Guest Post on Postpartum Psychosis and Breastfeeding

It would be cathartic to share my story and print my name and say to other women, this is real, and here is my story – but the social stigma is still too much to cope with. I knew eventually would write down my story about Postpartum Psychosis and how it threatened my sanity and made early parenting very frightening. It took a lot of years before I was far enough away from it to feel safe talking about it. Like it might come back if it heard me talking about it, or typing down the words.

I never really told my story- it was a thing of embarrassment to me. As if I lost control somehow, and it was my fault. I’m not sure who told me there was any control to be had with early parenthood, hormones, and brain chemistry but this is what I thought was true. I thought I could talk myself out of it, or meditate enough. Not possible. Needed medication.

As a new parent we tell ourselves things and believe them- particularly when we are suffering from a postpartum mood disorder. I thought there might be some choice in whether I had PPD, or postpartum anxiety, or something worse; that’s not true for any of us. We don’t choose depression, or anxiety, or PPP.

I’m not sure why it happened to me, but it did. All I wanted was a normal mothering experience, but that is not what I got. The truth is I had only one child ever because I could not willingly place myself in a position where I felt my sanity and objectivity leaking away again. My partner wanted more babies but I couldn’t do it again.

It came on very slowly. The first few days after birth were ok, but I was not sleeping at all. By day 4 Postpartum I was hallucinating people in the room talking. Objectively, I knew they were not there. I think that made it worse? It’s hard to define “worse” when you are holding your baby and your world is falling apart. If this is you, I want you to know it’s not normal, and you should not try to power through it without telling anyone.

I come from a line of highly creative people: artists, writers and several of them have some sort of bipolar issue or mental health issue. It turns out just having bipolar run in your family can put you at risk for mood disorders in the postpartum period. There is a higher risk of PPP in women that are bipolar themselves. None of these things were known to me until much later when I was trying to piece together how I ended up with postpartum psychosis. It was very very hard for me to think clearly when it was all happening. I spent a lot of my time focused on what I knew was real. This baby in my lap who was hungry again. Latching on my baby, her soft hair dewy with sweat and baby smell. The evening rolling around again. My husband watching me worriedly from his chair; I saw the fireplace, I heard the night crickets when the door was open. Some of these things were concrete and real. When I felt lucid and I was not tired, everything was ok. I also periodically heard things I knew were not in the room with me- generally two or more people talking. It always occurred when I was going to try and sleep. So I figured maybe I would just stop sleeping and that would solve it. But that is actually a sign of not thinking clearly.

I had a reasonable pregnancy combined with lots of moony dreaming, folding baby clothes and throwing up in the kitchen sink. As the months went on I saw less and less of my feet, found joy in watching animal planet on tv, and petting my baby through my body. Her small kicks and hiccups were reassuring to me. It was a very deep connection to the world, to feel life grow daily inside of me.  But I was isolated in my experience because knew no other women my age to talk with. I ate lots of soup and spicy foods that gave me acid indigestion, and speculated on the birthing process. I figured I’d read enough books to know everything and I did not seek out appropriate help or training.

My laboring time came and I spent 17 hours birthing my child. It was not what I anticipated. I had broken a rib a few weeks prior. My water broke and because I had no doula I went into the hospital at 10 minutes between my contractions. It turns out I was only 1 cm dilated but this was early 2000 and they kept me. I got an epidural after about 15 minutes at 1 cm dilated, because I was full of fear, and my RN offered it as an option. My legs went numb immediately. I had an OP presentation birth, and there was incredible pressure for many many hours. It changed my perception of what I had to do as a woman to move the baby out of my body, and I felt very disconnected to the whole process and labored with my eyes closed the whole time until my baby was out.

After my baby was born she was placed hot and steaming in my arms. I was able to get her latched and breastfeeding. I remember the overwhelming love that I felt, and waves of fierce protectiveness.  We were connected emotionally and snuggling, we looked at each other. Whatever fears I had in pregnancy were gone, and I was completely in love and attached. I didn’t let anyone hold my baby for a longtime- not even my husband.

The first two days were very challenging to navigate in other ways. I think the rapid changing hormones were perhaps too much for me. I felt very overstimulated in the hospital, with lights and noises and people barging in and out. I was worried about my daughter constantly. I was on high alert, and I was a survivor of many life traumas already and felt like I was busy keeping my daughter safe- I’m not sure from what. Never being sure who was coming through the door, and having a baby in a bassinet near the door meant I did not rest. My body was sure something was wrong, and I was frequently checking to see if she was breathing or too hot.

