D has not been accurately quantified and would vary according to the time of day and where you live.

Sun Smart Australia provides information to help you determine how much sun is enough. You can visit their site here.

#4: Not All Babies Are At Risk Of Vitamin D Deficiency

Not all babies are at risk of vitamin D deficiency. Breastfed babies who are particularly at risk are those:

Who are dark-skinned

Who receive too little sunlight (e.g. by living at higher latitudes)

Whose mother is vitamin D deficient. During pregnancy, a foetus lays down stores of vitamin D. The baby then uses this store during the first few months of life. If a baby is born to a vitamin D deficient mother, then his stores will be deficient at birth. Women are often tested early in pregnancy to assess their vitamin D status and begin supplementation if necessary

#5: The Ideal Vitamin D Level Is Unknown

There is controversy over what level of vitamin D is sufficient.

The Institute of Medicine suggests vitamin D sufficiency is a blood concentration of at least 50 nmol/L. The Endocrine Society suggests vitamin D sufficiency is a blood concentration of at least 75 nmol/L.

#6: Different Countries Have Different Recommendations

Depending on where you live in the world, the recommendation regarding vitamin D supplementation varies.

In the United States, for example, the American Academy of Pediatrics recommends 400 IU per day of vitamin D for all breastfed babies from birth.

In Australia, the recommendation to use vitamin D supplements of 400 IU is limited to 'at risk' breastfed babies such as those born to dark-skinned and veiled women.

#7: Supplementing Breastfeeding Mothers Can Improve Their Babies' Vitamin D Levels

Research shows that supplementing breastfeeding mothers can improve their babies' vitamin D levels. If a breastfeeding mother takes vitamin D supplementation of 6400 IU/day it will supply her breastmilk with adequate vitamin D to satisfy her breastfed baby's requirement. This offers an alternative strategy to giving a supplement directly to the baby.

...

Breastmilk cannot be expected to supply babies with their vitamin D needs, because human beings are meant to make vitamin D from sun exposure. However, because we have reduced sun exposure, due to lifestyle, or to minimise skin cancer risk, those at risk of vitamin D deficiency require supplementation.

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Vitamin D And Breast Milk - 7 Facts You Need To Know | BellyBelly

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Lately there's been much talk about breast milk and vitamin D deficiency. Could your breast milk be deficient? Or could there be another issue at play?

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While this article is about pregnancy, so of it has relevance for experiencing grief during early parenthood.

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Today we'd like to welcome guest author Dana Schwartz to discuss what she has learned from her experience grieving during pregnancy. As some of you know, this topic is close to my heart because I lost my own mother to cancer when I was 12 weeks pregnant. We've received quite a few emails from women discussing how happy-sad the experience of grieving while pregnant has been and so we know that Dana's article will resonate with many. Dana is a fiction writer and essayist often drawn to themes of motherhood and death. She blogs at Writing at the Table and is currently creating a grief journaling course through The Gift of Writing. She can also be found on Facebook and Twitter @danahschwartz.
Grieving while pregnant was never the plan. It rarely is. My husband and I had been talking about going off birth control in September, an idea we shared with my mother the winter before her death. She rolled her eyes, unimpressed. Looking back, I think she expected a more tangible announcement.

By the time our pregnancy test came back positive, my mom had been dead two months. I was gutted with grief, but I felt joy at the sight of those two lines. Cautiously at first, since I was now well versed in how quickly a life could be snuffed out. But joy nonetheless, which ran parallel to the deep river of sadness in my heart.

This was the first lesson I learned - that one extreme emotion did not negate or soften the other. Joy and despair existed simultaneously. Sometimes weaving together, other times sprinting side by side.

In one way, I was lucky to have my entire pregnancy to grieve my mom. In another, I was not, because I could never share my news with her. No matter when it happens, the intersection of grief and pregnancy hits hard.

Though it was challenging, I somehow knew to continue my mourning. If anything, the deadline of pregnancy encouraged me to grieve more deeply. I hope that my advice, gained through intuition and luck, trial and error, will help other women and couples traveling through pregnancy and grief. If anything, know you are not alone.

You Can Keep Grieving

I think some people expected my pregnancy to help "snap me out" of my grief, or at least, give me a boost forward. First of all, you don't need to stop grieving because you're going to have a baby. Secondly, even without grief, pregnancy hormones trigger tidal mood swings. It's okay if some days you can't muster up any happiness for your pregnancy, or if you resent it for taking time away from your grief. On the other hand, you may feel overjoyed and find your grief has waned. Either way, try to skip the guilt. You will cycle back and forth and round and round all the emotions. It's inevitable, and healthy.

Find Your Release - Mentally and Physically

After my mom died, I wondered if it was possible to run out of tears. Apparently not. Don't bottle up your feelings. Cry when you need to, laugh if the moment strikes. Be pissed off, be excited. The key is finding productive ways to release your emotions. For me, it was through writing and working out. I filled six journals in less than a year. Documenting my daily activities, scribbling down my dreams, and dialoguing with my mom helped me organize the rush of feelings.

Everyone knows working out is good for pregnancy, but it's also a balm for grief. I made a play list of depressing songs - on purpose - and I'd run and cry at the same time. Pounding my feet on the pavement while thinking about my mom and baby helped connect the three of us.

Tune Out the Noise

I remember being feeling a little defensive about my pregnancy, and wondering if some people might think it happened too soon, or worse, that it was an antidote to my sadness. In grief, just like in regular life, people say things that feel hurtful, or you may not agree with their assessment. Maybe your pregnancy was planned, maybe it wasn't. You don't need to rationalize or explain your choices.

Use the Internet Wisely

It was 2007 when I was pregnant and grieving, and there were far fewer online resources about pregnancy than there are now. Pregnant women in general face an avalanche of advice and warnings, often focusing on what can go wrong. Be informed but not overly so. If you're concerned that grief is affecting your pregnancy via depression or anxiety then by all means, tell your doctor, but don't scour the internet for answers. On the other hand, the internet can be a great place to find commiseration from other bereaved mothers-to-be.

Seek Support - Before and After

During your pregnancy, try to surround yourself with people who respect (if not completely understand) your grief. Some friends and family may expect you to focus more on your pregnancy, but you get to do both and on your terms.

Set up a support system for after the baby comes. One of the best decisions I made was hiring a postpartum doula after the birth of my second child. For three weeks, a loving and kindhearted woman wore my baby and folded heaps of laundry while I napped, showered, and cried. In her company I felt understood and cared for - two things that I lacked with my first baby. She also bore witness to the flood of emotions that are released after childbirth, which for me, included a new wave of grief.

Trust Your Intuition

A well meaning friend kept urging me to watch a popular comedy that came out the summer my mom died. I know she was trying to help, but I didn't want humor. Instead, I deliberately sought out melancholy books, movies, and music, all of which helped me grieve. Whatever your preferences are, trust them - for both your grief and your pregnancy.

Create a Legacy Before

Besides keeping a journal, I also went out of my comfort zone and got a little crafty. I collected photographs and made a scrapbook about my mom, documenting my parents' marriage, my birth, and childhood. Inspired by this, I decided to also make a photo album of just the two of us, with the intention of one day sharing it with my daughter. Think of ways you can create tangible memories of your loved one. It doesn't have to be Pinterest worthy, just a physical manifestation of your love.

Create a Legacy After

If your loved one would've been part of your baby's life, don't let death end the relationship. Talk about that person to your baby. Start early on. Call them by the name your child would've used. When they get older you can explain what happened. Young children are usually quite accepting of simple explanations, such as: "So and so died. That means you can't see them again, but you can look at pictures, talk about them, and keep them in your heart."

Some mothers keep their grief to themselves. My mom rarely spoke about her father, who died when she was eight. I can only assume she did so partly to protect me from such terrible sadness, but I wanted to know about him and how she coped with such a loss. It might have helped me with my own.

Parting Words

When the baby arrives, your grief will not stop. This may come as a relief or a hardship, but it's the truth. Having a new baby is all encompassing, and for a while, you'll be in survival mode. You may go days without grieving, you may grieve even more fiercely. I remember feeling a secondary loss, a strange sort of guilt, for losing touch with the all-encompassing nature of my grief. It might have helped to know it's okay to step back, or compartmentalize it temporarily.

Just don't ignore it. Check in with your grief when you can. This may seem impossible, especially in the early weeks, but even a few minutes of writing in a journal or taking a short walk can help.

There is a moment I will never forget in my daughter's infancy. After what felt like hours of crying - hers - she finally passed out. When I looked down at her beautiful peaceful face, I saw a glimpse of my mother. Though no longer in my life, a piece of her was in my arms.
Subscribe to What's Your Grief

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Making Time for Grief During Pregnancy - What's Your Grief

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Today we'd like to welcome guest author Dana Schwartz to discuss what she has learned from her experience grieving during pregnancy. As some of you know, this topic is close to my heart because I lost my own mother to cancer when I was 12 weeks pregnant.

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Responsive feeding - mothers have needs too.

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Responsive feeding - mothers have needs too.

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The mother above is practising responsive feeding but... brace yourself...her baby showed absolutely NO feeding cues before the breastfeed started. Wasn't remotely interested. No cues. No 'demand'.

And...put on a second brace...the mother looked at her watch before starting a feed. The feed started because of the clock.

How can that be?
Isn't responsive feeding all about being 'baby-led'?
Shouldn't the mother be feeding in response to the baby's cues and messages?
Isn't responsive feeding simply another way of saying 'feeding on demand' but we don't use the word 'demand' anymore because it sounds a bit bossy and rude?

Nope.

Responsive feeding is not just a polite way of saying 'feeding on demand'.

Let's imagine this mum was looking at her watch because she has to go and pick her toddler up in an hour. She wanted to get a feed in before she had to leave.
Still responsive feeding.

Let's imagine she has to leave for work. She has a Zumba class. She wants to go and have a bath and leave the baby with her partner.
Still responsive feeding.

She's feeling engorged. She is feeling anxious. She just had a horrible phonecall and really wants a cuddle.
Still responsive feeding.

Because mums can have 'demands' too. They are allowed to have needs and urges and instincts and wishes. Responsive feeding is a two-way street. It's a relationship between two people with back and forth and compromise. Sometimes one takes the lead. Sometimes the other.

It's not a mother under the control of a teeny babygro-wearing master (or mistress).

Mothers can make decisions too. They can take the lead. They can be demanding. Sometimes their feelings might take priority for a while. Responsive feeding isn't all about a mother sacrificing her own needs. Or always putting herself second (or third or fourth).

Responsive feeding is two people meeting each other's needs. The mother won't get milk out of the arrangement but then the baby often isn't looking for milk alone either. Responsive feeding meets the emotional needs of both mother and baby.

Here are some extracts from the UNICEF Baby Friendly infosheet which can be found in full here:
https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2017/12/Responsive-Feeding-Infosheet-Unicef-UK-Baby-Friendly-Initiative.pdf

"Responsive breastfeeding involves a mother responding to her baby's cues, as well as her own desire to feed her baby. Crucially, feeding responsively recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and mother."

"She can also offer her breast to meet her own needs, for example before she goes out, before bedtime or because she wants to sit down, rest and have a cuddle with her baby."

So, yes, sometimes a new mother might feed 'by the clock' and that can be OK. She might want to breastfeed for her own reasons - and that's how it's supposed to work.

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Sometimes responsive feeding looks like this...

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The mother above is practising responsive feeding but... brace yourself...her baby showed absolutely NO feeding cues before the breastfeed started. Wasn't remotely interested. No cues. No 'demand'. And...put on a second brace...the mother looked at her watch before starting a feed. The feed started because of the clock.

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Because mothers have needs too!

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The mother above is practising responsive feeding but... brace yourself...her baby showed absolutely NO feeding cues before the breastfeed started. Wasn't remotely interested. No cues. No 'demand'.

And...put on a second brace...the mother looked at her watch before starting a feed. The feed started because of the clock.

How can that be?
Isn't responsive feeding all about being 'baby-led'?
Shouldn't the mother be feeding in response to the baby's cues and messages?
Isn't responsive feeding simply another way of saying 'feeding on demand' but we don't use the word 'demand' anymore because it sounds a bit bossy and rude?

Nope.

Responsive feeding is not just a polite way of saying 'feeding on demand'.

Let's imagine this mum was looking at her watch because she has to go and pick her toddler up in an hour. She wanted to get a feed in before she had to leave.
Still responsive feeding.

Let's imagine she has to leave for work. She has a Zumba class. She wants to go and have a bath and leave the baby with her partner.
Still responsive feeding.

She's feeling engorged. She is feeling anxious. She just had a horrible phonecall and really wants a cuddle.
Still responsive feeding.

Because mums can have 'demands' too. They are allowed to have needs and urges and instincts and wishes. Responsive feeding is a two-way street. It's a relationship between two people with back and forth and compromise. Sometimes one takes the lead. Sometimes the other.

It's not a mother under the control of a teeny babygro-wearing master (or mistress).

Mothers can make decisions too. They can take the lead. They can be demanding. Sometimes their feelings might take priority for a while. Responsive feeding isn't all about a mother sacrificing her own needs. Or always putting herself second (or third or fourth).

Responsive feeding is two people meeting each other's needs. The mother won't get milk out of the arrangement but then the baby often isn't looking for milk alone either. Responsive feeding meets the emotional needs of both mother and baby.

Here are some extracts from the UNICEF Baby Friendly infosheet which can be found in full here:
https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2017/12/Responsive-Feeding-Infosheet-Unicef-UK-Baby-Friendly-Initiative.pdf

"Responsive breastfeeding involves a mother responding to her baby's cues, as well as her own desire to feed her baby. Crucially, feeding responsively recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and mother."

"She can also offer her breast to meet her own needs, for example before she goes out, before bedtime or because she wants to sit down, rest and have a cuddle with her baby."

So, yes, sometimes a new mother might feed 'by the clock' and that can be OK. She might want to breastfeed for her own reasons - and that's how it's supposed to work.

