Stress and Breastfeeding Failure: Related or not?

An unfortunate result of the breast vs bottle “war”, I’ve noticed, is that no conversation can be had on anything lactation or formula-related without it degenerating into defensiveness, anger, and accusations. This happened recently on a well-respected blog, while discussing an issue (that of inappropriate and, in my opinion, incredibly stupid marketing behavior on the part of the formula companies) that could have been an opportunity for bottle and breastfeeders alike to hold hands and sing kumbaya. It upset me, because I worry that we will never get anywhere in this debate; that we’re going to be talking in circles forever until the pendulum swings too far to the other side, once again. The middle ground seems to be a place of fantasy… I picture it like the “fairyland” Sookie and Bill recently visited on True Blood. Maybe they should add another supernatural character to the show: Able-to-love-breastfeeding-without-thinking-formula-is-bad Creature. Maybe it would look like a Wookie. Wookies are cute.

Anyway – one of the “sub-threads” that inevitably occurred on the blog in question involved one of our FFFs, Brooke, who was told she was “incorrect” and spreading false information about breastfeeding when she mentioned that the stress caused by having her home burn down weeks before her due date and subsequent health problems led to insufficient milk production. She was told that stress didn’t hinder lactation; that women in disaster situations were able to breastfeed successfully, and she’d been misinformed.

The blogger – a lactivist I have much respect for – did respond to the comment thread and acknowledge that studies are split on whether or not stress does affect milk supply; she accurately reported that it seems to be the let-down response that is most affected by emotion, but she wasn’t sure there was evidence for it hindering supply. I have also heard mixed messages about this; there’s allusions to stress being a factor in insufficient milk all over the Internet, but other sites contradict this, and say it’s all in our heads. So I decided to see what science had to say about it.

Strangely enough (please note the sarcasm dripping like maple syrup all over those words), there have been very few studies on the actual physiological effects of stress and depression on the mechanics of breastfeeding. Most have been observational studies, based on self-reported depression scales and the like, which try and link maternal depression, stress or anxiety to poor breastfeeding. Only a select few differentiate between the social and biological aspects of why stressed-out moms might not succeed in breastfeeding – these are two very different mechanisms, because we all know that breastfeeding is a supply/demand system; if you’re too depressed to nurse, or not encouraged/supported in early days, your supply will never establish. But what if you have all the lactation assistance in the world, but your milk just won’t come out? That might hint at a physiological component; but it might not. It’s a tough thing to figure out, so I don’t blame the researchers, but I do think that it’s misleading to say that stress definitely doesn’t effect lactation. We just don’t know.

I did find a few interesting studies. A woman by the name of C. Lau has done extensive research on this issue, and her findings do suggest that stress has an effect on lactation – although its still not clear whether this is due to social/situational reasons, or something more clinical. In the 2007 study , Ethnic/racial diversity, maternal stress, lactation and very low birthweight infants  Lau et al explain what might physically responsible for the correlation between breastfeeding failure and stress:

Stress, be it physical or psychological, may hinder lactation via physiologic/hormonal responses that inhibit milk synthesis (for example, prolactin), milk release (for example, oxytocin) and/or maternal behavior….We defined lactation performance as comprising behavioral and physiologic elements, namely the maternal drive to maintain milk expression and milk production, respectively. The distinction made between these two factors does not imply that they are independent of each other, as it is well known that frequency of milk expression is correlated with milk production.29 However, this approach was used to study the impact that each ‘component’ may have on the overall lactation performance. Therefore, we are working from the premise that lactation only exists if mothers initiate and maintain milk expression and is successful if the ensuing milk production is sufficient to meet the needs of the infant…. the physiologic component (milk production) is inversely correlated with depression; the more depressed a mother is, the more likely her milk volume will decrease. However, the more she practices STS (skin-to-skin) and frequent daily milk expression, the more likely her milk production will increase.

Another study, Maternal and fetal stress are associated with impaired lactogenesis in humans (Dewey, KG, J Nutr. 2001 Nov;131(11):3012S-5S.) acknowledges that while stress has been shown to damage lactation in animals, we don’t have sufficient info for our own species. The researchers go on to hypothesize that even if it is just the “let down” or ejection reflex that is affected by stress, this could lead to a decrease in supply in and of itself:

Experimental studies in breastfeeding women have shown that acute physical and mental stress can impair the milk ejection reflex by reducing the release of oxytocin during a feed. If this occurs repeatedly, it could reduce milk production by preventing full emptying of the breast at each feed. Prospective observational studies indicate that both maternal and fetal stress during labor and delivery (e.g., urgent Cesarean sections or long duration of labor in vaginal deliveries) are associated with delayed onset of lactation. The effects of chronic emotional stress on lactation are not known. Mothers who experience high levels of stress during and after childbirth should receive additional lactation guidance during the first week or two postpartum.

