For this edition of ‘Ask the expert’ we had the wonderful Dr Natasha Sriraman. Board certified paediatrician, academic researcher and mother of three. She addressed some major issues that many new parents face. Issues where there is a lot of misunderstanding and misinformation. Issues where with better education we could be a lot better off. Specifically we address some of her passions: postnatal depression and anxiety (the postnatal anxiety part often gets ignored and is much more common). Plus some major misinformation about breastfeeding that could be a game changer for you.

For the key highlights read on, or click here for our full conversation on our podcast. Highly worth a listen! 

So, lets start with a bit about Dr Natasha: 

I am a board certified academic paediatrician. That means that I see patients, but I also teach medical students and publish research. I also travel round the US speaking on key topics as well as helping to shape policy. Not only that, but i’m a mother of three – my oldest is 18 and youngest is soon to be 13. My husband is an ICU doctor. So, our house is a bit busy! 

My passion: 

As a paediatrician, actually I’m not just taking care of the child. I’m taking care of the parents/the mother as well. I’m particularly passionate about this because of my own personal struggles with the ‘4th trimester’ (the initial post parfum period). Frankly in the US the care for a new mother is pretty abysmal. Particularly when you think about how much attention the mother gets during pregnancy vs after. I had my own struggles postpartum so I am particularly passionate about this missing aspect of care. 

I never got my eldest to latch and was attached to a pump for a year: 

It was hard. Then when I had my second child I was sleep deprived too. When you’re in it, you don’t realise how tough it can be… 

The assumption is this is ‘just part of motherhood’:

As women we tend to put so much pressure on ourselves, particularly in these early days which are hard. Often we forget to take care of ourselves. Frankly, its only now that I’ve done so much work on maternal mental health that I realised myth own postpartum depression. It’s hard to see it when you’re in it. 

Feeling very overwhelmed is not normal. We need to empower mothers and open the conversation: 

At the time I tried to get help but honestly, I felt I had the door shut. Which was hard given its tough to ask for help in the first place. I still remember it 16 years later. As a result, as much as I pride myself on my training and my schooling my biggest pride is my focus on mothers and what they’re going through. Not only that but making help realistic, because I’ve been there! You don’t need to suffer. It’s better than it was, but, we are still far from where we need to be. 

Some of the warning signs you need more help: 

Obviously the first couple of weeks, especially with breastfeeding are tough. There are some major hormonal changes which don’t help. However, there are also some misconceptions. Generally speaking the literature (which is pretty misleading) suggests that in the first 14 days you’ll experience the most significant hormonal shifts. The intense emotions around this time, which are ‘normal’ are what people refer to as ‘baby blues’. 

Here’s the misconception… 

There is an understanding that after 14 days the hormonal shifts should settle and if they don’t, that is when you’re getting into Postpartum Depression territory. The reality is that the human body is not that mechanical. It is also not what I see in my practise. Emotional volatility in the early days can certainly be more than what we understand as ‘baby blues’.

In my experience we need to look at it in a different way: 

Yes it is normal to feel emotional post birth. However, the question I’d ask is more functional. Are the feelings of sadness, being overwhelmed etc preventing you doing what you have to do? Caring for the baby and also yourself? This can start very early. 

What actually happens to our hormones post birth: 

The initial couple of weeks after birth does indeed see large hormonal shifts. You have estrogen, progesterone, cortisol, insulin, thyroid hormones all working through your pregnancy. Then once the baby is born and the placenta is removed progesterone totally drops. That is what actually makes a mother start lactating. Then if you start breastfeeding you get another shift in hormones. This happens if you decide to breastfeed or not. Cortisol/Oxytocin will also shift. So, there are changes! The old notion is that there will be some ‘normalisation’ after two weeks, however, the body doesn’t seem to work like that in every case. This is why having a doctor screen for depression/anxiety early on is so important. A week can feel like a lifetime when you’re feeling bad…. 

Postpartum depression but what about postpartum anxiety?! 

Thankfully postpartum depression is getting more attention. However, typically more common but less discussed is postpartum anxiety. What does this mean? This can include things like excessive worry about the safety of your child. These feelings can be very overwhelming feelings. To the point where you struggle to rest/quieten your mind. Feeling extremely anxious a lot is also something that you may need help with. 