By day 3, I was home and trying to adjust to being a mother, to breastfeeding, to my body so raw and open. I remember sitting on the couch, and telling my husband that something was not right with me. I would look at the clock and around 9pm the waves of anxiety were always very bad for me. I had not actually slept in 3 days, even naps. No sleep at all. By day 4 there was still no sleep, and things started to change for me in new ways. My perception of the world was changing, all while I diapered and powdered this new scrawny little sweetheart I called my own. I held her and tried not to put her down, I soothed her, I sniffed her and knew she was mine.

I didn’t know about Postpartum Psychosis back then. I knew about Postpartum Depression; everyone does because about 85% of women have some sort of mood disturbance. The way I think of it is that basically someone you know has a form of at least one of the postpartum mood disorders. What we know about PPP is that it’s very rare, and can very dangerous. 1 or 2 out of 1000 women will have it, and among that group of women 5% will commit suicide and 4% will kill their infant. It has a rapid or sudden acute onset; sometimes within the first  48 to 72 hours after delivery. Most women who will get it will do so in the first 2 weeks. I had a rapid onset by day 4.

While those of use that have it cannot possibly have the same experience, I can tell you that mine wove in and out of reality, and that most of the time I knew that what I experienced was not real. It was the audio-hallucinations that I found frightening. When I would attempt to sleep I would hear two or more people in a conversation in the room with me. Most of the time I recognized the voices: my mother, old friends, a few times it was two men I did not know. The unnerving part was that I was lucid enough to know that my mother was 2 hours away, and that no one was in my room. As I was relaxing people would call out my name, as if to call me back… and I was so so tired. I could not rest. I would lie in bed with the lights off, – my husband trying to bottle feed a brand new baby on his own in the living room. I would lie there awake and people would jerk me out of sleep with their conversations. I was in an Empty room each time. I am grateful that I never had any command hallucinations that told me to hurt myself or my son; so grateful. Command hallucinations can be voices that tell you to do bad things, and they do occur for some mothers. This is part of the reason why the risk for suicide and infant death goes up with this diagnosis.

The cry of my baby brought me back  to my room,  over and over. I cried tears on her head in fear of what was happening. It was a chemical occurrence in my body, but it felt spiritual and disassociative. It was difficult to stay grounded in the everyday things of feeding my baby every 90 minutes, and each lost moment was something I could not get back.

In the most pivotal moment before I got help on day 4, I was again laying down and I was not hearing voices this time. I closed my eyes and instantly was moved into a glen, far away in the wilderness. The forest stretched out around me, the trees all moving and green. All shades. The forest surrounded the open clearing. The field was oval and I was in the middle of it somehow looking across. The tawny yellow and light green grass was about knee high, moving in the wind. Everything was moving. I was the grass and the wind. From the other side of the clearing there came a white horse with her mane flowing behind her. She was shining as white as a star, maybe the forest was the sky, the horse was the white full moon that I gave birth under. My eyes opened, and I was in my bedroom.

I stood up and started packing my clothes into an old ratty suitcase. My husband watched from the doorway and asked where I was going. I told him I needed to be checked into a psych hospital and I think he might have cried. I know that he chokingly said to me, “…but who will take care of our baby?” It was a comment that was so full of fear and pain. It was a hard time to be in my skin and to feel so out of control. I no longer trusted myself. I sat on the bed and instead we agreed to call my family Dr. When I went in to be seen, they kept me there for 6 hours in the clinic, and my whole family was in the room with me. It is important to have support, and effective medication. I was given a mood stabilizer and antidepressants, and also sedatives. I felt much better in a matter of days.

I could manage the things I needed to do for my baby but my spirit was wandering or at least that’s what it felt like. It did not feel safe and it stayed that was for many months. I have no pictures of me smiling and holding her in the first few months of her life.  Fortunately, my Doctors and family support systems rallied for me. There were a lot of psych medications for a great deal of time for me. Not something I every expected to take, having no mental health issues prior to delivering my baby. They did not fully remove the auditory hallucinations for me, but they turned the volume down on the voices so that they could not call my name loud enough to prevent sleep, or disturb me during the day. I knew that I had to keep my baby safe.

