Breastfeeding and post-partum depression: A possible cure, a possible cause

The Pediatric Insider

© 2014 Roy Benaroch, MD

An August, 2014 British study comes to two seemingly opposite conclusions: in some women, breastfeeding can protect against depression; while in other women breastfeeding seems to increase the risk of depression. It all depends on what mom’s intentions had been.

The study is complicated, and has a lot of tables—but they’ve kindly made it open-access, so you can read it yourself in detail (click the Download PDF button after the link, above.) Briefly, researchers looked at about 14,000 births, and tracked measures of mental health during pregnancy and periodically afterwards. They also tracked whether women tried or didn’t try to breastfeed, and how long breastfeeding continued. And, they kept track of what women had said their intentions to breastfeed had been prior to delivery. Results were corrected for things like socioeconomic factors and the health of the baby, since we know those have a big effect on the risk of post-partum depression.

The women who didn’t intend to breastfeed, and didn’t end up breastfeeding, were used as the comparison group, and the relative risks of post-partum depression were determined. What they found was fascinating:

Among women who intended to breastfeed, and who did in fact successfully breast feed, the risk of depression was cut in half. This effect was strongest for longer-duration nursing. The authors postulate that the beneficial effect of nursing in this group was conveyed by hormonal factors released during nursing.

Unfortunately, those positive hormonal factors were not seen in all women. Among women who had planned to breastfeed, but were in fact unable to nurse sucessfully, the risk of depression more than doubled. Most women who try to nurse find nursing a successful experience, but women who don’t meet their own expectations seem especially vulnerable to depression.

And: among women who didn’t plan to breastfeed, but did in fact end up breastfeeding anyway, the risk of depression was also increased. Perhaps these women, who hadn’t wanted or planned to nurse, felt bullied or coerced into nursing?

The obstetric and pediatric communities are fully in support of breastfeeding, which offers medical and psychological advantages to most women and their babies. But we need to acknowledge that nursing can be difficult, and that women who don’t nurse are still capable, good moms—they don’t need scorn or dirty looks when they use baby formula. It’s a shame that moms who are providing love, nurturing, and good nutrition though a bottle may be at higher risk of depression. We can do better than this.

When to start solid foods, and what to start with

The Pediatric Insider

© 2013 Roy Benaroch, MD

I like writing about food and feeding issues, especially for babies and toddlers—mostly because there is so much misinformation out there, information that’s complex and confusing and difficult for anyone to keep straight. Start avocados at 33 weeks, start egg whites at 42 weeks, move from stage 1 to stage 2 jars after baby gets 1 ½ teeth. Rules, rules, rules.

All that stuff is a crock. Feeding babies is much simpler.

When to start solids: somewhere between 4 -6 months of age is an ideal window. Babies are happy to meet new things and have new experiences then, and they’re really interested in what you’re eating. So give them a taste.

There’s plenty of medical evidence that 4-6 months is an ideal time. You’ll minimize your child’s risk of celiac and type 1 diabetes, and provide essential iron and vitamin D that’s inadequately supplied by nursing alone. Starting earlier than this window seems to increase the future risk of obesity; starting later can lead to problems with oral motor functioning, and can increase the risk of food allergies.

What foods to start with: anything you like. The old advice, to start with (and stick with) rice cereal never made any sense. There’s nothing magic about rice cereal.

The only requirement for first foods is that it can be mushed up. Junior isn’t going to chew anything just yet, so whatever you’re feeding him needs to be, essentially (but not literally) pre-chewed. You can start with a banana or avocado, and mash it up with a fork; you can start with some well-cooked noodles, and mush them up; you can start with some soup vegetables, or a bit of egg, or ground meat, or just about anything else. Don’t be afraid of flavor, and don’t limit yourself to what the baby food companies put in jars.

The only foods to watch out for are choking hazards, foods that are too stiff or unmushable for babies to handle. Think steak, pecans, raw vegetables, or Al Gore.