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Sometimes responsive feeding looks like this...

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The mother above is practising responsive feeding but... brace yourself...her baby showed absolutely NO feeding cues before the breastfeed started. Wasn't remotely interested. No cues. No 'demand'. And...put on a second brace...the mother looked at her watch before starting a feed. The feed started because of the clock.

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This means  recognizing your baby's cues for hunger and fullness and responding to them appropriately (feeding baby or stopping). This process is active and interactive. The parent is actively paying attention to baby while feeding, noticing the subtle cues the baby gives and responding to them appropriately. Here’s why

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A separate Padlet on babies emotional development and how you can support it in the way you parent

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The Breastfeeding Network has loads of information on this. And if you need further information, please call a Breastfeeding Counsellor and get support as we can point you in the direction of  specialist sources of information.

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An increasing number of mothers and health professionals have sought to find more information on the levels of medicines passing through milk to the baby. Standard reference books such as the British National Formulary (BNF) provide little information for professionals and parents to make decisions on individual situations. BfN endeavours to provide information to enable mothers to breastfeed their babies for as long as they wish and to provide information on the safety of medicines for each mother and baby pair.

Please use the below links for more information

We are constantly reviewing the information available on drugs and breastfeeding as new research is conducted. Therefore, from time-to-time the information on this website may be updated - please be sure to check regularly for any new information and changes to the drug information fact sheets and leaflets.

What is the Drugs in Breastmilk Information Service?

The original Drugs in Breastmilk Helpline was set up by BfN in response to the number of calls we were receiving that concerned medication.

In 2017 we noticed that majority of enquiries from parents and professionals to the Drugs in Breastmilk Helpline were coming via email or social media. As a charity operating on reducing funds we need to run the service in the most efficient and effective way possible without compromising the needs of parents. As a result we decided to run the Drugs in Breastmilk service via email and social media enquiry only.

You can still access information on taking prescription drugs while breastfeeding by sending a private message via our Facebook page or via . Please provide as much information as possible (age of baby, dose, frequency and name of medication or drug). All enquiries are answered as soon as possible by one of our small, volunteer team of qualified pharmacists or breastfeeding supporters. As we can't guarantee a response time, in an emergency situation, please do not wait for our reply, but access help from a trained healthcare professional.

If you call the old Drugs in Breastmilk helpline 0844 number, you will hear a recorded message with information about where to access alternative support. Calls won't be answered live and there is no voicemail service available.

If you still have the Drugs in Breastmilk helpline number on any materials or web pages please could you remove it and replace it with the following information:
'If you have specific questions about medications or treatments, please message the Drugs in Breastmilk information service Facebook page or email druginformation@breastfeedingnetwork.org.uk. If you require breastfeeding support, please call the National Breastfeeding Helpline on 0300 100 0212."

The service is open to mothers and professionals. As the time available to deal with breastfeeding support of mothers is limited, professionals are encouraged to find out the information to enable them to support the mothers themselves.

Evaluation of the Drugs in Breastmilk Information Service

In 2019, BfN commissioned Swansea University to undertake an evaluation of the DIBM service we offer. The executive summary of this report can be found and the full report can be found .

Become a Friend of Drugs in Breastmilk

Please click here for more information on how you can help support this vital service.

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Drugs In Breastmilk - Is It Safe? - The Breastfeeding Network

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An increasing number of mothers and health professionals have sought to find more information on the levels of medicines passing through milk to the baby. Standard reference books such as the British National Formulary (BNF) provide little information for professionals and parents to make decisions on individual situations.

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Breastfeeding has an anti-inflammatory effect, which can be helpful. See this paper on depression which mentions it.

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Abstract

Background

Research in the field of psychoneuroimmunology (PNI) has revealed that depression is associated with inflammation manifested by increased levels of proinflammatory cytokines.

Discussion

The old paradigm described inflammation as simply one of many risk factors for depression. The new paradigm is based on more recent research that has indicated that physical and psychological stressors increase inflammation. These recent studies constitute an important shift in the depression paradigm: inflammation is not simply a risk factor; it is the risk factor that underlies all the others. Moreover, inflammation explains why psychosocial, behavioral and physical risk factors increase the risk of depression. This is true for depression in general and for postpartum depression in particular. Puerperal women are especially vulnerable to these effects because their levels of proinflammatory cytokines significantly increase during the last trimester of pregnancy - a time when they are also at high risk for depression. Moreover, common experiences of new motherhood, such as sleep disturbance, postpartum pain, and past or current psychological trauma, act as stressors that cause proinflammatory cytokine levels to rise. Breastfeeding has a protective effect on maternal mental health because it attenuates stress and modulates the inflammatory response. However, breastfeeding difficulties, such as nipple pain, can increase the risk of depression and must be addressed promptly.

Conclusion

PNI research suggests two goals for the prevention and treatment of postpartum depression: reducing maternal stress and reducing inflammation. Breastfeeding and exercise reduce maternal stress and are protective of maternal mood. In addition, most current treatments for depression are anti-inflammatory. These include long-chain omega-3 fatty acids, cognitive therapy, St. John's wort, and conventional antidepressants.

Review

Depression in new mothers is common in many cultures, affecting anywhere from 10% to 20% of postpartum women. In some high-risk populations, the percentage can even be as high as 40% or 50% []. Since depression has devastating effects on both mother and baby, it's vital that it be identified and treated promptly. Depressed mothers are also more likely to stop breastfeeding with negative health effects for each []. In this paper, I describe a psychoneuroimmunology (PNI) framework for depression in new mothers and discuss its implications for breastfeeding women.

Inflammation and depression

In recent years, researchers in the field of PNI have found that inflammation is involved in the pathogenesis of depression. Maes and colleagues first documented that mothers with the postpartum blues had higher levels of inflammation than mothers who did not []. They concluded that the postpartum blues were caused by an activated inflammatory response system (IRS). In a later paper, Maes and colleagues noted that "it is generally accepted that in the early puerperium, there is an increased inflammatory responsivity in the serum ... suggesting an activation of the inflammatory response system" [] (p. 71).

When researchers first identified inflammation as increasing the risk of depression, most considered it an independent risk factor along with several others. The other risk factors included psychosocial stress, a broad category that included significant life changes, lack of social support, marital difficulties, infant illness or prematurity, and low income. Psychological trauma, another risk factor, includes current trauma or a history of trauma, which creates a vulnerability to future stressors even when there are no current symptoms. Sleep disturbance and pain are physical stressors that are common among new mothers and increase the risk of depression. The model portrayed on Figure shows these as individual risk factors and represents the old paradigm.

More recent research, however, suggests a new paradigm for understanding depression. PNI researchers have found that physical and psychosocial stressors (i.e., all the risk factors for depression) increase inflammation [-]. These recent studies constitute an important shift in the depression paradigm: inflammation is not simply a risk factor; it is the risk factor that underlies all the others []. This model is portrayed on Figure .

Puerperal women are especially vulnerable because their inflammation levels rise significantly during the last trimester of pregnancy - a time when they are also at high risk for depression. Moreover, common experiences of new motherhood, such as sleep disturbance, postpartum pain, psychological stress, and trauma also increase inflammation. Physical and psychosocial risk factors for depression are still important to identify. The old paradigm identifies the known causes of depression in new mothers.

The new paradigm moves the field forward and provides an answer to the next question: why? Why would psychosocial risk factors, such as lack of social support or marital strife or stress, increase the risk of depression? Why would depression be more likely in women who are sleep deprived or who have experienced trauma or pain? The new paradigm provides perspective on the mechanism by which previously identified risk factors increase risk. It also guides practitioners in their intervention efforts and suggests that targeting inflammation may increase women's resilience to other stressors.

Breastfeeding and depression in mothers

Breastfeeding also has an important role to play in mothers' postpartum mental health. Groër and Davis noted that "breastfeeding confers some psychoneuroimmunological benefits to mothers" (p. 599) in part because of its impact on stress []. In an earlier review, Groër, Davis and Hemphill noted that although women experience many stressors in the postpartum period, breastfeeding protects them by inducing calm, lessening maternal reactivity to stressors, and increasing nurturing behaviour []. The PNI approach is relevant to lactation specialists because it demonstrates that breastfeeding can protect mothers' mental health and is worth preserving whenever possible.

Method of literature review

The studies cited below were assembled from a wide variety of sources. Literature searches on PubMed and PsychInfo were conducted on depression, postpartum/postnatal depression, depression and inflammation, proinflammatory cytokines, pain, sleep disturbances, HPA dysfunction and depression, trauma, omega-3 fatty acids, inflammation and depression. In addition, several key PNI and psychiatry journals were manually searched for relevant articles including Psychoneuroendocrinology, Psychosomatic Medicine, Psychosomatic Research, Biological Psychiatry, Health Psychology, American Journal of Psychiatry, British Journal of Psychiatry, and British Medical Journal. Where appropriate, literature from the field of cardiovascular medicine was cited as this literature contains many studies that examine the links between depression, inflammation and risk of cardiovascular disease.

Physical and psychological stressors that increase inflammation and risk of depression

To understand the role of inflammation in depression, it's helpful to first review the normal physiologic response to stress. When faced with a threat, human bodies have a number of interdependent mechanisms in place designed to preserve our lives. The sympathetic nervous system responds by releasing catecholamines (norepinephrine, epinephrine, and dopamine). The hypothalamic-pituitary-adrenal (HPA) axis also responds: the hypothalamus releases corticotrophin releasing hormone (CRH), the pituitary releases adrenocorticotropin hormone (ACTH), and the adrenal cortex releases cortisol, a glucocorticoid. The immune system responds by increasing production of proinflammatory cytokines, which increase inflammation. Cytokines are proteins that regulate immune response. Proinflammatory cytokines help the body heal wounds and fight infection by stimulating an inflammatory response [].

Maes and colleagues described the interrelatedness of these systems and noted that inflammation influences levels of serotonin and catecholamines, and has an impact on the HPA axis, which controls cortisol levels [, ]. Once inflammation starts, it triggers the HPA axis to release cortisol, and the release of more proinflammatory substances []. Breastfeeding appears to attenuate these effects by lowering cortisol, ACTH, epinephrine and norepinephrine [].

(1) Immune and HPA dysfunction in depression

Depression is also related to some distinct abnormalities in the immune system and HPA axis. I will describe the immune effects first. For many years, researchers considered depression to be primarily immunosuppressive in that they observed that depressed people had fewer lymphocytes and the natural killer cells (NK) had lower cytotoxicity [, ]. These are both indications of a suppressed immune system. More recent studies, however, indicate that depression causes an immune dysfunction, meaning that some aspects are suppressed, while other aspects are elevated [, ]. In depressed people, inflammation is increased, including high levels of proinflammatory cytokines and acute-phase proteins, such as C-reactive protein (CRP), which are a physiologic response to chronic distress [, , ]. Levels of inflammation can be 40% to 50% higher in depressed people than their non-depressed counterparts [].

The proinflammatory cytokines that researchers identified most consistently as being elevated in depression are interleukin-1β (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and more recently, interferon-γ (IFN-γ) []. In the last trimester of pregnancy, levels of proinflammatory cytokines rise []. When these cytokines are within normal levels, they are adaptive because they help prevent infection. When they are abnormally high, they increase the risk of depression. Proinflammatory cytokines cause a constellation of sickness behaviors in humans, which includes alterations in sleep, appetite, activity, mood, energy, sexual activity and socialization - all behaviors associated with depression []. The relationship between inflammation and depression appears to be bidirectional: inflammation increases the risk of depression and depression increases inflammation.

Depression can also influence the systems that normally keep inflammation in check, such as the HPA axis. Cortisol is anti-inflammatory and is generally secreted when inflammation levels get too high. However, depressed people either have abnormally low levels of cortisol or they become less sensitive to cortisol. In either case, cortisol fails to restrain the inflammatory response. In one recent study of 72 women, depressed women had higher levels of IL-6 and TNF-α in response to an acute stressor than women who weren't depressed []. Also they were less sensitive to glucocorticoids that normally terminate the inflammatory response system []. The authors concluded that the depressed women had a blunted cortisol response to stress []. Groër and Morgan in their study of 200 postpartum women also noted a down-regulation of the HPA axis and abnormally low levels of cortisol in depressed women at 4 to 6 weeks postpartum [].

(2) Depression, inflammation and preterm birth

Depression poses another health risk to puerperal women - increased risk of preterm birth. Several researchers have noted that depression and posttraumatic stress disorder increase risk of preterm birth, and inflammation may explain why [, ]. In a study of 200 women at 4 to 6 weeks postpartum, depressed mothers had significantly smaller babies, more life stress, and more negative life events []. These women also had abnormally low cortisol levels meaning that the inflammatory response was not restrained. Another study in Goa, India (n = 270) found that babies of mothers who were depressed during their third trimester of pregnancy were significantly more likely to have low birth weight babies than their non-depressed counterparts. Mothers who were most severely depressed were at highest risk (Odds Ratio, OR: 2.5); these findings were significant even after for controlling for maternal age, maternal and paternal education, and paternal income [].

In a prospective cohort study of 681 women, the rate of spontaneous preterm birth for depressed women was more than twice that of women who were not depressed (9.7% vs. 4%; OR: 3.3) []. The authors speculated on two possible pathways by which depression might lead to preterm birth. Depression can lead to elevated cortisol levels, which increases corticotrophin releasing hormone (CRH). CRH triggers parturition. The other possible mechanism they cited is activation of the proinflammatory cytokines and prostaglandin E2, which is secreted in response to cortisol and proinflammatory cytokines. Prostaglandin E2 plays a major role in uterine contractions [].