Lastly, I found an old paper (from 1987… so start the Flock of Seagulls record…),  Stress-induced cessation of lactation, which cited two cases of lactation failure after a Mexican earthquake. I wouldn’t normally include something like this, as it only concerns two cases which could obviously be flukes, but I think that the author brings up a fascinating and intuitive point – the very state of not being able to feed a hungry baby causes more stress, adding to the trauma caused by the initial event:

The two women in this report clearly had abrupt cessation of milk and colostrum secretion, respectively, immediately following the major psychological stress caused by the earthquake experience. The initial failure of the let-down reflex on the lactating women was followed by further stress caused by the frustrating experience of a hungry, dissatisfied, crying infant….

Let’s summarize. We know that there have been studies which show a negative correlation between stress and lactation success. We also know that there have been cases – even if they are rarely reported – where clinicians have observed (extreme) stress causing (extremely) rapid cessation of milk production. We know it’s widely accepted that cows and other animals have a stress response that can impede lactation. We know that women after modern disasters have claimed that they are “unable” to breastfeed, although aid workers write this off as lack of education, folklore, and the effect of formula marketing (all of which may be true in many cases, but I tend to think that at least some of these women are legitimately having problems breastfeeding after losing numerous loved ones, their homes, and being displaced and underfed. But I’m no lactation expert, clearly.)

There are studies which contradict the ones I cited here, and have found no correlation between stress and impaired lactation. And there are certainly many instances of women breastfeeding in horrible situations.  I am by no means trying to argue that it is a “proven fact” that our emotional health can negate our breastfeeding success.

What I am saying is that in Brooke’s case, and I would assume in a good amount of other women’s experiences, too, according to the above-cited research,  her body had a response to stress that made it difficult for her to breastfeed. Her saying that this led to her formula feeding is not an “excuse” or “spreading misinformation”.  I do not disagree that telling her story might affect others’ perceptions of breastfeeding, though. Another woman who has suffered personal tragedy might read her words and either seek help before its too late, if she does want to continue breastfeeding; or if her supply is dwindling, for whatever reason – even if it is a chicken/egg scenario, where her state of being prohibits her from nursing on demand, ultimately leading to more problems – she might feel validated in her experience. That’s far more important to me than seeing that woman keep breastfeeding. I want her to do what is going to keep her healthy, and her family intact. A woman in a situation like Brooke’s has far more vital things to worry about than if her child might be at risk for a few more ear infections a year.

If that is anti-breastfeeding, so be it.

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.

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17 thoughts on “Stress and Breastfeeding Failure: Related or not?

  1. I greatly appreciate your research, for obvious reasons. I don't think I can add any more on my story than you already know. I obviously believe in this. But the logic here is clear. A story about a drug curing cancer in mice makes headlines on CNN and offers hope to patients everywhere. But a study showing a stress/lactation association is dismissed?

    I greatly appreciate your summary at the end…this is an age of compassion and understanding, sometimes to a level that defies most people's tolerance. If a person's experience can help the next woman, why dismiss it? Particularly if it will further the end goal of breastfeeding. If a woman in a stressful situation gets help from another woman in a stressful situation, does it matter what the research data says?

  2. I don't think it's anti-breastfeeding to suggest that at all, and from all Brooke has posted, I personally think she's reasonable, rational and correct. It's totally unscientific, of course, but to me, it seems that stress has so many physical effects on our bodies – it can affect your period, your skin, whether you want to eat a lot (or nothing, how you sleep, etc. Why would lactation be any different? And again, I'm not sure how denying something like that vehemently (especially when the science is split) helps people wanting to breastfeed.

    I know for me, my father was in his last stages of cancer when my daughter was born. And while this (and my c-section) had no effect on my supply (as I was shooting my daughter in the face with milk half the time), it most certainly had a major effect on my ability to deal with the stresses of being a first time parent with a child who was a terrible breastfeeder. Working on breastfeeding with bleeding nipples was just not at the top of my list. I had enough other stresses that I just said enough, and weaned my daughter. I don't see why another person with a lot of stress couldn't be struck with low supply.

  3. As someone who has successfully breastfed 1 child & trying to breastfeed another, I can tell you that my experience has always been that everything affects lactation. EVERYTHING. When I am stressed my milk production may not stall, but my ability to release that milk, “let down”, to my kids is severely affected. My ability to concentrate on my child is affected. I'm absolutely positive that stress also affects the taste of the milk produced. Again this is just my experience. My son has a hard time drinking pumped milk that was pumped during stressful times regardless of temp & surroundings.