There’s also a special admonishment against honey for babies less than 12 months of age, because it can transmit botulism in babies. That’s a really short list of things that babies shouldn’t be fed.

If you like, you can start with a single food and build up from there, starting a new food every few days. That’s been advised for years, to help parents tell which foods might have caused which reaction. But most babies will not have food allergies; and most food reactions in babies are mild. If there is a strong family history of genuine food allergies (say, in both parents or in siblings), you can take feeding slowly, one food at a time—but it is probably a mistake to delay solids altogether. Remember: introducing foods later may increase the risk of allergy.

That’s it—it’s almost too simple. Start at 4-6 months. Start with, pretty much, whatever you’re eating, just mushed up. Let your baby enjoy many different flavors, and share the meals (and the mess!) together. Yum!

Babies know when they’re hungry

The Pediatric Insider

© 2012 Roy Benaroch, MD

There seem to be two styles of baby-feeding: scheduled versus on-demand. Strict schedulists stress that babies need regularity, and that parents know best what and when and how much their babies ought to eat. In the opposite corner are the on-demand feeders, sometimes thought of as a bit more Earthy-crunchy, the hippie tie-dye, anything-goes crowd. Who’s right?

If preventing obesity is your goal, here’s one more point for the hippies.

A recent study from 2011 presented inAustralia looked at about 300 babies, comparing those fed on-demand to those who were strictly scheduled. The scheduled babies weighed more, on average, at 14 months of age. We know from a good body of prior research that overweight toddlers are much more likely to become overweight children and overweight adults, so that weight difference at 14 months does have important predictive powers.

The results, to me, make sense. An ongoing struggle I have with counseling families trying to control weight is to stress the simple concept: Eat when you’re hungry, but stop eating when you’re not hungry. Unfortunately, many of us eat for too many reasons. We’re bored, we’re upset, we’re anxious, we’ve been taught we need to clean our plates. It is crucial, even from a very early age, to allow babies to develop their own, internal sense of appetite, and to develop the ability to decide themselves how much to eat. After all, it’s the baby himself how knows if he’s hungry, or how hungry he is.

Efforts to over-schedule meals and intake prevent this normal development of a child’s internal hunger-meter. If mom and dad are the ones deciding when and how much to eat, Junior may just eat whatever’s put in front of him, hungry or not.

That’s not to say there are no benefits to scheduling. Schedules help babies sleep at more regular intervals, including through the night. And schedules are essential for working families, who need to get their babies where they need to be, fed, at a certain time. Some sort of schedule is certainly a good idea, at least for the timing of meals.

But at mealtimes, it really is best—from a very young age—to allow babies to decide how long to nurse, or how much to take from the bottle. Try not to second-guess your baby, or push more intake. Trust your own baby to know when she’s hungry, and help her learn that it’s OK to stop eating when her little tummy is full.

The picky eater guide: Part 2. The “Don’ts”

The Pediatric Insider

© 2012 Roy Benaroch, MD

Last post, the Picky Eater Guide started with some history and perspective. The bottom line: there is a huge nutritional problem in the developed world, and it’s causing huge health problems. But it’s not that kids don’t eat their veggies, or that kids don’t eat what their parents want them to eat. It’s that kids, and adults, eat too much. Unfortunately, some things parents do to try to get their kids to “eat healthy” might in the long run be contributing to the warped sense of appetite that seems to be a major cause of the obesity epidemic. This post is about what parents shouldn’t do—the “don’t” list of things that in the long run may end up doing far more harm than good. Got a picky eater? Let’s not make things worse by creating a picky eater with a weight problem.

Do not make food contingencies. That means, don’t make the availability of one food depend on whether another food is eaten first. Think about this common scene:

Mom: “Boscoe, if you eat your broccoli, you can have a brownie.”

Boscoe eats the broccoli, then eats the brownie.

What mom thinks: Good! I got him to eat the broccoli!