The proinflammatory cytokines IL-6, IL-8, and TNF-α ripen the cervix before birth and these are also elevated when women are under stress. In a study of 30 pregnant women, Coussons-Read and colleagues found that TNF-α and IL-6 levels were significantly higher, and the anti-inflammatory cytokine IL-10 was significantly lower, in mothers who were stressed compared with mothers who weren't []. The authors hypothesized that inflammation was the likely mechanism to explain the relationship between maternal stress and preterm birth. They noted that high levels of inflammation (particularly IL-6 and TNF-α) were associated with preeclampsia and premature labor. Infection also increases the risk of preterm birth and TNF-α is released in response to both viral and bacterial infections. They concluded that high levels of proinflammatory cytokines may in fact endanger human pregnancies [].

Inflammation may also explain another set of findings regarding preterm birth. In a study of 291 low-income pregnant women, participants were randomly assigned to receive either DHA-enriched eggs or regular eggs that they were to consume daily during the last trimester of their pregnancy []. This sample was predominantly African American (73%), a group generally at risk for preterm birth. DHA is a long-chain omega-3 fatty acid with anti-inflammatory effects (these effects are described in more detail in a subsequent section). Women who received the DHA-enriched eggs had an average increase in gestation of six days (SD = 2.3) []. The DHA-enriched eggs may have increased gestation length by decreasing inflammation.

(3) Physical and psychological stressors

As described in the previous section, human bodies are designed to respond a certain way when they are threatened. These threats can be physical or psychological; the physiological response is the same. Moreover, some types of stressors have both physical and psychological elements. Three stressors - sleep disturbance, pain, and trauma - are particularly relevant to new mothers. Studies that examine these stressors with regard to inflammation are described below.

(a) Sleep disturbances and fatigue

Sleep disturbance and depression are also mutually maintaining conditions: sleep disturbance can cause depression and depression causes sleep disturbances. Ross et al. noted that several factors suggest a relationship between sleep problems and depression in postpartum women []. These are as follows.

1. 1)

Insomnia is a significant risk for new-onset depression;

2. 2)

Sleep disturbances are common in most psychiatric disorders;

3. 3)

Treatments that manipulate sleep and circadian rhythms can be used to treat mood disorders.

In a review of polysomnographic studies of postpartum women, Ross et al. noted that there are differences in REM latency for women at risk for postpartum depression or who have current postpartum depression - reduced REM latency, increased total sleep time during pregnancy and decreased total sleep time postpartum []. REM latency refers to the time during the night when REM sleep becomes the predominant pattern. A pattern of reduced REM latency means that REM occurs earlier in the nightly sleep cycle, and is a symptom of depression. As a result of these sleep disturbances, women are more fatigued during the day. The authors noted that these changes may represent an underlying vulnerability to depression as they do with non-postpartum populations. They also noted that women with a history of affective disorders may be more sensitive to the normal physiologic changes of pregnancy.

In summary, sleep disturbances and fatigue are physical stressors that increase the risk of depression. The relationship between sleep problems and proinflammatory cytokines appears to be bidirectional: sleep disturbances increase cytokines and cytokines increase sleep disturbance by delaying sleep onset, increasing daytime fatigue, and perpetuating the cycle of disturbed sleep and inflammation. Motivala and colleagues hypothesized that interventions that target disordered sleep may also lower inflammation, thereby lowering the risk of depression [].

(b) Pain

The relationship between pain and inflammation also appears to be bidirectional. When a woman experiences pain, stress hormones and levels of proinflammatory cytokines increase. High levels of proinflammatory cytokines, in turn, increase pain. Cytokines (especially IL-1) are stimulated by Substance P. Substance P is the neuropeptide that is high in patients with pain. In one study, patients with major depression or posttraumatic stress disorder were compared to healthy controls (n = 101) []. The patients with depression or PTSD had significantly elevated levels of Substance P in their cerebrospinal fluid. Moreover, the levels of Substance P rose significantly when the patients were presented with a laboratory-induced stressor that reminded them of their traumatic event. The authors concluded that Substance P was related to both depression and PTSD and responded to acute stress []. High levels of Substance P are also related to lower levels of serotonin, which increases the risk of depression. In addition, cytokines increase prostaglandin synthesis, including the prostaglandin cyclooxygenase-2 (COX-2), which increases pain [, -]. In a study of mothers at eight weeks postpartum, a history of either violence or depression increased the risk of postpartum health problems including several types of postpartum pain [].

An interesting exception to the pain-sleep disturbance phenomenon is co-sleeping. Polysomnographic studies of breastfeeding mothers who are sleeping next to their babies for all or part of the night indicate that the mothers spend less time in deep sleep than mothers who are not co-sleeping. Despite significantly decreased slow-wave sleep, co-sleeping mothers do not appear to report an increase in body pain []. Co-sleeping may be less stressful for mothers than needing to completely wake for night time feeding. Or the higher levels of prolactin that co-sleeping mothers have may have an impact decrease inflammation and pain. This issue has never been specifically addressed and would be an interesting topic for future research.

In summary, postpartum pain is a common experience among women who have recently given birth []. Addressing pain promptly, and providing mothers the means to cope with their pain can halt the cascade of stress hormones and proinflammatory cytokines, decreasing their risk of depression.

(c) Current trauma or history of trauma

According to the Diagnostic and Statistical Manual [], a traumatic event is one in which the person felt that death or serious injury was possible for themselves or a loved one, and the person responded with fear, helplessness or horror. In addition, there must be symptoms in each of these three clusters: 1) intrusion: frequent re-experiencing of the event via nightmares or intrusive thoughts, 2) avoidance: numbing or lack of responsiveness to or avoidance of current events that remind patients of their trauma, and 3) hyperarousal: persistent symptoms of increased arousal including jumpiness, sleep disturbances or poor concentration [].

1) The impact of highly stressful births on breastfeeding

Women may also have experiences that are highly stressful, while not leading to PTSD [], can cause breastfeeding difficulties. Women who experience highly stressful births are likely to have abnormally high cortisol levels in the first few days postpartum. And elevated cortisol levels may cause problems. In a study from Guatemala, researchers measured the cortisol levels of 136 women before or after birth. For women with the highest levels of cortisol, lactogenesis II (the onset of copious milk supply) was delayed for several days [].

2) Prior history of depression or trauma

A woman with a history of depression or trauma is often more vulnerable to current life stresses. One way that that vulnerability manifests is a more rapid inflammatory response to current stressors. This effect has been noted in both human and animal research. For example, in an animal study, prior exposure to a stressor (in this case, inescapable foot shock) led to a hypersensitivity of the inflammatory response system and more rapid release of proinflammatory cytokines when exposed to a subsequent stressor []. This is consistent with human studies of childhood abuse that indicate that men and women who are abused in childhood have a significantly increased vulnerability when exposed to current life stressors. They may respond to these current situations with either depression of PTSD [].

Kiecolt-Glaser and colleagues also noted that stress and depression appear to prime the inflammatory response so that it is more reactive to subsequent stressors []. During the postpartum period, women experience a number of significant stressors, such a sleep deprivation and postpartum pain, that increase inflammation and the subsequent risk of depression [, ]. Women with prior histories of severe stress, depression and trauma are at increased risk of postpartum depression in part because of the way their bodies are primed to react to stress.

Implications: goals of prevention and treatment

A PNI approach suggests two important and related goals for the prevention and treatment of depression in new mothers: reduce maternal stress and reduce maternal inflammation. These recommendations are described below.

(1) Reduce maternal stress

Since physical and psychological stressors trigger the inflammatory response system, the first goal for preventing or treating depression is to reduce maternal stress. And one important way to do this is for health care providers to encourage mothers to breastfeed, and to support ongoing breastfeeding relationships.

(a) The adaptiveness of breastfeeding

Breastfeeding and stress in babies

Breastfeeding not only reduces stress for mothers; it also lowers stress that babies experience when their mothers are depressed. Jones et al. compared the infants of four groups of women: depressed mothers who were either breast or bottle feeding, and non-depressed mothers who were either breast or bottle feeding []. The outcome was the babies' electroencephalogram (EEG) patterns. This measure is used to determine if infants have physiological symptoms of depression - in this case, a pattern of right frontal asymmetry. Right frontal asymmetry is a pattern that also is found in chronically depressed adults.

The researchers found that the babies of the depressed/non-breastfeeding mothers had the abnormal pattern of right-frontal asymmetry []. In contrast, infants of the depressed/breastfeeding mothers had normal EEG patterns. In other words, breastfeeding protected these babies from the effects of maternal depression. The authors explained their findings by noting that the depressed/breastfeeding mothers did not disengage from their babies the way the depressed/bottle-feeding mothers did. The depressed/breastfeeding mothers continued to look at, touch and stroke their babies because these behaviors are built into the breastfeeding relationship. In contrast, when a mother bottle feeds, she doesn't have to even hold her baby. So it is easier for her to disengage, leading to the symptoms that babies typically exhibit when their mothers are depressed [].

In summary, breastfeeding protects maternal mood by lowering stress. When stress levels are lower, the mother's inflammatory response system will not be activated, thereby lowering her risk of depression. However positive these results, I must issue one caveat: they only apply when breastfeeding is going well. As noted earlier, when breastfeeding that is not going well, particularly if there is pain, it becomes a trigger to depression rather than something that lessens the risk. Mothers' mental health is yet another reason to intervene quickly when breastfeeding difficulties arise.

(b) Exercise and depression

Another way mothers can reduce stress is to exercise, which has also been found to alleviate depression. In a Finnish population study (n = 3,403), men and women who exercised two to three times a week experienced significantly less depression, anger, cynical distrust, and stress than men and women who exercised less frequently [].

In summary, by linking stress and depression, the PNI framework provides a rationale for why exercise would be an effective intervention for depression - something practitioners can share with mothers. The goal is improved mental health, not weight loss (although some might occur). Depressed mothers need this information because exercise is often the very last thing they feel like doing. But exercise is an effective technique for both decreasing their risk of depression and helping them cope with the stresses and strains of early motherhood.

(2) Reduce inflammation

The second recommendation is for mothers to reduce inflammation. As described earlier, psychosocial and physical risk factors for depression increase inflammation, which increases depression risk. One way to decrease inflammation is through consumption of long-chain omega-3 fatty acids. Omega-3s show promise in the treatment of mood disorders according to a 2006 expert panel convened by the American Psychiatric Association []. And they do so, in part, by decreasing inflammation. These studies and their relevance to pregnant and postpartum women are described below.

(a) Long-chain omega-3 fatty acids and depression

Over the past 100 years, the diet of people in many Western cultures has changed substantially. Some have theorized that these changes could explain the increase in depression during this same time period [, , ]. Of particular concern is the change in the ratio of omega-6:omega-3 fatty acids, with dramatically decreased omega-3s and increased omega-6s. Omega-6 fatty acids are found in vegetable oils and are a staple of processed foods. Omega-3s are found in fatty fish and some plant sources. While some omega-6s are necessary for good nutrition, they become harmful when the ratio of omega-6s to omega-3s is too high - as it is in modern diets. Kiecolt-Glaser and colleagues noted that the hunter-gatherer diet had an estimated ratio of omega-6s:omega-3s of 2:1 or 3:1 []. The typical North American diet ranges from 15:1 to 17:1. In Australia and New Zealand the ratio is 10:1 []. With regard to depression, the long-chain omega-3s are of interest: EPA and DHA []. ALA is the omega-3 found in flax and other plant sources. ALA is an essential fatty acid, and while important for good nutrition, it has no efficacy in the prevention or treatment of depression [].

(i) Anti-inflammatory activity of omega-3s

Omega-3s are powerful anti-inflammatories and lower proinflammatory cytokines. In a large population study, high levels of omega-3s (ALA, EPA and DHA) were related to lower levels of the proinflammatory cytokines IL-1α, IL-1β, IL-6, and TNF-α and higher levels of anti-inflammatory cytokines such as IL-10. For people with low levels of omega-3s, the opposite was true: these people had high levels of proinflammatory cytokines and low levels of anti-inflammatory cytokines []. Higher levels of proinflammatory cytokines increase the risk for depression.

In a study of older adults, the combination of depression and higher omega-6: omega-3 ratios dramatically increased levels of proinflammatory cytokines (IL-6 & TNF-α) beyond the individual contribution of either variable alone. The authors noted that a diet with a high ratio of omega-6s:omega-3s increases the risk of both depression and diseases related to chronic inflammation including heart disease, diabetes and cancer [].

EPA and DHA may also increase resilience to stress by regulating and attenuating the stress response. Maes and colleagues noted that an imbalance of omega-6s:omega-3s leads to an overproduction of proinflammatory cytokines in response to psychological stress []. When omega-3 levels are higher, the levels of proinflammatory cytokines are reduced. Their study included 27 college students who were exposed to a laboratory-induced stressor. The students with lower serum levels of omega-3s had a significantly greater stress-induced elevation of TNF-α and IFN-γ than those with higher serum omega-3s or a lower ratio of omega-6s:omega-3s [].

(ii) Omega-3s in population studies

Population studies have provided support for the efficacy of omega-3s in preventing depression and other mental health problems by demonstrating that populations who naturally consume more omega-3s in their diets (usually by eating fatty coldwater fish, e.g. such as salmon or mackerel) have lower rates of a variety of mental health problems. For example, populations with higher levels of EPA and DHA in their diets had lower levels of major depression, bipolar disorder, and future suicide risk [-]. A prospective study in Osaka, Japan of 865 pregnant women, however, failed to find a relationship between fish intake or the intake of omega-3 fatty acids and prevention of postpartum depression []. These findings could be due to a ceiling effect in that the entire population already eats large amounts of seafood [].

(iii) Treatment with EPA and DHA

Positive findings have been noted in randomized clinical trials, where researchers have given either EPA/DHA supplements or a placebo to people currently receiving treatment for unipolar or bipolar depression. When EPA was added to patients' normal regimen of antidepressants, EPA made the antidepressants more effective in treating depression than the placebo []. Similarly, in a study of childhood depression, children who received EPA and DHA in addition to their medication had significantly improved depression compared with children who received their medication and a placebo []. EPA also helped stabilize symptoms of bipolar disorder in a 12-week double-blind trial [].