    I have also found that stress makes me resent breastfeeding. It's one more thing that ties me down. At least that's how I feel at that moment. It's one more thing that prevents me from dealing with whatever is causing the stress in the 1st place. Again… just my experience.

    Are there an studies that look at the ability to release that milk under stressful situations rather than the actual act of producing milk?

  4. I wonder if there is some sort of other hormonal/chemical component that affects the way a woman handles stress and also affects lactation. Maybe, for example, women who are more prone to PPD or have difficulty managing stress and anxiety have some sort of hormonal/chemical thing that also affects lactation. This might explain why women in disaster-type situations are able to continue breastfeeding while others can't? Maybe the women who are able to continue breastfeeding in a disaster situation are able to handle the stress in a different way due to some sort of hormonal/chemical thing than women who don't produce enough milk during times of stress.

  5. Love this post. I am a big believer that stress impacts supply. I get that it may be the let down that is effected, but poor let down seems to mean poor extraction of the milk, which in turn leads to supply drop. But isn't that just semantics? of course not every women WILL for sure experience this, but it makes sense that some do. I am pretty sure that was a piece of the puzzle that was my experience.

    Now to go off topic:

    “This happened recently on a well-respected blog, while discussing an issue that could have been an opportunity for bottle and breastfeeders alike to hold hands and sing kumbaya (that of inappropriate and, in my opinion, incredibly stupid marketing behavior on the part of the formula companies). It upset me, because I worry that we will never get anywhere in this debate; that we're going to be talking in circles forever until the pendulum swings too far to the other side, once again.”

    This- this I am so frustrated about. It has me asking why I even bother. This weekend sucked for that. Every blog I went to seemed to suffer from this same issue…. with people on all sides taking the conversation to such a negative place, rather then just standing together. So frustrating.

  6. I would believe that stress could affect breastfeeding. Maybe exactly how it affects it would vary depending on how soon pp the stress occurred, whether or not it's constant background stress (simply introducing a newborn into a family is pretty stressful) or some major event, like a house fire or death of a loved one. And of course, it probably doesn't affect everyone the same way, maybe not at all for some.

    I also find the refusal to seek that middle ground frustrating and perplexing. I was looking at a website that I knew was aimed at BFing/APing, but there was a woman on there who got reamed for figuring out that her baby would be soothed to sleep with hair combing. The woman who ripped her a new one thought she should be offering the breast ONLY as a soothing technique and that somehow, combing, instead of comfort nursing was detrimental to the BFing relationship. What?
    Anyway, that's a little off topic, but trying to further illustrate your point about extremes and failure to find common ground.

    I have no idea if stress played any role in creating my meager supply when I was trying to BF. There were so many possible factors in play, it would be impossible to tell. But, I still believe that stress could play a role in a decreased supply.

  7. When you are pumping many of the bfing literature out there encourages you to look at pictures or objects related to your baby so you can aid your milk supply. Why because it affects your hormones so yes why wouldn't stress affect your hormones thus affecting your lactation. I think it plays a much bigger role than most think.

  8. I didn't read the original blog comment thread that was referenced here. Probably a good thing. I get so irritated at the constant need for some lactivists to tell other women that they are wrong about THEIR OWN EXPERIENCE. The lactivist is simply sitting at their own computer, however many miles away,reading words. And from this, they can determine that a woman is “spreading false information” about what that woman went through? Please.

    Stress affects everyone in different ways, and it has real, physical effects. That's a biological fact.

  9. FFF, maybe it's because I live in the midwest and maybe I'm a 'older' working mommy who doesn't have time to do the mommy and me things but in my experience that perfect world where breastfeeders and formula feeders can be get along exists and it's called the real world as opposed to the on-line world. I know exclusive breastfeeding moms, combination feeding moms and exclusive formula feeding moms and I don't see the lectures and recriminations. Maybe that's because the on-line lactivists are a lot nicer in person or maybe because decent people make the decision to exclude the obnoxious on-line activists.

    I don't have on-line discussions about breastfeeding (I guess other than this). I don't read crunchy forums. I don't have the tolerance for it and I don't think it does any good to fight with them.

  10. Thanks for writing this reply about the post-that-shall-not-be-named. I, too, am in favor of women helping women, versus women telling each other that they're stupid and irreparably damaging their children.

    I'm also in favor of fostering the idea that we are big girls and can make our own decisions. Don't know about you ladies, but I'm pretty darn capable of looking at a website without being brainwashed by pop-ups or other inline ads (whatever they may be).

    Just sayin.

  11. Good point anonymous—while I have run into lactivist types in real life, they are much more rare there, than online.
    And like you, once I figure out that a woman or group of women is likely to be all up in my grill about some parenting thing or other, I avoid her/them. In real life, AND online.