I was granted a reprieve by way of treatment. It is very very important that if you think this is happening to you that you reach out right now, and get help. I mean right this instant. Tell someone. Tell anyone.

When I was told by a psychiatrist that I had to sleep at least 6 hours I agreed to 3, and I introduced a bottle. I would breastfeed my baby, then hand her off to my husband and go lay down. Sometimes I would sleep for 2 hours in a row. My husband would pick up the next feeding with pumped milk, and then the next time my daughter woke to feed I was back on again. For me, the longest my daughter could make it was every 2 hours around the clock, and I was determined to breastfeed. It can be done while you are medicated for Postpartum Psychosis. It can be done with very little sleep. It can be done if you are determined. I never used any formula, but I did commit to pumping a little all day so my husband could give me the one nap.

It wasn’t ideal but I made it work for me and I breastfeed on demand all the other times. I attachment parented my baby, I held her close and kissed her feet. I was able to be the mother I was supposed to be with the help of my family and doctor. We went on to breastfeed for many, many years; about 6.

The shadow of PPP is a haunting one. It never really goes away because you don’t forget the experience or perhaps you don’t forget the places it takes you. The experience is uncomfortable to talk about. I am a grounded person normally, and these days are far from hallucinations or feeling crazy.

I think that my own story may be the part of why I am able to tap into how overwhelming the postpartum period is for many of us. I try to be the gentle hand that reaches out. Please don’t suffer in silence. Please get help right away!

 

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Dr. Jack Newman’s APNO Recipe

 

THE “ALL-PURPOSE NIPPLE OINTMENT” OR APNO

We call our nipple ointment “all purpose” since it contains ingredients that help deal with multiple causes or aggravating factors of sore nipples. Breastfeeding parents with sore nipples don’t have time to try out different treatments that may or may not work, so we have combined various treatments in one ointment. Of course, preventing sore nipples in the first place is the best treatment and adjusting how the baby takes the breast can do more than anything to decrease and eliminate the breastfeeding parent’s nipple soreness. Please note that the “all-purpose nipple ointment” is a stop gap measure only and that the definitive treatment of sore nipples is to help the baby latch on as well as possible.

See these other information sheets: Sore NipplesLatching and Feeding Management.

THE APNO CONTAINS:

  1. Mupirocin 2% ointment. Mupirocin (Bactroban is the trade name) is an antibiotic that is effective against many bacteria, including Staphylococcus aureus including MRSA (methicillin resistantStaphylococcus aureus). Staphylococcus aureus is commonly found growing in abrasions or cracks in the nipples. Mupirocin apparently has some effect against Candida albicans (commonly called “thrush” or “yeast”). Treatment of sore nipples with an antibiotic alone sometimes seems to work, but we feel that the antibiotic works best in combination with the other ingredients discussed below. Although some mupirocin is absorbed from the gut when taken by mouth, it is so quickly metabolized in the body that it is destroyed before blood levels can be measured. Most of it gets stuck to the skin so that very little is taken in by the baby.
  2. Betamethasone 0.1% ointment. Betamethasone is a corticosteroid which decreases inflammation. By decreasing the inflammation, the APNO also decreases the pain the breastfeeding parent feels. Most of the betamethasone in the ointment is absorbed into the skin by the parent, so that the baby takes in very little.
  3. Miconazole powder to a final concentration of 2%. Miconazole is an antifungal agent, very effective against Candida albicans. Because it is added as a powder, the concentration of miconazole can be increased to 3% or even 4% or decreased to less than 2%. We feel 2% is the best concentration for most situations. Fluconazole powder to 2% may be substituted for miconazole and so can clotrimazole powder to 2%, but I believe that clotrimazole (Canesten) irritates more than the other drugs in the same family. Miconazole cream or gel cannot be substituted for miconazole powder as the compound will usually separate. Where miconazole or any of the above mentioned drugs (fluconazole, clotrimazole) are not easily available as powders, it is better to use only the mupirocin and betamethasone ointments mixed together than add a cream or gel or nystatin ointment for example. By using a powder, the concentration of the other two ingredients is not as decreased as they would be if another ointment were used for the anti-fungal agent (for example, nystatin ointment). Thus, in the above preparation the concentration of the betamethasone becomes 0.05% (due to combination withthe mupirocin) and the mupirocin concentration is decreased to 1%.