In a recent review, EPA had efficacy in the treatment of depression in four of the six studies reviewed []. The authors found that 1 gram of EPA per day was the effective dose. Doses higher than two grams seemed to have the reverse effect []. EPA affects the function of both the proinflammatory cytokines and the eicosanoids. The eicosanoids include prostaglandins, leukotrienes and thromboxanes []. Given its direct action on proinflammatory cytokines, the efficacy of EPA as a treatment for depression is consistent with previous studies on depression and inflammation.

A preliminary study demonstrated that EPA and DHA may have efficacy in the treatment of postpartum depression. The study was limited, however, by a small sample, no control group, and subjects who were not blind to the treatment condition. This study was intriguing, however, because depression decreased 48% to 51% in the eight-week study period []. At the very least, these findings suggest that a follow-up study would be useful.

(iv) DHA in the perinatal period

During the perinatal period, DHA appears to be particularly important []. Pregnant women's diets are often deficient in DHA, which is unfortunate given babies' high need for it in utero. And this may put their mothers at risk for depression. As Rees and colleagues describe, during the last trimester of pregnancy, babies accumulate an average of 67 mg/day of DHA []. The average intake for Australian mothers is 15 mg/day. In contrast, DHA consumption among Japanese, Koreans, and Norwegians is about 1000 mg/day. Because babies need DHA for brain and vision development, women's bodies will preferentially divert DHA to the baby, and the baby will take the DHA it needs from maternal stores. With each subsequent pregnancy, mothers are further depleted [, ]. Current recommended intake is 200 to 400 mg/day as a minimum dose.

DHA appears to have a role in the prevention of depression, but according to two recent reviews, has no efficacy in treatment of depression when used alone [, ]. In the Adelaide Mothers' and Babies' Iron Trial, a 1% increase in plasma DHA was related to a 59% decrease in depressive symptoms postpartum []. In a large population study, women who consumed high amounts of seafood during pregnancy and had high levels of DHA in the milk had lower rates of postpartum depression [].

DHA may have another effect that could help prevent depression postpartum. In a study of infant sleep, mothers with high levels of DHA during pregnancy had babies who exhibited a more mature sleep pattern in the first few days of life []. The investigators examined the ratio of quiet to active sleep using a monitor placed beneath the crib mattress. A higher percentage of quiet sleep is characteristic of older babies, and is considered a more mature sleep pattern. Babies whose mothers had high levels of DHA during pregnancy exhibited more mature sleep patterns as neonates. The investigators concluded that babies of high-DHA mothers had more mature central nervous systems than babies of mothers who were low in DHA. Although this was not study of depression per se, babies with more mature sleep patterns also allow mothers to get more uninterrupted sleep - and this could have an indirect effect on their mothers' mental health [].

(v) Sources of EPA and DHA

As the previously cited studies indicate, women are often deficient in long-chain omega-3 fatty acids during the perinatal period. However, pregnant or breastfeeding women often need to limit the amount of fish they eat, the prime source of EPA and DHA, because of contaminants in seafood. Fortunately, there are a alternative sources of EPA and DHA that are tested for contaminants and are contaminant free. A listing of sources of EPA/DHA that are tested for contaminants can be seen in Additional file .

(b) Other anti-inflammatory treatments for depression

Conclusion

Recent research has identified inflammation as a key factor in depression, and inflammatory response system is triggered by both physical and psychological stress. Postpartum women are particularly at risk because their inflammation levels are naturally elevated in the last trimester of pregnancy, and this elevation continues through the postpartum period. Two approaches may prevent depression or reduce its severity: lowering maternal stress and reducing inflammation. Breastfeeding has been shown to reduce stress and protect maternal mood. Breastfeeding also reduces stress of babies of depressed mothers and protects them from the harmful effects of maternal depression. Treatment approaches that are anti-inflammatory have efficacy in treating depression. These include EPA and DHA, exercise, cognitive therapy, herbal anti-depressants such as St. John's wort, and standard antidepressants. Research is needed to assess if anti-inflammatory approaches used proactively can prevent depression from occurring in the first place.

Abbreviations

Declarations

Acknowledgements

The author wishes to thank two friends and colleagues for their input into the early conceptualization of the role of inflammation in depression: Robert C. Drugan, Ph.D., University of New Hampshire and James H. Flatt, Ph.D., Martek Biosciences Corporation.

Electronic supplementary material

Competing interests

The author worked briefly in 2006 as a consultant and continuing education provider for Martek Biosciences Corporation. This paper was written independent of that work and was completed several months after the consulting agreement ended.

Below are the links to the authors' original submitted files for images.

Authors' Affiliations

Family Research Laboratory, 126 Horton Social Science Center, University of New Hampshire, Durham, USA

References

McGovern P, Dowd B, Gjerdingen D, Gross CR, Kenney S, Ukestad L, McCaffrey D, Lundberg U: Postpartum health of employed mothers 5 weeks after childbirth. Ann Fam Med. 2006, 4: 159-167. 10.1370/afm.519.

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A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health

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Research in the field of psychoneuroimmunology (PNI) has revealed that depression is associated with inflammation manifested by increased levels of proinflammatory cytokines. The old paradigm described inflammation as simply one of many risk factors for depression. The new paradigm is based on more recent research that has indicated that physical and psychological stressors increase inflammation.

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We all want the best for our children. The way we care for a baby can help build a baby who is confident and happy, able to make secure relationships. It’s all a out parenting responsively.

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Swansea University - 'Put Down the Baby Care Books' Animation

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Our new animation for Swansea University College of Human and Health Sciences explains that a good baby is a perception held by our society that babies should act in a certain way, and that some baby care books take advantage of this by suggesting parents should encourage babies to be in a strict routine for their feeding and sleep.

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“Don’t give in. Whether you’re breastfeeding, bottle-feeding or both; feed your baby. Feed them anywhere and everywhere.”

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I’m breastfeeding everywhere – and guess what? People are great about it | Nell Frizzell

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I’ve been truly surprised by the support of strangers. A kind word doesn’t take much but for anxious mums it means a lot, writes freelance journalist Nell Frizzell

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Dealing with criticism and disagreements 

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Dealing with criticism and disagreements 

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When you become a parent, you can feel very vulnerable. Everyone seems to have an opinion, from your mother to your health professionals. Here are some tips for navigating your way through.

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Many new parents are surprised to find themselves feeling helpless when their baby first arrives. However well you prepare for your baby's arrival, it is common to lack confidence or to worry that you don't know what to do.

There are thousands of books which will confidently tell you precisely what your baby needs; apps to keep track of whether you and your baby are doing the right things at the right times; healthcare professionals with charts and lists of milestones to tell you how your baby should be developing; family, friends and even strangers may be telling you how to take care of a baby and what you shouldn't do.

However well-meaning all this advice and support, it can often feel like you are being told that you're wrong, told that you don't know anything, or criticised for the choices that you are making. Sometimes as mothers we can feel criticised even when nothing is being said at all; the very fact that other people choose to parent in a different way can make us feel like they must think we are doing the wrong things.

Responding to comments
Talking with friends and family
Expressing your opinions and feelings
Disagreements with healthcare professionals
How to cope with feeling criticised

Responding to comments

If someone else asks questions about the way you parent your child, or tells you that you should be doing something differently, you don't necessarily need to discuss it in detail. For example, a neighbour might suggest giving your child a dummy when you have chosen not to, or a stranger in a shop might tell your toddler "you're too heavy for your mummy to keep carrying you around like that!". Particularly if the person is well-meaning, and perhaps someone who doesn't have much involvement in your child's life, it can be enough to have a few stock phrases to use. Here are some suggestions that parents have found helpful:

"Thanks for your suggestion, I'll think about it / maybe I'll try to find out more about that."

"This is working for us right now, but we may decide to do things differently as time passes."

"You're right, it's difficult to get a baby to sleep / help a toddler to be more independent. How did you manage that with your children?"

"We're working on it! I'm sure things will be different / he'll be out of nappies / he won't still be breastfeeding by the time he leaves home!"

"My midwife/health visitor/GP recommended that I do it like this, I'm just following instructions."

"I know it looks like hard work, but we've tried lots of ways and this is what we all enjoy most."

Or you can just smile, thank the person for their support, and change the subject to a less controversial one.

Talking with friends and family

If the criticism or disagreement comes from people close to you, it might not be as simple as moving the conversation on to an easier topic. You may well want the important people in your life to support and encourage you as a mother, and differences of opinion can really get in the way of that.

If you think it would be helpful to discuss a disagreement in more detail, you could plan to bring it up at a time when you are relaxed and have enough time to do the conversation justice, and invite the other person or people to discuss it with you. For example, you could start with "I've been thinking about what you said the other day about me picking up my daughter when she cries. Would it be OK for us to talk some more about that? I'd like to understand what you think about it. Is this a good time?"

Also think about what you want to get out of the discussion. You might be having this conversation with somebody like your partner or a grandparent who regularly takes care of your child and treats them in a way that is different from your own parenting style. In that case it could be important to you to persuade this person to change their opinion, or at least their behaviour, so that your child is not treated in a way that you find unacceptable.

However, in many circumstances it is not necessary to try and persuade another person that you are right. Particularly if you are talking to someone who has treated their children in a very different way from you, trying to persuade them that they have made mistakes as a parent may not be constructive. It can be helpful to bear in mind that the person talking to you may have raised children many years ago, or in another country or culture, and the advice they were given about how to treat children could be very different. You may be able to find ways of acknowledging that they did their best with the information they had at the time, just as you are trying to do now.

Expressing your opinions and feelings

Often, if you feel criticised or attacked, you just want an opportunity to express your point of view, or to defend your right to make your own choices about parenting. Even if the other person does not change their mind, it is common to feel better simply because you've been able to express yourself or defend your decisions. In this case, it can really help to start the conversation in a way that makes it clear you are not trying to start an argument, but would just like to express your thoughts.

For example:

"I know you and I have made very different decisions about discipline / weaning / etc. I'm sure you're doing what works best for you and your family, just like I am."

"When you tell me that I'm spoiling my baby, I feel criticised and hurt."

"If there was one right way to look after a baby, all our lives would be a lot simpler, but I'm enjoying getting to know my baby and finding out what they need from me."

"Different approaches might work for different babies, and for different parents too."

Many of us find the day-to-day work and decision-making of mothering to be draining and difficult at times, and often we just want emotional support from those around us. When family and friends offer practical suggestions, they may be trying to acknowledge the demands of parenting and help you to cope, but it can feel like criticism. You can help loved ones to support you by describing the kind of support you feel you need:

"I know that it's hard for you to see me so tired, and I appreciate your offer to look after the baby so I can rest, but even though it's tiring I do feel better having him with me. If you'd like to help, I'd love... [to come round to have lunch with you one day / some company in the evening when they're fretful / someone to take my toddler to the playground so I can nap when my baby does]"

"You're right that I'm having some difficulties with breastfeeding, but it's really important to me to make this work for me and my baby. I could really do with some encouragement to keep me going through the difficult days."

"When I tell you I've had a bad day, I know you want to come up with solutions to make life better for me. What helps me most is if you can listen and give me a hug, then I feel like I've got the strength to carry on."

"I'm working this out as I go, just like any parent, and doing the things that we find work best for us. Even though it must be strange to see me doing some things very differently from how you did them with your children, it means a lot to me to know that you want the best for us, and that you love us even when you disagree."

Disagreements with healthcare professionals

Sometimes a healthcare professional may suggest approaches that you are not comfortable with, or may disagree with decisions you take as a parent. This could be anything from a health visitor suggesting early introduction of solids to a doctor prescribing a medical intervention that you do not want your child to have. Many parents find it hard to speak up when they are being given instructions by someone who has some kind of authority; it can help you to feel more confident if you prepare in advance, take someone with you for support, or put your concerns in writing if you find that easier.

Here are some suggestions for how to approach difficult conversations with healthcare professionals:

Ask for information: what are the expected benefits of the suggested action and how likely are they? What are the possible risks and how likely are they? What are the current evidence and best practice guidelines in this area? What alternatives are there? Is it possible to get a second opinion?

Offer information: talk with your healthcare professional about any information you have and where it came from; look for respected sources of information such as medical journals and NHS guidelines. Give any background information that you think may be relevant (such as "my first baby was also on the 5th centile for weight at this age", or "we have a family history of allergies and eczema").

Don't be afraid to express your opinions and feelings. For example, "I understand that you believe this is in my daughter's best interests, but it's important for me as her mother to understand exactly what you're recommending and why."

Remember that healthcare professionals have good intentions and want the best for the children they work with, even if you disagree with their views.

Healthcare professionals have experience and training in their specialism; you have expertise and experience with your own child. Working together and using their medical knowledge and your understanding of your child can help everyone to find the best possible course of action.

How to cope with feeling criticised

Parenting can be tiring and difficult, and feeling criticised or unsupported by people around you can make it harder. It is important to take care of yourself, and to find ways to let off steam or wind down. It can be really good to have at least one supportive friend or relative who is willing to listen to you without judging or making suggestions, and to support you whether or not they agree with all the decisions you make. You may have other ways of dealing with stress - through exercise, creativity, relaxation; it can be hard to continue taking care of yourself in these ways once you have children to look after, but spending some time on your own wellbeing can really help you to be the kind of parent you hope to be.

And don't forget that you can contact other mothers through La Leche League, whether by speaking to a Leader on the helpline, attending a meeting of your local group or joining them on social media. Our aim is to provide mother to mother support, by listening without judgement and providing a welcoming atmosphere, whatever your choices and experiences.

Find your local group here.

Written by Emma Taylor for LLLGB

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Dealing with criticism - La Leche League GB

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Many new parents are surprised to find themselves feeling helpless when their baby first arrives. However well you prepare for your baby's arrival, it is common to lack confidence or to worry that you don't know what to do. There are thousands of books which will confidently tell you precisely what your baby needs; apps [...]

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A quick reference article that answers most questions

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Do I need to maintain a perfect diet while breastfeeding?