This could be a signal you need some support: 

If you are very worried, are struggling to rest and feel a lot of anxiety then that may be a signal you need some help. What I commonly see is that this is the mother who is bringing the baby into my office every week. Who rushes to the emergency room, who is extremely fearful over the baby’s health and wellbeing. 

I’m in a great position to pick this kind of thing up: 

Obviously my patient is the baby, however, on average in the first year I will see the mother and the baby as many as 9-12 times. Compare that to how many times a woman sees her doctor after birth. Perhaps once 6 week after birth? That is not enough if you’re having trouble. I’m in a privileged position to be able to see and pick up clues that the mother may need help.

When to be extra vigilant: 

The research suggests that if you have a previous history of anxiety and depression it may worsen with pregnancy and in the postpartum period. 

How do we go about practically tackling it? 

Firstly it is raising awareness amongst paediatricians and building the resources around for support and then it’s about opening up the conversation. What I’ve seen is that mothers actually want to talk about this and welcome it. Often no other medical professional is really asking a mother how she is doing. It’s also easier as a paediatrician as I am seeing the mother so much more often. Asking a mother how she’s really doing: normalises it….

One easy place to start: 

Anxiety is difficult to deal with. It is also very individual. However, sleep is a great place to start. Every mother knows how much sleep can impact your mood and ability to cope. This is not to say everyone ‘must get 8hrs sleep’ of course and every situation will look different. A breastfeeding mother will be potentially up more in the night than a mother whose partner is helping give a bottle. It is about finding ways to improve your own sleep situation. 

Click here for more from another ask the expert: sleep specialist Rosey Davidson who specialises in improving baby and adult sleep. 

Another key area to tackle with a strong link connection with anxiety and depression: Breastfeeding challenges: 

I am also a lactation consultant. Once again partly because I learnt first hand how much of a problem this can be. It is such an emotional topic and feelings of ‘failure’ (whatever that means to you) can cause a great deal of stress. Getting help if you’re struggling from someone who really understands the physiology of breastfeeding can be invaluable. I am also of the view that ‘some is better than none’ so don’t beat yourself up about giving formula. Sometimes allowing your partner, mother, maternity nurse to feed the baby is ok, especially if it means you can take care of your mental health. There are often free support groups (as there are in our hospital). Peer support: can also be important. Knowing you’re not alone. The most important thing however is that if you’re struggling, it is more than ok to ask and look for help.  

We spend so much time on birth plans, but what about an after birth plan?! 

We all focus on a birth plan, but what about a postnatal plan? My big passion is the postpartum plan. I am actually not a huge fan of the birth plan, really as a physician mother with three unplanned c-sections I know that baby’s will do what they want to do! That is not to minimise it, if it works for you. I just feel that we should also really be focusing on a plan for the postpartum period at least equally. 

Guilt if birth doesn’t go according to ‘plan’: 

The other challenge with a birth plan is that it can give rise to guilt or negative feelings when the birth doesn’t go according to that plan. As doctors, from a medical perspective we are happy as long as there is a safe and healthy delivery. However when it doesn’t go to ‘plan’ some mothers see it as a ‘failure’ or even traumatic. That can also play a part in feelings of anxiety and depression post birth. 

Postpartum plans are simply about preparing to give yourself support if you need it: 

Often postpartum doesn’t go to ‘plan’ either! A postpartum plan is more preparing for support you may need. This isn’t trying to control the situation as babies will do what they want to do! It is more planning for support you may need. Thinking and talking to your partner ahead of time about shifts in your relationship and roles within. It may also be planning ahead for professional support. Researching lactation consultants ahead of time that you may need. Who do you call when you need a rest/to take a shower? Who can deliver groceries etc? Having a stocked freezer. A good postpartum plan is devising a systematic way while you’re pregnant to get prepared with help if you do find yourself struggling. I know for myself when I was struggling and hadn’t done this I was scrambling and it made my anxiety worse. 

The challenge of conflicting advice: especially when it comes to breastfeeding: 

The trouble with breastfeeding (for those that want to but find it hard) is that there is so much conflicting advice. As it stands there is no ‘standard of care’. For all three of my children I received totally different advice how to do it. That can make it worse. 

