One of my partners had just returned from the big city where she attended a continuing medical education session on sleep. She excitedly told me, “You know one group is about to publish something about the relationship between sleep-deprivation and postpartum depression?” I smugly replied, “I hope you weren't surprised by their results.” She knows that I wasn't. For decades it has been clear to me that many women and a few men with “baby blues” (I guess the politically correct term is now “maternity blues”) have gotten into that state in large part because they are sleep deprived.
Unfortunately, this association has up to this point received little or no attention on the scale it deserves. In the American Academy of Pediatrics' recent Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice (Pediatrics 2010;126:1032-9), the word “sleep” appears only once and that is in a laundry list of preventive health that includes the Back to Sleep program. This exhaustive report does include some concerning statistics about the scope of the problem, and the associations between postpartum depression and numerous pediatric developmental and mental health issues.
The report offers an abundance of strategies for helping pediatricians identify and then refer parents with postpartum depression. However, there is no mention of “prevention” of postpartum depression in the report. If I and the researchers who are investigating the association between sleep deprivation and postpartum depression are correct, at least some (and probably many) cases are preventable, and pediatricians can and should play a role.
At prenatal classes and office visits, the issue of sleep hygiene must be on the agenda. Parents-to-be may have heard from other parents that they won't be getting much sleep. But they need to hear it again, and need to hear from the pediatrician some concrete suggestions about how to minimize the impact of sleep deprivation. Immediate postpartum plans for visitors, activities, and travel need to be reality tested. Strategies for using phone answering systems and social networking Web sites to discourage inconsiderate visitors during those first critical days when new parents are exhausted and breastfeeding is on its first wobbly legs should be offered. Empowering a new father to tell visitors, “The pediatrician says Mom and baby really need to be sleeping if the breastfeeding is going to work. Can you come back at another time? You can check our blog for feeding updates and pictures.”
Does the family have a good plan for a support system that includes knowledgeable advisers who are available 24/7? What will be the pediatrician's role on that team? Is the first office visit appropriately timed? In 3 days breastfeeding can crash, and parents can be exhausted beyond repair.
The AAP Clinical Report cites at least one study that refers to an association between not breastfeeding and early cessation of breastfeeding. In my experience, this can be one of those chicken-egg-chicken associations. A sleep-deprived woman will often experience problems with breastfeeding, and a woman who is having trouble breastfeeding can become sleep deprived. Sometimes the solution is to have someone come into the home to relieve the family of other responsibilities. Knowledgeable breastfeeding advisers who are sensitive to a mother's sleep needs can rescue the situation.
There is a fine art of determining when it is time to get an exhausted (and potentially depressed) mother some sleep by offering some formula. If done well, breastfeeding can be saved and depression prevented. If breastfeeding finally crashes, pediatricians must be aware that this can trigger depression, and they must become chameleonic advocates of good nutrition in general, not just advocates of breastfeeding.
At every visit, parents should be asked not only how their child is sleeping, but how they themselves are sleeping. Red flag answers must be dealt with on the spot with sound advice and timely follow-up both by phone and face to face.
The AAP Clinical Report refers to a survey in which pediatricians felt that they lacked sufficient training to diagnose and treat maternal depression. I know that's how I feel. But I certainly can suspect and refer. But more importantly, there is a lot I can do to prevent. When all is said and done, prevention is the pediatrician's mantra.