The short answer to this question is NO - you do not need to maintain a perfect diet in order to provide quality milk for your baby. In fact, research tells us that the quality of a mother's diet has little influence on her milk. Nature is very forgiving - mother's milk is designed to provide for and protect baby even in times of hardship and famine. A poor diet is more likely to affect the mother than her breastfed baby.

It's common to hear women say that they want to wean (or not breastfeed at all) because they miss drinking coffee, or want to have an occasional glass of wine, or don't like worrying constantly about everything they eat. Guess what? You can drink caffeinated beverages (in moderation), have an occasional drink, eat what you want and still provide your baby with the absolute best nutrition and immunological protection - mother's own milk.

According to Katherine A. Dettwyler, Ph.D., breastfeeding researcher and anthropologist, women throughout the world make ample amounts of quality milk while eating diets composed almost entirely of rice (or millet or sorghum) with a tiny amount of vegetables and occasional meat.

Are healthy eating habits recommended for mom? Absolutely! You will be healthier and feel better if you eat well. It is best for anyone to eat a variety of foods, in close to their naturally-occurring state, but this is not necessary for providing quality milk or for maintaining milk supply. Although it is certainly not recommended, a breastfeeding mother could live on a diet of junk food - mom would not thrive on that diet, but her milk would still meet her baby's needs.

What IS needed for maintaining an ample supply of milk?

The main thing needed to maintain an ample milk supply is simple -
The more often and effectively your baby nurses, the more milk you will have.

Occasionally, a mother's calorie or fluid intake can affect milk production:

Calories: In general, you should simply listen to your body and eat to appetite - this is usually all you need to do to get the calories you need. Counting calories is rarely necessary unless you are having problems maintaining a healthy weight. Excessive dieting can reduce milk supply, but sensible dieting is generally not a problem.

Liquids: It is not necessary to force fluids; drinking to satisfy thirst is sufficient for most mothers. Unless you are severely dehydrated, drinking extra fluids is not beneficial, may cause discomfort, and does not increase milk supply. It is not necessary to drink only water - our bodies can utilize the water from any fluid.

The main message on calories and fluids - Eat when hungry & drink when thirsty.

See Do nursing mothers need extra calories or fluids? and How does milk production work? for more information.

How does my nutrient intake affect breastfeeding?

Are there any foods that I should avoid while I'm breastfeeding?

There are NO foods that you should avoid simply because you are breastfeeding. It is generally recommended that a nursing mother eat whatever she likes, whenever she likes, in the amounts that she likes and continue to do this unless baby has an obvious reaction to a particular food.

It's suggested that everyone, particularly pregnant and nursing mothers, avoid eating certain types of fish that are typically high in mercury.

It is a good idea to restrict caffeine and alcohol to a certain extent, but it is rarely necessary to eliminate them.

Some food proteins (such as cow's milk protein or peanut protein) do pass into mother's milk. If there is a history of food allergies in your family, you may wish to limit or eliminate the allergens common in your family.

Any baby might react to a particular food (although this is not very common). If baby has an obvious reaction every time you eat a certain food, it may be helpful to eliminate that food from your diet. For more information, see Dairy and other Food Sensitivities in Breastfed Babies.

Making women think that they must maintain 'perfect' diets in order to have thriving breastfed babies is an unnecessary obstacle to breastfeeding.

Additional information

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How does a mother's diet affect her milk? * KellyMom.com

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The short answer to this question is NO - you do not need to maintain a perfect diet in order to provide quality milk for your baby. In fact, research tells us that the quality of a mother's diet has little influence on her milk.

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Information sheet from the Breastfeeding Network

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Alcohol in breastmilk - just how much is a baby exposed to?

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Alcohol in breastmilk - just how much is a baby exposed to?

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This interesting article presents a reasoned argument

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It's cocktail season - that time of year when it becomes socially acceptable to overdo it slightly, and if necessary, calm down family politics with an 11am sherry or two.

But if like me you're a breastfeeding mum, you may be feeling slightly left out of the party, sipping lime soda as you nurse your baby and watch everyone else hitting the bottle.

Much of the advice on drinking and breastfeeding is...well...don't do it. A quick glance at the official channels and the outlook is sobering: NHS Choices states that for nursing mums, "one or two units once or twice a week is not harmful", but that, "to be on the safe side, some women choose to avoid alcohol."

It gets worse. Both the RCOG and the Royal College of Midwives recommend "total abstinence during pregnancy and whilst breastfeeding".

But, pour yourself a strong one, because I've got a double measure of shocking confessions to make. Firstly, I'm on my third breastfed baby. I've nursed all three somewhat beyond the WHO recommendation of two years, which means I've been happily lactating for nearly eight years.

And secondly, but perhaps no less controversially, I really like wine.

Before you souse me in brandy and flambé me at the stake like a festive pudding, let me explain.

Often, as women, our default mode of 'guilty' blinds us to the actual facts. Breastfeeding is an absolute crucible for this phenomenon: the success of it relies on us placing utter trust in our bodies, which for most of the rest of our lives, we've been taught are singularly unreliable.

It means the whole process of nursing a baby becomes fraught with anxiety: are they getting enough, am I eating a good diet, am I drinking too much coffee? The list is endless, but they all have the same common denominator. In short. is the offering of my body inadequate or even damaging in some way, and would my baby be better off with the neat, predictable, and brilliantly marketed stuff that comes out of a packet?

World renowned breastfeeding expert Dr Jack Newman believes that the idea of totally abstaining from alcohol is one of the many breastfeeding myths that often result in women giving up nursing their babies:

Credit: Alamy

"Reasonable alcohol intake should not be discouraged at all. As is the case with most drugs, very little alcohol comes out in the milk. The mother can take some alcohol and continue breastfeeding as she normally does. Prohibiting alcohol is another way we make life unnecessarily restrictive for nursing mothers."

Of course, we all know that breastfeeding or otherwise we need to limit our alcohol intake, and that if we are in charge of a small baby or child it is inappropriate and potentially dangerous to drink to excess. But we need to separate out that very valid concern from the idea of a breastfeeding mum enjoying a couple of glasses of decent wine with her turkey.

Another expert, paediatrician and author of Breastfeeding Made Easy Carlos Gonzalez, explains the actual process of the effect of alcohol on breast milk:

"Alcohol passes easily and quickly from the mother's blood into her milk, and vice versa, so that the concentration in both liquids is the same."

It's easy to read this and make the quick assumption that if a mother is drinking 15 per cent Cabernet Sauvignon, her milk is of a similar strength, but of course, that's not how it works. Gonzalez goes on:

"The legal driving limit in the UK is 0.08 per cent. If your alcohol level is higher than 0.15 per cent you are unmistakably drunk. If it goes above 0.55 per cent you simply drop dead. Therefore, it's absolutely impossible for breastmilk to contain more than 0.55 per cent alcohol."

However, as Gonzalez points out: "Alcohol-free beer can legally contain nearly double this level - up to 1 per cent alcohol. Consequently, even the breastmilk of a completely inebriated mother could be bottled and labelled 'alcohol free'."

Gonzalez is keen to stress that heavy drinking and breastfeeding is not a healthy combination, but adds that excessive consumption is likely to have the most negative effect on the mother, not the baby, and that "even if the mother drinks three glasses of wine a day, breastfeeding is still better for her baby than bottle feeding."

As ever, it's a case of where to safely draw the line, and perhaps those who recommend total abstinence for nursing mothers do so because they don't think women can navigate the 'grey areas' and make safe and healthy decisions based on their own judgement and circumstances. What is safe for a toddler who feeds two or three times a day is not necessarily safe for a tiny newborn who nurses constantly 24/7.

Emma Pickett, Chair of the Association of Breastfeeding Mothers, believes that a blanket ban can deter some women from continuing to nurse. "Those who suggest abstinence 'just in case' don't appreciate many women may end breastfeeding entirely in order to drink alcohol. These mums feel it's a valued party of their social life and complete abstinence feels like one more way breastfeeding separates you from 'normal'. It's another sacrifice we're asking mums to make just in case they can't be trusted to drink carefully and moderately."

Lack of trust seems to cultivate fear and misinformation, so you have a world in which breastfeeding mums are frowned upon or even arrested for having a beer with their dinner, where mums are sold products to test their milk for absurdly low alcohol levels and encouraged to 'pump and dump' (a pointless activity since alcohol leaves the milk as soon as it leaves the blood), and where many a woman ends her breastfeeding relationship or never even starts it because she's afraid of what the odd glass of wine might do to her baby.

So this Christmas let's put an end to this nonsense and raise a glass to the sensible women everywhere who are more than capable of doing their homework and who care deeply about the welfare of their baby. Everything in moderation. Cheers!
Click here for the full factsheet on Alcohol and Breastfeeding from the Breastfeeding Network.

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Breastfeeding mums rejoice! You can drink alcohol (Christmas or no Christmas)

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It's cocktail season - that time of year when it becomes socially acceptable to overdo it slightly, and if necessary, calm down family politics with an 11am sherry or two. But if like me you're a breastfeeding mum, you may be feeling slightly left out of the party, sipping lime soda as you nurse your baby and watch everyone else hitting the bottle.

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about what new mothers need after birth. Other cultures support and care for new mothers. Perhaps that’s why they have a very low incidence of postnatal depression.

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Is ours not a strange culture that focuses so much attention on childbirth-virtually all of it based on anxiety and fear-and so little on the crucial time after birth, when patterns are established that will affect the individual and the family for decades? Suzanne Arms.

As citizens of an industrialized nation, we often act as if we have nothing to learn from low-income, developing countries. Yet many of these cultures are doing something extraordinarily right-especially in how they care for new mothers. In their classic paper, Stern and Kruckman ( 1983) present an anthropological critique of the literature. They found that in the cultures they studied, postpartum disorders, including the "baby blues," were virtually nonexistent. By contrast, 50% to 85% of new mothers in industrialized nations experience the "baby blues," and 15% to 25% (or more) experience postpartum depression.
What makes the difference?
Stern and Kruckman noted that cultures who had a low incidence of postpartum mood disorders all had rituals that provided support and care for new mothers. These cultures, although quite different from each other, all shared

5 protective social structures

1. A distinct postpartum period. In these other cultures, the postpartum period is recognized as a time that is distinct from normal life. It is a time when the mother is supposed to recuperate. Her activities are limited and her female relatives take care of her. This type of care was also common in colonial America, when postpartum was referred to as the "lying-in" period. This period functioned as a time of "apprenticeship," when more experienced mothers mentored the new mother.

2. Protective measures reflecting the new mother's vulnerability. During the postpartum period, new mothers are recognized as being especially vulnerable. Ritual bathing, washing of hair, massage, binding of the abdomen, and other types of personal care are prominent in the postpartum rituals of rural Guatemala, Mayan women in the Yucatan, Latina women both in the United States and Mexico. These rituals also mark the postpartum period as distinct from other times in women's lives.

3. Social seclusion and mandated rest. Postpartum is a time for the mother to rest, regain strength, and care for the baby. Related to the concept of vulnerability is the widespread practice of social seclusion for new mothers. For example, in the Punjab, women and their babies are secluded from everyone but female relatives and their midwives for five days. Seclusion is said to promote breastfeeding and it limits a woman's normal activities. In contrast, many American mothers are expected to entertain others-even during their hospital stay. Once they get home, this practice continues as they are often expected to entertain family and friends who come to see the baby.

4. Functional assistance. In order for seclusion and mandated rest to occur, mothers must be relieved of their normal workload. In these cultures, women are provided with someone to take care of older children and perform their household duties. As in the colonial period in the United States, women often return to the homes of their family of origin to ensure that this type of assistance is available.

5. Social recognition of her new role and status. In the cultures Stern and Kruckman studied, there was a great deal of personal attention given to the mother. In China and Nepal, very little attention is paid to the pregnancy; much more attention is focused on the mother after the baby is born. This has been described as "mothering the mother." For example, the status of the new mother is recognized through social rituals and gifts. In Punjabi culture, there is the "stepping-out ceremony," which includes ritual bathing and hair washing performed by the midwife, and a ceremonial meal prepared by a Brahmin. When the mother returns to her husband's family, she returns with many gifts she has been given for herself and the baby. The following is a description of a postpartum ritual performed by the Chagga of Uganda. It differs quite a bit from what mothers in industrialized countries may experience. ￼

Three months after the birth of her child, the Chagga woman's head is shaved and crowned with a bead tiara, she is robed in an ancient skin garment worked with beads, a staff such as the elders carry is put in her hand, and she emerges from her hut for her first public appearance with her baby. Proceeding slowly towards the market, they are greeted with songs such as are sung to warriors returning from battle. She and her baby have survived the weeks of danger. The child is no longer vulnerable, but a baby who has learned what love means, has smiled its first smiles, and is now ready to learn about the bright, loud world outside (Dunham, 1992; p. 148).

What American mothers experience

By contrast, American mothers often find that people are more concerned about them before the birth. While a woman is pregnant, people may offer to help her carry things or to open doors or to ask how she is feeling. Friends will give her a baby shower, where she will receive emotional support and gifts for her baby. There are prenatal classes and prenatal checkups, and many people wanting to know about the details of her daily experience.

After she has her baby, however, mother-focused support rapidly declines. Typically, a woman is discharged from the hospital within 24 to 48 hours after a vaginal birth, or 2 to 4 days after a cesarean section. She may or may not have anyone to help her at home-chances are no one at the hospital has even asked. Her mate will probably return to work within the week, and she is left alone to make sure she has enough to eat, to teach herself to breastfeed, and to recuperate from birth. The people who provided attention during her pregnancy are no longer there, and the people who do come around are often more interested in the baby. There is the tacit-and sometimes explicit-understanding that she is not to "bother" her medical caregivers unless there is a medical reason, and she must wait to talk to her physician until her six-week postpartum checkup. There probably are resources in her community that may help, but she has no idea where they are, and feels too overwhelmed to seek them out for herself. So she must fend for herself as best she can.