The first step is communication and standing up for yourself, whatever your goals are: 

Breastfeeding is an individual choice. However, I have seen first hand how setbacks to a mother’s intentions and even disempowering the mother can start really early. For example, in hospital, if a baby is given a bottle without proper education/communication about what the mother wants to do it can be an immediate setback for that mother.

Major misconception: ‘the baby isn’t getting enough’: 

There is still a lack of education around the early days of breastfeeding. Particularly around Colostrum vs first milk (which comes in around day 4-5). Most of us know that the very first production is Colostrum which is highly nutrient dense and important for the baby. It doesn’t come in huge quantities and many mothers worry that the baby ‘isn’t getting enough’. Particularly given milk doesn’t come in for several days. This is often when many are tempted to give a bottle, because they are panicked that the baby is not giving enough. This is incorrect from a physiological standpoint. 

The Colostrum is enough: 

Colostrum is rich in immunoglobulins. The goal therefore is to get the baby on the breast in the first hour or so of birth. It’s often referred to as the baby’s first vaccination. The key thing to remember is that it is a different volume to breastmilk, but it’s actually very thick. You may have noticed this if you’d squeezed it out. A baby does not need a huge amount. The temptation of course is that with a bottle you can see how much a baby is getting and we all want our babies to have enough. However, physiologically speaking he colostrum is enough. 

Here’s a way to understand how much your baby really needs: 

As medical professionals we correlate the amount a baby needs with the size of the baby’s fist. This is roughly how big his/her stomach is. So, when you put this into context you can feel reassured. This is not something we typically learn during pregnancy and actually if we knew it could probably relieve a lot of the early stress. 

It is normal for a baby to lose weight in the initial 10-14 days: 

The baby will lose weight within 10-14 days. That is normal. The other major misinformation (even amongst medical professionals) is weight gain with breastfeeding vs formula. There is a difference. Often many of us paediatricians will react that the baby is ‘not gaining weight fast enough’ but actually the guidelines are often not adjusted for breastfed vs bottle and the rates are different. That can really disempower a mother and bring guilt. It can also lead to more formula given. 

Doctors have shortcomings too! 

A lot of time as paediatricians we don’t know how to fix a latch. Which is usually the majority of the cause of issues. We don’t train in breastfeeding and we often have very short slots to see people which is ridiculous. So, instead, it is easier to recommend giving formula. That is fine if thats what you want to do. However, if you do want to exclusively breastfeed it can add to feelings of ‘not being good enough’. Many of us do not know this. Further, physiologically the more you give formula the less breastmilk you produce so it can quickly become a self fulfilling action. 

Simple supply and demand: 

The less feeding you do (or pumping) the less you produce. Which leads to a very common issue/complaint amongst women I see of ‘not producing enough’. We need to support people with proper education. If you are being told to give more bottles of formula then you will produce less milk. 

The things your partner/family should know if you’re breastfeeding: 

Breastfeeding is hard work. It can be helpful to educate your partner or your individual support system – particularly benefits for the mother of doing it. Partners can feel disempowered and ‘left out’. However, often when those around us understand they will go the extra mile to make it easier. Did you know that there are physiological benefits to a mother from breastfeeding? (Caveat: not if it comes at the detriment of your mental health and sanity). The big one is the link between breastfeeding and reduce risks of hypertension and heart disease. The other big one is cancer and it is cumulative. So for example, I breastfeed three children for three years, research suggests that this can act together to reduce breast and uterine cancer. People don’t tend to talk about this and we should. 

Many mothers are so focused on feeding the baby they forget to feed themselves: 

Once again, educating partners/family and those supporting the breastfeeding mother how important it is for her to eat and drink enough is crucial.

What you really need: 

Ultimately as new parents we put incredible stress and pressure on ourselves. What you need to remember is that we are all doing the best we can. The best approach is to Lessening the guilt, increase the support and filling our children with love. That’s enough. Sometimes this is the very thing we don’t hear enough! 

For more from Dr Natasha – check her out on instagram – click here. 

————————————————————————————————————————————————————

This article is for informational purposes only. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The information on this website has been developed following years of personal research and from referenced and sourced medical research. Before making any changes we strongly recommend you consult a healthcare professional before you begin.

Copyright © 2023