Note that nystatin ointment, which we used to use and which decreases the concentration of the other ingredients, is far inferior to miconazole and also tastes bad.

I write the prescription this way.
1. Mupirocin ointment 2%: 15 grams
2. Betamethasone ointment 0.1%: 15 grams
3. To which is added miconazole powder to a concentration of 2% miconazole
Total: about 30 grams combinedApply sparingly after each feeding. Do not wash or wipe off.
NO SUBSTITUTIONS

If possible, it is best to get the prescription filled at a compounding pharmacy. You can find a list of compounding pharmacies by going to http://www.pccarx.com/. Click “Find a compounder” at the top, then add relevant information.

HOW TO USE THE OINTMENT:

1. Apply sparingly after each feeding. “Sparingly” means that the quantity of the ointment used is just enough to make the nipples and areola glossy or shiny.
2. Do not wash it off or wipe it off, even if the baby comes back to the breast earlier than expected.

HOW LONG SHOULD THE OINTMENT BE USED?

Any drug should be used for the shortest period of time necessary and the same is true for our ointment. If the breastfeeding parent still needs the ointment after two or three weeks, or the pain returns after the breastfeeding parent has stopped the ointment, the parent should get “hands on” help again to find out why the ointment is still necessary. The most important step for decreasing nipple pain is still getting the “best latch possible.” Sometimes a tongue tie has not been noticed and is a reason for continued pain.

Some pharmacists have told breastfeeding parents that the steroid in the ointment will cause thinning of the skin if used for too long. While this is a concern with any steroid applied to the skin, we have not seen this happen even when breastfeeding parents have used it for months.

Updated February 2017

The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.

This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!

Questions or concerns?  Email Dr. Jack Newman (read the page carefully, and answer the listed questions).
Make an appointment at the Newman Breastfeeding Clinic.

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6 Ways to Tell if Your Breastfeeding Baby is Full!

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New babies are notoriously confusing. They fall asleep after 5 minutes, and then wake up 2 minutes later starving. It’s hard for a new mother to figure out what the baby wants let alone whether they did a good job filling them up! To that end here is a short list to review!
1.) Your baby was really hungry, and had tightly balled fists. As you nurse for a while the little hands open like flowers and become relaxed. Might be full.

2.) Look for Zombie Arm. This is what I call the super floppy arm that happens when a baby is totally milk wasted. You should be able to lift the arm and it drops like a log. Might be full.

3.) Always double check the upper lip. You say you have the Flower Hand, and the Zombie Arm? Check the upper lip by tickling. If you baby hunts for the air nipple, probably not full.

4.) Your baby might look like this:
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or this:

 

 

 

 

 

 

5.) Look at your baby as a whole being. Do they seem relaxed? Are the hands relaxed and open? No tension in the arms or back? Is your baby resting in your hands as you look them over? It their mouth relaxed and not pursed. Might be full.

6.) If you cannot wake your baby up, and you have tried the follow things: A warm washcloth bath, tickled ribs and shoulders, massaged the palms of the hands, and you’ve even tried the dreaded “fake out the baby by pulling the velcro tab on the diaper” trick? Might be full.

(c) Serena Meyer, RN, IBCLC 2016

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10 Tips For Successfully Breastfeeding Your Newborn!

  • A12721663_821694297956914_273166528_n newborn is very alert the first hour of birth. Let your baby relax on your chest without clothes. They will start to stick their tongue in an out, and knead their fingers in the breast like a kitten does. This means it’s time to latch on! Gently scoot them near the breast! Don’t rush the moment, just allow it to happen naturally.
  • Your job is to get your baby close to your nipple so that they can nuzzle and lick your skin for a while first. That part is normal and a necessary first step to breastfeeding! Babies have some expectations; they expect to be on your chest naked and they want to know you. Their experience of life is through their mouth. Relax and allow your baby to learn more about who you are through normal infant behaviors before breastfeeding.
  • Getting that first latch: tickle their upper lip, wait until they open wide, then pull your baby in towards your breast! You want to have your baby rolled inward toward you before you latch, so that you are tummy to tummy. Line your baby up close to nose to nipple right before you tickle the upper lip side to side with the nipple! I usually guide women to use the “cross cradle position” which is one hand on the breast and one hand holding the baby.

