In my previous post, I reviewed the findings from our recent study. Our results suggested that breastfeeding mothers got more sleep, were less fatigued, and reported better physical health than mothers who were mixed- or formula-feeding. We also found that reported depression was significantly lower in the mothers who were breastfeeding only compared with those who either mixed- or formula-fed. [Click here to read the original article.]

In this post, I want to suggest some strategies for working with a very fatigued breastfeeding mother. Most of us can probably recall what it was like to feel so tired that we thought we were going to die if we didn't get some sleep. That can happen even when a mother is exclusively breastfeeding. So the question is what should you do? When a mother is in that state, we want to address her fatigue immediately as it increases her depression. Fortunately, there are some things you can suggest that will help.

Some Approaches You Might Suggest

• Brainstorm with the mother on some strategies to help her cope with fatigue (e.g., encourage her to accept offers of help). She may have been reluctant to accept help from others, assuming that she should do everything herself. As health professionals, we can let her know that she doesn't have to do everything by herself and that accepting help will be both good for her and good for her baby.

• Treat depression. Depression can have a severe and negative impact on sleep quality, reducing the amount of slow-wave (deep) sleep that mothers receive. This will make her feel more tired during the day. Treating depression will likely improve her sleep. Indeed, one of the first symptoms that antidepressants address is sleep quality. So medications may prove helpful in this case.

• Use cognitive-behavioral sleep interventions [click here to learn more]. Non-pharmacologic treatments for depression also work, including cognitive-behavioral therapy. This is another option that addresses both depression and sleep issues.

• Use medications specifically for sleep. Sleep medications may be another alternative. Most are compatible with breastfeeding. However, any mother taking a medication that makes her sleepy should not bedshare.

• A history of psychological trauma can also cause a number of sleep issues. If mother has a trauma history, The Post-Traumatic Insomnia Workbook will likely be a helpful resource. In addition, some medications that are used for sleep are also helpful in that they address trauma-related sleep issues. Some examples are the SARIs (serotonin antagonist reuptake inhibiters, such as trazodone) and the atypical antipsychotics (such as olanzapine).

Rule Out Physical Conditions

Severe fatigue may also be caused by an underlying physical condition. To rule those out, the following tests may be helpful.

• Blood work to rule out hypothyroidism, anemia, autoimmune disease, low-grade infection, or vitamin D deficiency
  • TSH, T3, T4 for thyroid function
  • Complete Blood Count for anemia and/or possible infection
  • Erythrocyte Sedimentation Rate for inflammation. This is a sensitive, but non-specific test that will measure whether some type of inflammatory process is going on. An abnormal finding can indicate an infection, autoimmune disease, or even cancer. An abnormal finding should lead to further testing to narrow down a more-specific cause. But this can be a helpful screening tool.
  • Vitamin D level to rule out a possible deficiency. Many mothers are deficient in vitamin D. Supplementing will likely improve her health and decrease her level of daily fatigue.
  • Possible sleep study to rule out sleep-breathing and sleep-movement disorders. This is not a strategy for every mother. But if other conditions have been ruled out, it can be helpful to determine whether she has either sleep apnea or restless leg syndrome.

If limiting nighttime feedings becomes necessary to preserve a women's mental health, a stretch of 4-5 hours will be easier to implement, will meet mental health goals, and will be less disrupting to breastfeeding than trying to avoid breastfeeding for an entire night. Some of the current recommendations of avoiding nighttime feeding for 8 hours or more may lead to mastitis in a breastfeeding mother, or possibly a permanent disruption in her milk production for that pregnancy. In any case, before limiting nighttime feedings, mothers need to give informed consent about how these interventions might impact breastfeeding. It's not fair to mothers to implement these types of programs without letting them know about possible negative effects of them.

In conclusion, severe fatigue in mothers is something that we should address promptly because it dramatically increases their depression risk. However, trying to address fatigue by avoiding nighttime breastfeeding or advising a mother to supplement with formula will likely prove counterproductive. Fortunately, there are strategies that can help. Our job is to help mothers find the best strategy for them.

Posted by: Kathleen Kendall-Tackett, PhD, IBCLC, FAPA, who is a health psychologist and board-certified lactation consultant. She is clinical associate professor of pediatrics at Texas Tech University Health Sciences Center in Amarillo, Texas. She is owner and editor-in-chief of Praeclarus Press, a small press specializing in women's health. She can be contacted at www.KathleenKendall-Tackett.com.

Published: October 20, 2011

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