What Boscoe thinks: Wow, a brownie must be extra special—it’s a reward food! And broccoli must be some kind of horror. After all, I got a brownie for eating that dreck. I’ll keep in mind that no one in their right mind would voluntarily eat broccoli. I wonder if I can make some kind of deal to get more brownies?

So, net, after this scene, Boscoe did in fact eat some broccoli. But the cost of this was to reinforce how special and wonderful brownies are, and to encourage him to continue to crave them—while at the same time teaching Boscoe how nasty and unloved broccoli must be.

Remember: the point of a meal isn’t to get a serving of broccoli inside a child. (If that were the case, we could just sedate the kids and feed them through tubes.) The point is to 1) enjoy the meal as a family and 2) help reinforce healthy social and eating habits to last a lifetime.

Another big don’t: don’t force feed anything. You’ll create food aversions and a warped sense of anxiety and power struggles at meal time. If you’re forcing anything, you’re causing problems. Stop it. You also shouldn’t distract and fool children into eating, by, say, leaving a television on while you shovel the food in. Junior might continue to eat (kind of like a little bird, just opening up that mouth), but that’s not a way to teach children how to choose foods and modulate their own food intake. It’s also, well, creepy.

Next: how to reinforce The Rule, a Universal Truth and simple philosophy that should be the guiding principle of mealtime. When you’re hungry, eat. When you’re not hungry, don’t eat.

 

The picky eater guide: The whole enchilada:

Part 1. What’s the problem?

Part 2. The “Don’ts”

Part 3. The Rule

Part 4. The jobs of parents and kids

Part 5. Special circumstances, vitamins, and a muffin bonus

I am not drinking that

Susan posted, “My 19-month old does not like whole milk. He nursed exclusively for a year. Then I would nurse him and pump. I would mix the pumped breastmilk with whole milk for when he went to daycare. Now I am trying to wean him completely but am reluctant to because he does not like to drink anything. He still nurses when he wakes up and just before he goes to bed. I feel like I need to keep doing this so that he gets some hydration. He does not like to drink in general, only taking sips of water or juice from a sippy cup at mealtime. He has had lots of problems with constipation and I have to give him Miralax in small doses every day. I can’t force him to drink but I don’t know what to do. I have also tried soy milk and giving the milk a flavor like chocolate or strawberry. He still has no interest. Help!”

You’re going to have to take a leap of faith here: when your son is thirsty, he will drink. If he’s neurologically normal, his hypothalamus will provide him with an irresistible desire to drink when his body needs fluids. He may not drink as much as you think he needs, but he will drink enough to stay healthy.

Peanuts, when?

Gretchen asked, “When is it ok to feed a child peanut butter? I have heard that you should wait until 4 years old because if you try sooner then the child could become allergic. I have been feeding my 14 month old peanut butter since his first birthday and he has shown no signs of allergy, but can he develop one if I give him peanut butter too often (another rumor I have heard)? He eats it about 3 – 4 times a week.”

There is no consensus among allergists or pediatricians about when kids can safely start peanut butter. There is no “official” recommendation from either the American Academy of Pediatrics (AAP) nor the American Academy of Allergy Asthma and Immunology (AAAAI). Since there’s really no evidence that delaying introducing peanuts prevents allergies, there’s no good reason to delay peanuts as long as many people suggest.

For a long time, a strategy proposed to prevent allergy was to delay introducing certain foods. You’ll find all sort of tables with specific “recommendations”—strawberries at 12 months, or peanuts at 3 years, or whatever. But until recently there really was very little research to help guide these sorts of suggestions. The tables were arrived at by a process of “expert consensus,” a fancy term for “making things up.”

The best recent studies, summarized here, do not support delaying food introduction. In fact, some studies have found that by delaying certain foods, you might increase your child’s risk of allergy.