Is it any wonder that many women find the postpartum period to be extremely stressful? One popular book written for new mothers (Eisenberg, et al., 1989) describes this transition as "the reverse Cinderella-the pregnant princess has become the postpartum peasant" with a "wave of the obstetrician's wand" (p. 546).

Here are some comments mothers have shared with me.
I felt like I didn't matter. I felt like they weren't interested in me after I had my baby. My husband said, "Of course they are not interested. You've had your baby." After the birth, I had several people tell me that the most important thing was that I had a healthy baby. Yes, that is important. But what about me? No one pays attention to the fact that you've had major surgery. They would have paid more attention if I'd had had my appendix out.
As a culture, we have woefully neglected the needs of new mothers. But this was not always so. Historically, we recognized the importance of a community of women helping women, who provided this much needed practical and emotional assistance. In so doing, they provided a chance for postpartum women to recuperate and assimilate the major change that had taken place in their lives. Chances are it will be many years before there are organized efforts aimed at providing care for new mothers. The good news is that a grassroots movement has begun that seeks to meet the needs of postpartum women.

The word " doula"-from the Greek word for servant-is becoming part of our vocabulary. A postpartum doula is someone who takes care of postpartum women by providing practical and emotional assistance (Lim, 1995; Webber, 1992). Friends, family or a woman's partner can be doulas. Or women in some communities might be able to hire a professional doula. In either case, the doula movement is in response to the lack of postpartum care available from traditional care providers.

In the following account, doula Salle Webber describes her care for new mothers and the types of support and assistance that they need.
In my work as a doula, my focus is on the mother. I want to provide whatever it is that she needs to feel comfortable, nourished, relaxed, and appreciated: to facilitate a harmonious transition for both mother and child in those profound first days and weeks after birth.
A mother needs someone who cares about how many times the baby woke to nurse in the night, how many diapers were changed, how her breasts are feeling. She may need her back massaged or her sheets changed, or she may need someone to provide an abundant supply of water or tea, salads readymade in the refrigerator, a bowl of cut-up fruit. She needs to be able to complain about how little her mate understands what she's going through, and perhaps, some gentle reminders of all the contributions he has made. She needs someone to hold the baby so she can take a shower or even go to the bathroom; someone to answer the phone when she's napping; someone to water her plants or garden, to clean the kitchen and bathroom, to keep up on the family's laundry. She may have many questions and concerns that only an experienced mother can understand. She needs patience and kind words and a clean and calm environment (Webber, 1992, p. 17).

While our culture continues to lack supportive postpartum rituals, the work of individual women can make a significant difference. Many are surprised that this decidedly "low-tech" intervention can work. Yet this is perhaps the most important lesson we can learn from the cultures that Stern and Kruckman described.

We must begin to change the way we think about providing care for new mothers. This care should not stop once the baby is born, but should continue throughout the postpartum period.

In conclusion, we have learned that women can make a comfortable and peaceful transition into motherhood. Postpartum mental illness is not inevitable and in many cases can be prevented. It is time that we recognize and meet the needs of postpartum women. The health of our families depends on it.￼￼￼￼￼￼￼￼￼￼

References

Eisenberg, A., Murkoff, H.E., & Hathaway, S.E. (1989). What to Expect the First Year. New York: Workman.

Lim, R. ( 1995). After the Baby's Birth: A woman's way to wellness. Berkeley, CA: Celestial Arts. New edition: ( 2004). After the Baby's Birth: A Complete Guide for Postpartum Women.

Stern, G. & Kruckman, L. ( 1983). Multidisciplinary perspectives on postpartum depression: An anthropological critique. Social Science and Medicine, 17, 1027-1041.

Webber, S. (1992). Supporting the postpartum family. The Doula, 23, 16-17.

Kathleen Kendall-Tackett, PhD, IBCLC, FAPA is a health psychologist and International Board Certified Lactation Consultant, and the owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women's health. She is Editor-in-Chief of two peer-reviewed journals: Clinical Lactation and Psychological Trauma. She is Fellow of the American Psychological Association in Health and Trauma Psychology, Past President of the APA Division of Trauma Psychology, and a member of the Board for the Advancement of Psychology in the Public Interest. Dr. Kendall-Tackett specializes in women's-health research including breastfeeding, depression, trauma, and health psychology, and has won many awards for her work including the 2016 Outstanding Service to the Field of Trauma Psychology from the American Psychological Association's Division 56.
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What can we learn from the cultural postpartum rituals of low-income, developing countries?

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In most situations there is a medicine that is compatible with breastfeeding. Click on the link below to find out more

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Drugs in Breastmilk factsheets - The Breastfeeding Network

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These factsheets have been compiled by our Drugs in Breastmilk information service team of pharmacists. If you are unable to find the information you are looking for below, or you still have questions, you can contact the team by sending a private message via our Facebook page or via email. Please provide as much information as possible (age […]

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It helps to have other people around who are looking after you!

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It helps to have other people around who are looking after you!

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In most cultures, there is a strong tradition of caring for new mothers for an extended period to help them make the sometimes difficult transition to motherhood.

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There's no doubt about it-from maternity leave (or lack thereof) to postpartum care traditions for mother and baby, the United States is seriously lacking. Which is why we've found the book The First Forty Days: The Essential Art of Nourishing the New Mother so inspiring. Rooted in Chinese practices and giving a nod to rich postpartum rituals around the world, this thoughtful tome is filled with healing recipes and guidance on how women can take care of themselves after birth (or recruit others to take care of them). One of our favorite sections of the book is a rundown of other global postpartum care traditions that are thoroughly engrained in culture. Read some of them, excerpted from the book, below. Who knows, maybe some of these time-tested cultural traditions will inspire your own postpartum plans.

China: In its purest form, traditional Chinese zuo yuezi advises a tough-love approach of sponge baths instead of showers (to reduce the chance of catching a chill), no books in case reading strains the eyes, and no movies in case sad scenes upset you and disrupt your flow of chi-while others take over all your household duties, of course. Zuo yuezi is often referred to as "the Gateway," as it is a threshold between one way of being (your life before baby) and an entirely new existence (life with baby). The reward for spending dedicated time in this revitalizing in-between space? The mother can emerge more beautiful and rejuvenated than before. Traditional Chinese medicine (TCM) doctors say that if the woman shirks this recovery, she may experience a yin deficiency, resulting in insomnia, excessive night sweats, hair loss, anxiety, or headaches. Chinese-American families frequently do a bit of zuo yuezi without even realizing it. Many a relative has shown up to visit mom and newborn at the hospital with traditional chicken soup, appalled at the idea of her picking at a limp tuna sandwich from the canteen cooler. (A customary gift of dried longan fruit might come with the soup.) That small warming gesture in itself is tradition in action.

Zambia: In Zambia, the mom is strictly banned from any work around the house until the umbilical cord falls off. (A whopping week to ten days usually-and then it may be back to doing the dishes as normal).

Latin America: In many parts of Latin America, a forty-day period known as la cuarentena -it literally means "quarantine" yet also plays off the Spanish word for "forty," cuarenta-has female relatives take on all domestic duties to ensure the new mother rests at home, in order to safeguard against future exhaustion-related illnesses or ailments. Her midwife may visit frequently over the first two weeks to check on baby and mother's well-being, and homemade chicken soup simmers on the stove (overly spicy or heavy dishes are nixed). The new mother's abdomen is wrapped in a faja or cloth to help keep her belly warm.

Japan: Japanese mothers return to their mothers' houses for a month or two of focused care and traditional food.

Native Americans: In many Native American tribes, ceremony is key: The customary "lying in" period after birth culminates in ritualistic bathing, a baby-naming ceremony, and going to a sweat lodge to boost circulation and help mom's body eliminate any toxins. The Hopi people in the southwestern United States recall practices of twenty-day seclusion periods for mother and babe, during which the mother might be served blue corn piki bread, a ceremonial food. Prepared in an hours-long process by a wise elder woman of the community, the flaky, thin-as-air bread was served to honor rites of passage.

India: In India, the new mother often returns to her parents' home with her newborn for up to three months of focused care. There, many pairs of hands are on call throughout the day. The women of the family cook soft and nurturing foods, boil fresh milk three times in a row to break down its proteins, and stir in melted ghee (clarified butter) and special spices, so it becomes easy to digest and restores the mother's depleted state. These loving hands also hold the baby whenever mom needs a break. If members of the new mother's family are versed in Ayurveda-the five-thousand-year-old healing art of India-she may drink herbal tonics for energy, immunity, and lactation and receive daily, warm-oil massages from a specially trained technician to soothe her nerves by calming the excess vata or "wind" in her system after birth. She even gets taught how to gently massage her little one's body as well-a relaxing and bonding experience for both parties.

The Middle East: Forty-day rest periods for the new mother are traditional in Jordan, Lebanon, Egypt, and Palestine.

Korea: Korea's postpartum tradition of samchilil decrees a period of at least twenty-one days, and ideally thirty days, of specialized maternal care dedicated to keeping mom warm, snug, and well fed. Miyeokguk, a traditional seaweed soup with beef, chicken, or anchovies, is served several times a day, every day, to boost circulation, restore lost nutrients, and enrich breast milk. Gums are tender so icy foods are banned to avoid dental problems later. At one hundred days, the baby is introduced to the wider family for the first time with a baek-il ceremony-a kind of fourth-trimester graduation party! This also ends the close-up focus on mom care-she's ready to graduate, too.

Vietnam: Vietnamese parents don't introduce strangers to their babies for six weeks, to protect them from envy or, simply, too much attention.

Ivory Coast: Female relatives descend on the new mother's home in the Ivory Coast right after birth. The mother is bathed and massaged in shea butter by her own mother-a pampering rite that saturates skin with healing oils-while her grandmother and grandaunts gently bathe and dress the baby. Younger cousins and aunts cook a delicious meal, and after eating all together, the circle lets the new mother nap, with baby safe in their sights.

Indonesia: In Indonesia, a bright light burns in the new mother's home for forty days after birth to honor the new life that has arrived. The midwife visits daily to massage mom; bathe her in therapeutic baths; feed her jamu, a special nourishing concoction of egg yolks, palm sugar, tamarind, and healing herbs; and wrap her belly to support her uterine healing while also checking in on baby. For forty days, the placenta is preserved and kept near the mother before being ceremonially buried. It is believed that the placenta still holds protective spiritual power that can safeguard the new mother from infection or illness.

Moldova: The Eastern European country of Moldova has a special chicken soup to encourage breast milk production.

Malaysia: In Malaysia's pantang protocol, the mother secludes herself for forty-four days and receives hot stone massages, full-body exfoliation, herbal baths, and hot compresses to care for the life force that is sourced in her womb. Her mother or mother-in-law may oversee this, or an experienced live-in helper might guide her through this process. And it doesn't stop there. Ask women of different ethnicities and backgrounds about their maternal customs and the stories keep coming. What does it take to help the expanded winter melon-sized uterus return to its normal pear-like size? The dramatic changes in the body of a new mother have to be nurtured slowly back to its prenatal form. If the new mother does not take care during this time, the roots of various ailments will establish themselves and lie dormant in her body, surfacing in her middle age. Thus, a new mother should not be annoyed when her mother-in-law keeps advising her to eat more digestive food, drink more nutritional tonics and soups, and keep away from specific foods. Proper postnatal care, rest, and diet will rebuild a
more mature, yet beautiful, body for the new mother.

Shanghai & Hong Kong: At the far other end of the scale, in Shanghai and Hong Kong, high-luxury "confinement hotels" offer upwardly mobile women a red-carpet way to experience zuo yuezi-call it five-star confinement-and conveniently lets them sidestep the drama of having mother-in-law take up camp in their home for a month. Sumptuously bathrobed in her plush hotel room, the new mom is served medicinal soups from gourmet chefs and can visit an on-site spa as often as she likes, while uniformed nannies handle baby's every need, taking him out for sun baths daily and dipping him in warm pools to tone his muscles. It may be the antithesis of attachment parenting-and it certainly is a status symbol for the parents-but it hits the spot for busy women of means: Every moment of the month is devoted to optimal health for the newborn, and optimal rest and pampering for mom.

Europe and North America: In the past, special pui-yuet or confinement companions might have been hired by Chinese households to help run the month of care. Modern-day variations of this are emerging, putting traditional programs of postpartum care in reach of women wanting to experience the old ways: In Europe and North America, an emerging field of practitioners known as Ayurdoulas, postpartum doulas trained in Ayurvedic care, can be hired to visit the home over several weeks, bringing food, giving massages, and helping mom learn about baby care. In Canadian cities like Toronto and Vancouver, zuo yuezi -trained doulas do a bustling trade visiting homes in Chinese communities, and highly traditional cooking services can bring breast milk-enriching fish and papaya soup to your door. In New York and other U.S. cities, there are even humble Mandarin- or Cantonese-speaking guesthouses where first-generation immigrants who have no relatives nearby can "sit the month" in the old ways with a clutch of other mothers.

Reprinted with permission of the authors of The First Forty Days: The Essential Art of Nourishing the New Mother.
Related Article: An Arugument For Taking The First 40 Days Slow Postpartum.

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There's no doubt about it-from maternity leave (or lack thereof) to postpartum care traditions for mother and baby, the United States is seriously lacking. Which is why we've found the book The First Forty Days: The Essential Art of Nourishing the New Mother so inspiring.

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This guest blog from breastfeeding counsellor Emma Pickett discusses the dangers of promoting a strict feeding schedule at the expense of responsive, flexible infant feeding.
Add your voice to Unicef UK's Change the Conversation campaign, calling on UK governments to take urgent action to protect, promote and support breastfeeding.
Somehow, somewhere, new mothers got the message that the gap between when a baby stops a breastfeed and the time they start to need another one matters a very very great deal. 24 hours a day.

It seems to matter beyond all logic and reason. They see this magic number - 90 minutes, 2 hours, 3 hours - as a measure of something sacred.

And it's crap.

