Two stories about maternal stress and letdown worries

Case 1. A woman believes that a terribly stressful life event has stopped her letdowns

Once, I saw a woman who’d presented with nipple pain and concerns about the baby’s weight gain. When she came in, she told me she was under an enormous amount of stress, which was was interfering with her capacity to have letdowns, so that she hardly ever felt a letdown now.

This woman’s father was seriously ill. I offered assistance with the breastfeeding and suggested follow-up a week later. It was a couple of weeks before she came back in, and her baby’s weight gain hadn't been good in that time, though the baby was adequately hydrated and safe. Sadly, in the time since we first met, the baby's grandfather had died.

Looking back over the previous terrible fortnight, this exhausted woman described having had difficulty putting the baby to the breast frequently and flexibly, partly because of the nipple pain she was still experiencing. She also explained how she hadn't been able seriously think about the fit and hold strategies we'd worked on together. There had been too much going on, with family flying in for the funeral, and so much else to think about and to organise. And she'd probably spaced out feeds more than she meant to, just because everything was so overwhelming.

This lady explained how she'd been kind to herself and started using formula supplementation the day her father passed away – trying to sort out the breastfeeding had felt too hard over her father's last days and the week of his funeral.

Here's what was going on

However, I could see that this was not a situation where stress was impacting on her letdowns, as she'd thought. It was a case of stress affecting the behaviours which surrounded breastfeeding. Also, this lady had had some misunderstandings about the nature of letdowns (e.g. that she should be able to feel them, which isn't the case).

When the woman breastfed her baby in our second consultation, I could again see her shoulders tightening up with the nipple pain, which worsened the breast tissue drag inside her baby's mouth, which therefore worsened her pain.

With some help, this grieving mother came to realise she was having letdowns afterall, because she was able to observe her baby’s sucking patterns change at times, or hear the sound of baby swallowing. After she saw me that second time, and practiced the gestalt method and frquent flexible feeds, her baby's weight gains returned to normal and the pain disappeared.

Case 2. A woman worries that she doesn't get letdowns when she is ovulating

I saw a group chat once between breastfeeding medicine doctors about a baby who was nine months of age, and whose mother reported having trouble letting down her milk whenever she ovulated. The little one was gaining weight well.

Here's what this mother described.

• She only noticed the problem with letdowns when directly breastfeeding her baby, not with pumping.

• She'd tried warmth, tried looking at pictures of the baby, tried guided imagery, tried distraction.

• Her inability to have a letdown lasted for a few days. If she breastfed without having a letdown, she would then pump and bottle-feed.

• She also noticed that when she was pumping she was no longer getting the ‘feel good’ sensations of a letdown. Her baby typically fed about five times each breast in 24 hours, and was on the breast for only five or ten minutes. Baby was taking solids well.

The doctors noted that this patient had a history of anxiety, and was taking Zoloft. They also expressed concern that her high stress levels were affecting her letdowns. There were discussions about the dose of Zoloft she was on, and whether to increase it. Other anti-anxiety medications were proposed.

But these breastfeeding medicine doctors had been trained in the biomedical paradigm, which they were applying to a very complex breastfeeding challenge.

Here's what was going on

Here's what I believe was required to help this distressed woman and her little one. She needed reassurance that

• It is normal not to feel letdowns

• The experience of letdowns varies between women and varies over time

• Her baby is thriving so she can be confident that her baby is getting enough milk and food

• Because her baby is enjoying solids, her milk supply will have dropped off to volumes which are normal for a nine-month-old, which is likely to alter her experiences of her own breasts and milk

• Some breastfeeds don't transfer much or any milk, and older babies often only want to be on the breast for very short periods of time during the day

• She has done something wonderful breastfeeding her baby for nine months so far. She can relax and let her breasts and body do their job, because her breasts are now very experienced! She could experiment with letting everything be as easy as possible with breastfeeding now, having worked so hard to get to this point. There's no need to think about letdowns as they are not going to affect her little one's wellbeing or weight gains.

Of course, the doctor who was managing this lady may well have discussed all these things. But that group chat did get me thinking about how easy it is, with the best of intentions, to accidentally and unhelpfully pathologise something that really isn't a cause of problems at all!