Keep in mind that your child’s risk of food allergy depends very much on the parent’s history. If neither parent has food allergies, a child has a very low chance of food allergy, less than 2%. If one parent has a food allergy, it’s up to 8%; if both parents have food allergies, their child has about a 50% chance. You could also consider siblings—the more siblings with allergy, the higher the chance. And once a child has one food allergy, the risk of having others is fairly high. So if there is no family history of allergy, and a child hasn’t shown signs of any other food allergies, the chance of a peanut allergy is very small.

Since your child is tolerating peanuts fine, there is no reason to restrict them. It is not true that frequent peanut ingestion can lead to allergy. Your child can continue to eat peanut products safely as often as he’d like.

I routinely suggest that children who don’t have a strong family history of allergy can start having peanut products at twelve months of age. It’s important for all families to keep Benadryl in the house, and know their child’s dose (ask your pediatrician.) If a rash develops after peanut (or any other food) is ingested, give Benadryl. If there are any signs of trouble breathing, tongue swelling, or decreased consciousness, call 911. If you’re not sure what to do, contact your child’s pediatrician immediately.

Organic infant formula? One brand is a bad idea

As reported by the New York Times, parents thinking that Similac Organic Infant Formula is healthier than conventional formulas are in for a surprise. The company that makes it, Ross, decided to use cane sugar as a sweetener. This makes Similac Organic taste sweeter than other infant formulas, and much sweeter than human milk. It’s riskier for a baby’s teeth, and is very likely to lead to over-eating. Worse still, it may help imprint a desire for sweeter foods starting at a very young age.

As discussed in this post, I’m not a proponent of organic foods. They’re more expensive, and I’m not convinced that they’re healthier or better for children. In the case of this particular infant formula, parents are paying about 30% more for a product that’s very likely to be less healthful than non-organic alternatives. You can’t assume that organic = more healthful.

Baby disinterested at mealtimes

“My daughter who is one does not seem interested in feeding herself. Whenever I sit down and eat with her – I try to guide her fingers into her mouth while she is holding a piece of food. She starts crying hysterically. After 30 min of sitting there and playing with her food, I end up feeding her jarred baby food. She has even gone as far as handing the finger foods back to me and then opening her mouth to show me that she wants me to put it in her mouth. The same goes for sippy cup vs. bottle.”

You’ve got some ingrained habits that may not be quickly fixable, but I’ll answer the question in a general way that should help you and other families. You should talk with your pediatrician for more specific advice, and consider asking for a referral to a “feeding center” which works with children to establish better eating and feeding routines. I don’t know if your child is unable to feed herself, or unwilling. You didn’t mention any sort of motor delay or oral-motor problem, so I suspect it is more a matter of habit. However, you two are certainly locked in a battle of wills at this point, and you may need more hands-on expertise to work your way out of it.

Food Fights Fixed: How to have a successful family meal

Eating together as a family has tremendous health benefits. Kids who regularly eat with their families do better in school, watch less television, and are less likely to struggle with obesity. They also tend to get more exercise and eat a more healthful diet, including more vegetables and fewer processed foods.

But a healthy, relaxing family meal may not come easily. Parents say the kids just won’t eat what they’re served, and get whiney and surly. Mom inevitably heads back to the kitchen to make something separate for every child, and the nice relaxing family meal becomes a frustrating experience that no one enjoys. Needless to say, those vegetables sit untouched on their plates.

Routines versus flexibility

Holly posted, “From an early age we established a daily routine for our 22-month-old twins, and it has worked very well thus far. So well, in fact, that we can almost set a clock by them, and they become distressed if we deviate too far from the routine. We purposely chose routine over adaptability, but at some point they will need to learn a little flexibility. I am not considering a change in bedtimes or mealtimes, but was curious in your thoughts on the age at which an established routine relaxes and becomes less vital to children’s comfort needs.”

It would probably be best to let the kids take the lead on this one. As they get older, they’ll sleep less, and there will be more opportunities for unplanned outings and special events. Some kids—and adults—find routines appealing and reassuring. Other people find routines stifling. To some degree kids will take cues from parents, but like most issues of personality children will have a mind of their own.