There are mums sitting at home, relaxing and nesting with their gorgeous new baby. There's a disk from a box set in the DVD player, a cup of tea on the go, a recent chat with a friend. Breastfeeding is going well. Weight gain is fine. Baby is content. But when baby shows hunger cues after only 40 minutes instead of the hoped for 1 hr 30 minutes, their heart sinks and they feel a sense something is fundamentally wrong. They aren't 'doing it right'. Their friend's baby 'goes longer'. Doubts creep in.

As adults, we grab a cup of tea, a glass of water, a sweet, a snack. We respond to our personal cues and we're flexible depending on time of day, the temperature, our mood, our energy levels. Many go to bed with a glass of water or sip from a bottle throughout the day. I don't know any adults that look at their watch and say, "Only 30 minutes till my next sip of water or mint! Not long now". But yet we expect teeny growing babies to be governed by this artificial notion of time.

Basic misconceptions

I spoke to a new mother last week who was perfectly happy with her feeding routine but wondered if she should start to stretch her baby's intervals because 'that's what you do'. When I explained that it wasn't necessarily, she said she was more than happy to go on as she was.

Where do these ideas come from? They don't come from anyone with any breastfeeding education, nor antenatal classes with breastfeeding professionals, nor books written by those trained to support breastfeeding.

They come from popular baby care books and relatives and peers.

They seem to come from a fundamental misunderstanding of the science of breastfeeding and breastmilk production. Often they come from mid-20th century ideas based around the norms of formula-feeding and pseudo-science. And that's all incredibly dangerous.

There are still people out there, surrounded by breastfeeding, who believe that a baby who feeds after 4 hours rather than 3 hours will 'take more milk'. There are people who believe that you need to wait and hold a baby off to let your breasts 'refill'. There are people who believe that when a baby does want to return to the breast after only an hour that must reflect a 'problem' and perhaps the mother even has a supply issue.

It's scary and extremely frustrating that basic messages about how milk production works don't reach the people who need them.

Searching for "normal"

So what is normal? Well, how long have you got? Because there's a lot of normal. A newborn should feed a minimum of 8-12 times in 24 hours. That means some might be going every 3 hours and others will be feeding more frequently than 2 hourly. Some babies may feed every 10 minutes every hour. Some may feed for 10 minutes every 2 hours. Some may feed for 40 minutes every 2 hours. For periods in the day, a younger baby will often cluster feed and not be happy away from the breast for any longer than a few minutes at a time. This natural cluster feeding may dominate an evening.

A very common call to the National Breastfeeding Helpline goes like this: "My baby used to sleep in the evenings and now he's awake for 3-4 hours. The only thing that seems to settle him is the breast. I feel like I must not have enough milk as he's on there for ages. Surely there can't be anything there." As the baby swaps from breast to breast, getting small quantities of very high fat content milk and decompressing at the end of a long day, they know exactly what they are doing.

And soon their patterns will change again. Some babies will start to longer intervals in the day as the months go by. But not all will.

One of the most popular babycare books (which I better not name) gives a strong direction that while frequent feeding might be occasionally acceptable during growth spurts, this holy cow of the interval between feeds matters greatly. A 3 month old baby might be going 3 hourly intervals but if this isn't increasing at 4 months, then oh dear. This same writer believes a woman can measure her milk supply by doing a yield test and using a pump to extract milk which apparently will be the equivalent amount to what her baby extracts during a feed using an entirely different process. What this woman doesn't know about breastfeeding could fill an encyclopaedia.

What I find particularly dangerous about her message that longer intervals are 'better' and 'correct', is that is means new mothers doubt their milk supply with absolutely no justification. And I know from having spent time on the message boards associated with this writer, many mothers will end up supplementing with formula to try and reach these magic numbers of minutes.

Why?

Babies are no longer being exclusively breastfed and parents are not following Department of Health recommendations because of incorrect information in a baby care book.

There are parents who choose to use formula for a whole host of complex reasons. Some do so happily and some do so miserably. But to do so, merely because you have read a lie in a book, seems tragic to me.

Our knowledge about breasts has been transformed over the last 20 years. Much of the pioneering work has been done in Australia by scientists like Professor Peter Hartmann and Dr Donna Geddes, Steven Daly and their teams.

We used to think most women had a pretty similar number of milk ducts but the ultrasound research revealed there were less than previously thought and the range was big. One woman had 4 ducts at the nipple. One had 18.

But it's the findings about breast storage capacity that we need to talk about here. When a baby feeds, some milk is manufactured during the feed itself and some is taken from milk that has been stored in the breasts between feeds.

Ultrasound revealed that a mother's storage capacity cannot be guessed from breast size. Breast size is obviously not just about glandular tissue. The range in breast storage capacity was huge.

One mother was able to store about 2.6oz per breast. Another woman stored more than 20oz. That's not a typo.

Women with a smaller breast storage capacity had a healthy milk production over a 24 hr period and their babies had good weight gain. But their babies might need to feed more frequently to access this healthy milk production.

Is this a mother with a supply problem?

No, it is not.

Her baby may continue to feed 2 hourly or even more frequently for a few months during the day, cluster feed at certain points and perhaps continue to wake a couple of times hungry at night. Her friend's baby may settle into a pattern of feeding less frequently over a 24 hour period. This friend's baby may not be receiving more milk overall.

When breasts are fuller, milk production slows. When breasts are emptier, we make more milk. When babies feed more frequently and from emptier breasts, they receive milk with a higher fat content. Frequent feeding has value. And as human milk has a fat content of around 3-5% compared to some mammals who have a fat content of 40% +, it seems pretty clear we're designed as a species to need feeding more frequently.

But let's imagine the mother with the smaller breast storage capacity has read this baby care book. She might become distressed that her baby still wants to feed 2 hourly. She might even try and stretch the interval between feeds in the mistaken belief this will increase her baby's intake. And in doing so, her breasts spend longer at full storage capacity and their milk production slows and her breasts receive the signal to decrease milk supply.

So in her attempt to stretch between feeds as the advice she is reading suggests she does, she may actually be decreasing her overall milk production in 24 hours and be doing some actual harm.

So what should we suggest to this mum who never seems to be able to stretch her baby to longer intervals in the ways that her friends seem able?

First off, we should congratulate her for responding to her baby's cues. Thankfully she knew not to try and impose some routine early on and therefore her milk supply is at its maximum capacity. Let's check breastfeeding is otherwise going well: that feeds are comfortable for her, baby does settle for periods of contentment after a feed (though it may only be an hour or even less, rather than 3), weight gain and nappies are fine and latching and positioning is at maximum efficiency. If all this is true, and never reaching a magic 'interval' is her only concern, then we need to make sure she knows as much as possible about how milk production works. It is possible she is one of the mothers who has a minimal breast storage capacity and she will need to feed more in 24 hours to maximise the volume of milk her baby receives. And there might be nothing she can do about that. What happens next is about acceptance and support and attitude.

She has to keep that up for ideally around 6 months if her baby is going to get the full benefits of exclusive breastfeeding. She might need greater support with feeding outside the home - perhaps learning how to feed in a sling or experiment with different positions for different environments. It's possible she may be woken at night more than her friend with the longer intervals - though we would expect night time intervals to be longer and for her to get a block of longer rest. She may benefit from support on safe bed-sharing practices.

And it is just a matter of months. After solids have been established, patterns will change. It's surprising what we can cope with for just a few months. We have jars of pickle in our fridge significantly older than that. We may even have toothbrushes that are around that long. In terms of an adult lifetime, it's a blink of an eye.

What won't help these mothers is the relentless message that they just need to stretch their baby a little more. That if they leave him to cry for 15 minutes, magically he will take more milk and life will change. That just isn't what science tells us is true for all women.

Responsive feeding: So much more than milk

Of course breastfeeding isn't just about milk anyway. Apparently there are people who think that a baby comes to a breast primarily to get milk but I've not met a parent of a baby who thinks that's true. Just as we don't measure our sips of water, sweets and snacks, we also don't measure every time our family smiles warmly at us, communicates with us, looks for comfort, hugs us, checks in, helps us to feel safe. No smart phone app can measure all the complexities of our relationship with our baby and all the things that responsive feeding can do. You are trying to count and measure love.

And I'm talking about myself here, by the way. My children under 6 months never went longer than 2 hours between feeds in the day and not much longer at night. My red record book records me feeding at 3 months every 90 minutes or so. So I learnt to feed while babywearing. I went to friendly groups and friendly places and met up with people at home. I read about safe co-sleeping practices which I know beyond a shadow of a doubt saved my bacon. And thankfully, I never felt anything was 'wrong'. I just trusted my body. I trusted my baby and we worked as a beautiful team. I sat at home on the sofa and fed relatively frequently, enjoyed my box sets and my healthy and not-so-healthy snacks and that was OK.

It really wasn't for long. But the benefits of exclusive breastfeeding will be.

Why should a watch or clock tell me how to be a mother? I'd rather pay attention to my baby.
Sources

Anatomy of the lactating human breast redefined with ultrasound imaging. DT Ramsay, JC Kent, RA Hartmann, and PE Hartman. 2005.

The magic number and long-term milk production. Nancy Mohrbacher IBCLC

Studies on Human Lactation: Development of the computerized breast measurement system. D.B Cox, R.A Owens, Peter E. Hartmann

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Guest blog: Breastfeeding: The dangerous obsession with the infant feeding interval - Baby Friendly Initiative

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Advice that babies must follow a strict three-hourly breastfeeding routine is causing mothers distress and guilt,and reducing breastfeeding rates.

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A useful article if you are worrying that certain foods may affect your baby, or wondering about losing weight, or how much liquid to drink.

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The majority of mothers are aware of the importance of eating nutritious foods while they are expecting a baby. Assuming that you ate an adequate diet while you were pregnant, you can produce plenty of milk for your baby by keeping up this motivation and making sure that you continue your healthy eating patterns during lactation. While you should attempt to eat a "good diet" while you are nursing, you need to be aware that your diet doesn't have to be perfect in order to support breastfeeding. You can still nurse your baby even if your diet is less than ideal. You may be surprised to learn that studies have shown that maternal nutrition has only a minor effect on the composition and quantity of breastmilk produced. Usually, unless a mother is severely malnourished, her milk is fine. Mothers whose diets are poor deplete their own energy levels, and may become anemic, but their bodies will continue to produce the milk their baby needs by pulling from the mother's energy stores at her expense, but not her baby's.

Most women in this country don't suffer from a lack of food, but rather from eating too much of the wrong kinds. There are no special dietary rules to follow during lactation. If your eating habits are fairly healthy, there is no reason to change them while you are nursing. There are no special foods to avoid, or certain foods that you need to eat (like milk) in order to produce a plentiful supply of nutritious breast milk. With rare exceptions, nursing mothers can eat pretty much anything they want to - including chocolate, broccoli, pizza, and diet soda - in moderation.

Many dietitians and lactation experts feel that one advantage to breastfeeding may be that the milk is flavored by the foods the mother eats, so the baby becomes used to a variety of taste sensations, and tends to have fewer feeding problems as he gets older. One well-known study showed that when mothers ate lots and lots of garlic, their breast milk tasted and smelled like garlic. Not only did the babies who drank the milk not have any digestive problems, but they actually preferred the garlicky milk over the unflavored milk.

Think about it - women in South America who eat lots of peppers, or women in India who eat lots of curry don't have babies any more colicky or fussy than babies in the U.S. You've probably heard that eating "gassy" foods like cabbage, beans, or broccoli will make your baby gassy. That's one of many "old wives tales", because gas is produced when bacteria in the intestine interact with the intestinal fiber. Neither gas or fiber can pass into the bloodstream, or into your breast milk, even when your stomach is gassy.

Although it is possible for a baby to be sensitive to a food in his mother's diet, he is much more likely to react to a food given to him directly. I suspect that most mothers who swear that they can't eat - pizza, Mexican food, broccoli , cabbage, beans, chocolate, etc. - while they are nursing are actually overreacting to their baby's normal behavior on any given day. There is a natural tendency for a nursing mother - and everyone around her - to attribute every little thing her baby does to breastfeeding. ALL babies have days when they are gassy, fussy, and spit up, or are just cranky in general. Some babies have sensitive digestive systems, and no matter what you feed them, they will experience outb s of intestinal upsets. The one thing you can be sure of is that there is nothing you can put into a sensitive infant's stomach that will be easier to digest than breast milk. (See " Spitting Up: Is it Reflux? ")

When you're nursing, you start to think things like "He's so gassy today...could it be something I ate? Yep, I had pizza for dinner last night...that must be it. I can't eat pizza from now on. And I really do love pizza..." When taken to extremes, this sort of thinking can lead to a diet of nothing but boiled chicken and plain white rice.

In over 35 years of experience in working with nursing mothers, I have seen very few cases of food sensitivity that required extensive diet modifications. I'm not saying it doesn't exist, just that it is not nearly as common as most moms think. It is estimated that only 3-7% of babies will have any type of food sensitivity or allergy, and the majority of these allergies will be mild.

Signs of food sensitivity can include: inconsolable fussiness, suddenly waking in obvious distress, skin rashes, wheezing, and green mucousy stools. Of course, all of these symptoms can be caused by other things besides diet, so that makes it even harder to tell if your baby is reacting to something in your milk, or if the rash or the fussiness is due to something else entirely. If you see a consistent pattern with specific foods, that makes it more likely that your baby may be reacting to something you ate. A strong family history of allergies (food or other) can also increase the possibility of food sensitivity. If you think your baby may be having problems with a food you have eaten, remember that it takes 4-6 hours after ingestion for a food to affect your breastmilk, so that salad or candy bar you just ate is not what's making your baby fussy. If you really think that something in your milk is upsetting his tummy, try eliminating the food you suspect from your diet for a week or two. Of course, during that time, he may outgrow his sensitivity anyway as his digestive system matures, and you'll never know whether it was the food causing his symptoms or not. Probably not, but it won't hurt you or your baby to cut back on certain foods if your diet meets all your nutritional needs without it.