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    There is an extra helping hand here! The mother is holding the left breast with the left hand, and scooping the baby in toward the breast with the right!

  • Does it hurt/pinch? Breath through it and count to ten, if it still hurts, unlatch right away by breaking suction with a finger placed into the corner of your baby’s mouth. Slowly insert your finger into their mouth and trade out a nipple for a finger! Never pull a baby off a nipple without breaking the seal first! It will probably hurt if you do.
  • What are a few reason for the pinching? Number one is typically that their mouth wasn’t open wide enough before you pulled them toward you for latching. Be patient and really wait for the wide open mouth!  When you see it quickly pull your baby onto the breast.
  • The second common reason for a pinchy latch is that they need to be tummy to tummy with you or they end up pulling the nipple a bit. Spending time lining your baby up into a comfortable position is key.
  • New babies have three jobs! 1.) Look cute, 2.) Smell good, 3.) Open wide.
    That’s it! Your baby can’t get to you yet, so you have to really pull your baby in for a good latch to happen. Once they open wide you can stuff lots of breast into their mouth. That’s how babies get a deep latch and plenty of milk!
  • “My baby is asleep, can I let him just sleep?” A newborn is going to need to be reminded gently during the first few day that it’s time to eat. Hospitals might say every 3 hours, but as an IBCLC I’m going to share the following information. Babies that gain weight well, eat every 1.5-2 hours in the first few days. This means that long periods of rest are not normal. Try and feed your baby very frequently. Your job is to offer the breast.
  • If your baby is just born try and get a latch in the first hour. It’s not called the Golden Hour for nothing! babies that get latched on right away statistically breastfeed better, and more effectively for the following feeds.
  • In the case of a surgical birth or a situation where there is separation, do your best to either start breastfeeding as soon as you are together or start manually moving out milk no later than hour four. Ask for a pump, use breast compressions, and don’t let anyone get in the way of  your success!

(c) Serena Meyer, RN, IBCLC 2016

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The Creator’s Gift to Mothers

This video discusses the importance of breastfeeding, as well as the myths that often prevent moms from breastfeeding. Breastfeeding truly is “the Creator’s gift to mothers!”

For more information about some of the topics discussed in the video, please see:
Frequently asked questions about breastfeeding and diet
Breastfeeding Myths (part 1)
Breastfeeding Myths (part 2)
Breastfeeding information for dads and partners
Breastfeeding and cigarette smoking

For breastfeeding information or support anytime:
La Leche League or toll free at 877-4-LALECHE
The National Breastfeeding Helpline toll free at 800-994-9662
WIC  (find your local office)
Breastfeeding USA
Find an IBCLC

For more information about this video produced by the Shibogama First Nations Council, please see:
The Creator’s Gift to Mothers

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Stress and Breastmilk Production

stressDoes stress reduce milk production?

Consider this scenario: You are late for an important appointment. You are just starting out the door when you discover baby poops through his last clean outfit and all over you, too! Your phone is buzzing in your purse and your hands are full with baby, diaper bag, and poop. That is a stressful moment, right? Every mom experiences high stress moments just like this.

Moms often hear that they should stay calm because feeling stressed will cause milk to “dry up”. The business of daily life, finances, relationship issues, illness, etc. are all common stressors moms face. Sometimes stress is sudden and ongoing such as in the case of natural disaster or war. The woman’s body is made to not only grow a baby, but also nourish and protect him once born. Moms can continue to breastfeed despite incredible circumstances.

Sometimes moms experience stress that is severe and intense, which can temporarily inhibit letdown. This is thought to be a protective mechanism. As one doctor put it so well, you wouldn’t want to be leaving a trail of milk behind if you were running from a tiger! Over a long period of time, it is possible for chronic stress to inhibit letdown often and long enough that milk production can be decreased. This is usually not the case, as breastfeeding releases hormones that helps mothers and babies both relax and have an easier time enduring stress, even under the worst of circumstances.

What can I do if  I’m in a situation where I’m under ongoing, chronic stress and it is affecting my letdown? 

Letdown can be triggered by associations, such as sights, smells, and emotions. Below are some tips for initiating letdown before and during breastfeeding or pumping. You can try any combination of these that makes sense to you.