    Still, it can be frustrating when you run into something that disparages your parenting choices, in a magazine, book or online. Of course, you can stop reading, but you didn't know you'd come across it in the first place,yo know?

  12. Michelle K — great point! Similar to another issue I've noticed, that plenty of lactivists will cheerfully admit that they have an *over* abundant supply, but then not believe that other women have an *under* abundant supply. If it can be skewed one way, why not the other?

  13. In my experience I think stress did play a major part in my decision not to push myself to breastfeed very early on after my son's birth. An all-day labour experience resulting in being fully dilated yet still with a cervix that was too high and baby's heart rate dropping meant that I had to have an emergency C. I then reacted badly to the pain medication they gave me and developed a fever, so I was also put on a course of antibiotics. Toxema in my legs and feet made walking impossible, and the C wound just HURT. In my case, I think my body produced cortisol – not oxycontin or milk! – just to cope with the incredible pain I was in. Also, I was mentally very vulnerable, made worse by my reaction to the pain medication which greatly enhanced my levels of anxiety and nausea.

    Then again, my girlfriend, who had given birth to her son a couple of weeks before me, had her house burn down after she came back from the hospital – and she was able to breastfeed her baby boy without incident and without trauma.

    Bottom line is, I think it's how you deal with stress – how you cope. Me, I'm a control-freak and anxious and fearful. I was TERRIFIED of my own baby when he first came home. That's just the kind of mother that I am. It's getting better now that he's almost in his 18th week, but I still do have to fight panic and sweating over the small stuff. And for every day that he gets stronger and chubbier on formula, I, too, get more brave and more relaxed over his health and well-being.

    Thanks for another great post FFF.

  14. WOW! I am a reproductive acupuncturist and specialize in childbirth. I am just finding this post, and I love it. I am a propenent of breastfeeding if a mother is capable, and I understand that not every mother will be able to. It is my job to help women acheive sufficient lactation, but, again, I understand that every woman will be able to, and a site like this is a nice support system for those women. I often treat women who are having lactation difficulities, and I have seen and understand the affects that stress can have on lactation. Stress affects every woman differently. What seems stressful to one person may not be for another and vica versa. Birth is a very trying period taking so much out of a women physically and mentally. Situations where there is prolonged labor, difficult delivery, excessive blood loss, or even a very fast delivery to the point that the most did not have a chance to really appreaciate her birth experience, can all play a role is low production or blockage. Like you mentioned in case histories, even stressful and shocking events later on can have the same effect. When stressed the body goes into fight or fllight, and there is an increased production of adrenaline and catacholamine. These chemicals divert blood from the peripheral to the important vicera. In the natural scheme of these, the body’s self preservation takes precedent over milk production. If the stress is not treated quickly, the production may stop completely. In any case, once milk production has slowed later in breastfeeding, it is often difficult and trying to increase production without help from herbs or acupuncture. THANK YOU for highlighting this topic is such a wonderful, open way.

  15. I am pro breastfeeding and pro evidence based research. I loved this blog and agree with everything you have written but can’t help to feel let down by your last sentence. Stress can be a vicious cycle and does have an affect on milk flow – stress releases vasopressin which constricts blood vessels. Breast milk is made from the blood and during lactation the % of blood flowing to the boobs is second to the brain. Adrenaline is also released during stress which makes sure that blood flow is redirected to the major organs such as heart, kidney and liver. This will also have an affect on the blood flow to the boobs and therefore could reduce milk flow.

    Stress prior to birth, during or just after labour can also reduce the amount of the hormone oxytocin, which is essential for lactating.

    The main point though is none of these psychosocial stress states are permanent and are reversible which also makes the affects of stress on breastfeeding reversible. A lady that came to our boob group, didn’t feed for the first three weeks due to a very difficult C Section. With determination she was able to relactate and has been combination feeding her baby ever since. If it doesn’t go right in the first few weeks, it still doesn’t mean the end of boobing. I personally feel that whilst most babies will thrive on artificial milk (I did), evidence shows it goes so much further than just reducing the risk of ear infections – I wasn’t breastfed and two years ago my mother developed breast cancer. By breastfeeding both my children I have reduced my risk by 12% – this doesn’t sound a lot but what is so much more important is by breastfeeding my daughter, I have reduced her risk by 25% and if she goes onto breastfeed, the risk will keep reducing by 7% for each year she feeds.

    So it is important that we seek out all the facts and keep an open mind for our daughters and not just pass on our anecdotal beliefs that may influence them away from trying to breastfeed. That to me IS anti-breastfeeding.

  16. Pingback: Breast Is Best; Formula Is Poison

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