The food that is the most common offender in causing problems with sensitivity and allergies is cow's milk. It was made for calves, not for human babies, so it doesn't 'suit' his sensitive little digestive system the way mama's milk does. Cow's milk is the first food you should work on reducing or eliminating if you suspect your baby has a food sensitivity. It may take 10 days 2 weeks to eliminate cow's milk protein from your diet, so wait at least 2 weeks before you decide whether cow's milk is what's making your baby fussy. Even is your baby can't tolerate whole milk, he may be able to tolerate milk products, like cheese and yogurt. If he has a reaction to milk and/or milk products when he's 6 months old, he may be fine with them when he's 9 or 12 months old, so reintroduce them periodically to see if he has a reaction or not.

The problem with cow's milk is the protein, which is difficult for babies to digest, and not with the lactose. Human beings are not born lactose intolerant, unless they are born with a rare metabolic disorder. Lactose intolerance is caused by a deficiency of the enzyme lactase, which breaks down lactose (milk sugar) so it can be easily digested. Mammals are born with this enzyme in their intestines. As they grow older and wean, the lactase enzyme decreases. That's why lactose intolerance rarely shows up in humans before age 3 or 4, since that's around the natural age of weaning (if that surprises you, check out the article on Weaning.)

Lactose intolerance is most common in Asian and African adults. The proteins in cow's milk are primarily caseins, which are harder to digest than whey proteins, which are more prominent in human milk. It's possible for the proteins in cow's milk to pass into your breast milk, and can cause digestive problems for your baby. These proteins may even sensitize your baby before birth if you drink lots of milk during your pregnancy. If you decide to reduce or eliminate dairy products, remember than processed milk presents less of a problem than whole milk. You may be able to continue eating yogurt and cheese while cutting back on or eliminating milk. Since milk and milk products are important sources of calcium, be sure that your diet includes calcium from other sources, such as broccoli, nuts, spinach, and canned salmon. Taking a calcium supplement would be a good idea if you are limiting your intake of dairy products. You need about 1,000 mg of calcium a day if you are between 18-50 years of age, whether you are lactating or not. While nursing mothers do lose some bone mass during lactation, by the time your baby has been weaned for a year, this lost bone mass is not only completely restored, but is actually greater than it was before you breastfed your baby. Research has shown that women who breastfeed have half the risk of bone fractures as women who never breastfed. The longer you nurse, the lower the risk. Breastfeeding actually protects you from osteoporosis.

If you are anemic, don't worry that your milk won't have enough iron for your baby. Breast milk contains less iron than formula, but the iron is absorbed and used more efficiently, so y our baby is less likely to become anemic than a formula fed baby. You may need to take iron supplements to make you feel better, but they will not affect the level of iron in your breast milk.

The guide to how much fluid to drink while nursing is to "drink to thirst". There is no evidence to show that forcing fluids will increase your milk supply. (Another"old wives tale".) Drinking too much water (over 12 glasses a day) can actually decrease your milk supply. The problem is that when you are a new mom, you often forget to take care of yourself while you are so immersed in taking care of the baby. Try drinking a glass of water whenever you sit down to nurse. You can also get water from other sources - juice and yes, even soda count...but take it easy on the soda, because it contains a bunch of chemicals and/or sugar that your body doesn't need. Most mothers find that they are thirstier when they are nursing. If you produce large amounts of pale urine and are not constipated, then you are probably drinking enough. If your stools are hard and dry, and your urine is concentrated and dark, then you may need to increase your fluid intake. Remember that it is normal for your first void of the morning to be darker and more concentrated than at any other time during the day.

A good rule of thumb is to take in 200-500 calories in excess of what you needed to maintain your weight before you were pregnant while you are nursing. Breastfeeding doesn't make you gain weight - in fact, you use up calories when you nurse, and you may actually shed those extra pounds more quickly while you are nursing. Your body stores up fat during your pregnancy to provide the extra calories needed for milk production. It is easier to lose lower body fat (hips, buns, and thighs) when you are breastfeeding compared to the mom who is formula feeding. (YAY!). Remember to factor in the weight of your breasts when setting your weight loss goals. The 'average' mom (remember, the one who doesn't exist in real life?) - will carry around about 3 extra pounds of breast tissue while she's lactating. Some more, some less, but don't expect to lose that weight until after your baby weans.

If you are a vegetarian, you probably already eat a healthier diet and make wiser food choices that those of of who eat meat. Mickey Ds was my home away from home a lot when my kids were younger. We spent half our waking hours in the car, going to and from school, sporting events, and all the million other places that school age kids need to be. I don't care if I never see Ronald or the Golden Arches again.

Vegetarians and Vegans don't need to change their diets unless they don't include any animal protein at all (vegan and macrobiotic diets). Since animal protein is the best source of B12, consider taking a vitamin supplement containing vitamin B12 if you don't want to consume any animal products. If you don't eat dairy products, you also need to make sure to get enough calcium. I recommend that every nursing mom continue taking prenatal vitamins for as long as she lactates, just to make sure her nutritional bases are covered.

Just like "drinking to thirst", you should "eat to hunger" while nursing. Studies have shown that most nursing mothers tend to lose up to one and a half pounds a month for the first 4-6 months after giving birth, and continue to lose weight at a slower rate beyond that time. Moms who breastfeed tend to lose more weight than formula feeding moms, even when bottle feeding moms take in fewer calories than they do. If you want to lose weight - and most of us do - it's so depressing to still be wearing those old maternity clothes we got so sick of after the baby is born - plan to do it slowly. It's best not to try to aggressively lose weight during the first couple of months after birth, because during that time your body needs to recover from childbirth. You're going to be more tired than you think, even if everything goes smoothly and you're feeling great. Spend this time establishing your milk supply, and resting with your baby. If you want to get out and about, fine - push your baby in the stroller for short walks, carry him in a sling while you putter around the house ( puttering may be all you can accomplish during those early weeks) and that's just fine. What you should avoid is things like shopping trips to the mall, planning a birthday party for your 5 year old, cleaning the house because your in laws are coming over, and entertaining guests, whether they are friends or family.

Losing weight too quickly (more than one to one and one half pounds per week) isn't good for you, especially during the early weeks of breastfeeding. Extreme dieting won't have much effect on your milk supply, but it does deplete your energy levels, and you need as much energy as possible to get through the early weeks of mothering and breastfeeding.

Read Establishing Your Milk Supply to get you off on the right start. You need to rest and enjoy your baby while you both learn to latch and love. Get to know your little one and fall into a rhythm together before you start worrying about your weight. You're going to be all puffy and squishy bellied for a while, no matter what you do. The skin doesn't stretch out that far when you're pregnant and then just snap back in place like a rubber band. It takes time.

Begin your weight loss program slowly when you are breastfeeding. Increase your activity level and eat less fat and sugar, and more fruits and vegetables. Try to take in at least 1,800 calories each day, and definitely no less than 1,500 calories. Even moderate dieting during lactation can help you lose 4-5 pounds each month, but don't expect to lose much body fat until about 2 weeks postpartum. The weight you lose immediately after birth is mostly fluid loss.

Mothers who breastfeed more frequently lose weight faster than mothers who nurse less often, and mothers who nurse for shorter periods of time tend to lose weight more slowly than mothers who nurse longer. You may get lucky and find that you can eat more than you ever could before and still lose weight while nursing. That was the case with me, but I did find that eating a whole container of Ben and Jerry's Chunky Monkey before bedtime every night kept me from losing weight as quickly as I would have liked. Go figure.

Despite one highly publicized but very questionable study about exercising during lactation, there is NO evidence that moderate exercise is anything but beneficial for nursing mothers (or anyone else, for that matter.) Plan to exercise after nursing so your breasts won't be full and uncomfortable. Wear a supportive sports bra, especially if you have large breasts. Drink a glass of water before and immediately after exercising, and drink more in hot weather. If you regularly lift weights or do other exercises involving repetitive arm movement, take it easy at first. If you develop plugged ducts, cut back and start again more slowly.

Rinse off your sweaty breasts before nursing - some babies don't like the taste of the salt.

Take walks with your baby. If you carry him in a sling or backpack, his extra weight will use up even more calories. Weather permitting, go for lots of walks - this counts as exercise and gets you out of the house as well. It the weather keeps you inside, try carrying your little one in a sling while you do housework - and try dancing with him. You may feel silly, but he'll love it and so will you. Nobody will see you, and postpartum mothers are supposed to act a little bit goofy - the technical term for this is "baby brain".

In summary: try to eat a nutritious diet while you are nursing, for your sake and your baby's. Don't worry if your diet isn't perfect - your milk will still be fine. If you want to lose weight, you will probably lose it without radically altering your diet while your are nursing. If you want to lose weight faster, start slowly, increase your activity level, and eat nutrient dense and healthy foods. Moderate exercise is good for both you and your baby. Try to make it fun so that you'll stick with your exercise program.

Eat anything you want to in moderation, and remember that many mothers lose weight while lactating even without modifying their diet or exercise routine.

You will usually keep about 3 pounds of extra tissue in your breasts as long as you are nursing, so factor that into your weight loss goals. Enjoy nursing your baby, eat a healthy diet, and you most likely will lose weight while eating more food than you were used to eating before your little one arrived.

Sources include: Breastfeeding and Human Lactation, 2nd Edition; Riordan and Auerbach, 1999; LLLI The Breastfeeding Answer Book, revised edition, 1997; and The Complete Book of Breastfeeding, 3rd edition; Eiger and Wendkos Olds, 1999

(Edited September, 2013)

*Please 'Pay it Forward'!*

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Nutrition, Exercise, and Weight Loss While Breastfeeding

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The majority of mothers are aware of the importance of eating nutritious foods while they are expecting a baby. Assuming that you ate an adequate diet while you were pregnant, you can produce plenty of milk for your baby by keeping up this motivation and making sure that you continue your healthy eating patterns during lactation.

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Parents often feel that their baby needs a routine. The truth is a young baby only know what is happening now and cannot be comforted by the predictsbility of a routine for the simple reason that he cannot predict what will happen in 5 minutes time.

Strict routines can be harmful - see the link. However having a pattern to the day can be helpful for parents, as it gives structure. The pattern does need to be flexible to cope with the unpredictability of life with a new baby!

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Modern women are expected to juggle work, homelife and motherhood, mostly by themselves. Monkey Business Images/Shutterstock

The transition to becoming a new mother can be one of the most stressful times in a woman's life. A loss of independence and control combined with the overwhelming, unrelenting realisation that you are now responsible for an unpredictable tiny human can leave feelings of being overwhelmed, anxious and can increase the risk of postnatal depression - particularly if a woman is used to a high powered career, financial security and freedom before they gave birth.

As part of this transition to motherhood, new mothers take part in a process called " maternal role attainment", where they look to other mothers around them to see how they act and decide which behaviours they are going to adopt or not. Years ago women would look to their own mothers, extended family and all the other women in the street who had young babies. Today, families are more dispersed, women are having fewer babies and life is lived far more in private, meaning we often replace this casual information with that of self-styled "experts" and their "how to" guides.

There is a multi-million pound market just waiting for new mothers, to sell them a dream of how their life could really be. The baby care book market is vast. Numerous titles have been written to target that out-of-control feeling many modern mothers have with a new baby. They promise to be able to get babies into strict feeding and sleeping routines that will give mothers more predictability, control and ultimately free time. They offer a vision of a "supermum" complete with settled baby.

These promises are often too good to be true. Baby care books can have many unintended consequences, one being they may simply not work, as the babies themselves have not read them and so don't follow the "rules". At worst this can mean mothers are mis-sold the promise of a settled baby, which doesn't happen and leaves parents feeling like they have failed.

But what if you can follow the instructions? Typically authors recommend responding to babies according to strictly timed routines rather than when they are naturally hungry, sleepy or simply want a cuddle. This can be damaging in a number of ways. Leaving a baby to cry raises levels of the stress hormone cortisol, which may negatively affect a baby's developing brain. Suggestions that encourage putting a baby to sleep in a separate room for the first six months, rather than sleeping in the same room as the mother, have been linked to an increased risk of sudden infant death syndrome (SIDS).

One of the other main risks of strict routines is through damaging breastfeeding. Breast milk is very easily digested and frequent feeds are needed to build up milk supply. Breastfed babies can easily feed every two hours or more, and missing out or trying to extend the time in between feeds can reduce supply because the body thinks the milk isn't needed. Babies also wake up at night for reasons other than hunger, and whether they are breastfed or drinking formula doesn't affect this, but it can cause anxiety for new mothers who think their baby is feeding too much or should be sleeping.

It's not surprising that new mothers turn to these experts to try and get their baby into a promised routine. However, research shows that mothers who try to follow a strict routine to breastfeed are less likely to carry on breastfeeding, often stopping because they think they don't have enough milk.

Thinking that babies should be in a routine, worrying about how much they feed and thinking they can manipulate you has also been shown to be linked to early stopping of breastfeeding. Meanwhile the perception that a baby is feeding too often and so breastfeeding should be stopped is predictive of postnatal depression.

It is easy to understand why these books and routines are so appealing to new mothers. In a society where mothers are isolated, unprepared and pressured to "get their lives back" it is little wonder that they look for advice. But how about rather than trying to force babies into routines and damaging breastfeeding, society pulls together to support new mothers, mothering and caring for them, leaving them free to care for their babies while others help with everything else?

In cultures around the world, such as in India and China, new mothers are cared for after the birth for at least six weeks and have far higher breastfeeding rates and lower rates of postnatal depression than Western society. If mothers are going to be able to care for the next generation, society must culturally change how it values and cares for new mothers.

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Why getting babies into strict routines isn't all it's cracked up to be

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The transition to becoming a new mother can be one of the most stressful times in a woman's life. A loss of independence and control combined with the overwhelming, unrelenting realisation that you are now responsible for an unpredictable tiny human can leave feelings of being overwhelmed, anxious and can increase the risk of postnatal depression - particularly if a woman is used to a high powered career, financial security and freedom before they gave birth.