  • Find a location to feed your baby (or pump) where you feel very comfortable and safe. Choose a place that is free from intrusion and distraction.
  • Make an effort to relax as much as possible before feeding or pumping. Listen to music, take a few cleansing breaths, pray, smell a relaxing scent, or do anything else that helps you feel at peace.
  • Consider trying breast massage prior to nursing or pumping. It has been shown to assist with milk ejection and overall milk removal.
  • Bend over at your waist so that your breasts dangle from your rib cage, and shimmy your shoulders (move them back and forth) so that your breasts shake. This movement helps loosen tension in your neck and shoulders and assists milk in moving forward in the breast.
  • Consider using Reverse Pressure Softening (RPS) to promote letdown: “Steady stimulation of the nerves under the areola automatically triggers the milk ejection reflex, propelling milk forward in the breast, nearly always within 1-2 minutes or less.”–Jean Cotterman
  • Enjoy the moment. If you are with your baby, smell his head and stroke his hair. If you’re away from your baby, smell a piece of his worn clothing and/or listen to his cries on a recording. Some moms like to watch videos of their baby cooing, crying, or breastfeeding on their phone. This creates an emotional connection, and can help promote milk release.
  • Visualize milk spraying forth from your breasts like a waterfall or a rushing river. It sounds strange, but it often works!
  • If you are with someone you trust and feel comfortable asking, have them rub your shoulders and apply pressure between your shoulder blades. This, too, can help trigger the release of oxytocin and assist in milk ejection.
  • Drink water. Moms often sip water while nursing, so that alone may initiate letdown through what is known as conditioned response.
  • If you’re pumping, the hands-on pumping technique can aid in milk ejection and help you maximize milk removal.
  • Consider breastfeeding while bathing with your baby. This can help release tension in your muscles, and may help your milk flow freely.
  • Between feedings, spend time in skin-to-skin contact with your baby. This will help you  both relax, and aid in release of hormones associated with breastfeeding.


Breaking free from stress

  • Talk to a counselor or traditional healer.  Ask family and friends for support. Stress is often relieved by talking through your feelings and concerns, even if there isn’t a solution to your current problem.
  • Contact your IBCLC, WIC PC, or volunteer breastfeeding counselor for continued support, including tips to manage stress as it relates to mothering and breastfeeding.
  • Eat well and exercise. Eating nutrient-dense foods gives your body the necessary vitamins, minerals, and energy needed to overcome stress. Exercise is a well-known stress buster. Even a 30 minute walk around the block can lower blood pressure, ease tension, and clear your mind.
  • Contact a medical or mental health professional if you’re experiencing ongoing, chronic stress. They can provide information for stress management, and evaluate for related issues like depression and anxiety.
  • Consider talking to your doctor about taking a magnesium supplement.  This mineral is often depleted during times of chronic stress, and some experts suggest that supplementation may help reduce stress-related symptoms.

Stress Resources:

Coping With Perinatal Stress and Depression by Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM

Mental Health Care for Postpartum Depression During Breastfeeding by Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM

American Heart Association: Four Ways to Deal With Stress

American Psychological Association: Coping with Stress and Anxiety

Working Moms and Stress Relief

Stress Management for Parents

Uppity Science Chick: The stress-lowering effects of breastfeeding (list of reference articles)

The Toxic Effects of Stress on American Indians


References:

Chen, D., Nommsen-Rivers, L., Dewey, K., & Lonnerdal, B. (1998). Stress During Labor and Delivery and Early Lactation Performance. Obstetrical & Gynecological Survey, 68(2), 81-82.

Dewey, K. (2001). Maternal and Fetal Stress Are Associated with Impaired Lactogenesis in Humans. The Journal of Nutrition, 133(11), 30125-30155.

Groer, M., Davis, M., & Hemphill, J. (2002). Postpartum Stress: Current Concepts and the Possible Protective Role of Breastfeeding. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 31(4), 411-417.

Heinrichs, M., Neumann, I., & Ehlert, U. (n.d.). Lactation and Stress: Protective Effects of Breast-feeding in Humans. Stress: The International Journal on the Biology of Stress, 195-203.

Lau, C. (2001). Effects of Stress on Lactation. Pediatric Clinics of North America, 48(1), 221-234.

Mezzacappa, E., & Katkin, E. (2002). Breast-feeding is associated with reduced perceived stress and negative mood in mothers. Health Psychology, 21(2), 187-193.

© Jolie Black Bear 2015

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