www.jped.com.br
REVIEW
ARTICLE
Breastfeeding
and
postpartum
depression:
state
of
the
art
review
夽
Bárbara
Figueiredo
a,∗,
Cláudia
C.
Dias
b,
Sónia
Brandão
c,
Catarina
Canário
d,
Rui
Nunes-Costa
daAssociateProfessor.withAggregationEscoladePsicologia,UniversidadedoMinho,Braga,Portugal bResearcher.EscoladePsicologia,UniversidadedoMinho,Braga,Portugal
cPhDCandidate,InstitutodeCiênciasBiomédicasAbelSalazar,UniversidadedoPorto,Porto,Portugal dPhDCandidate.EscoladePsicologia,UniversidadedoMinho,Braga,Portugal
Received9October2012;accepted13December2012 Availableonline20June2013
KEYWORDS Breastfeeding; Pregnancy depression; Postpartum depression; Hormones Abstract
Objective: Toreviewtheliteratureontheassociationbetweenbreastfeedingandpostpartum depression.
Sources: AreviewofliteraturefoundonMEDLINE/PubMeddatabase.
Summaryoffindings: The literature consistently shows that breastfeeding provides a wide rangeofbenefitsforboththechildandthemother.Thepsychologicalbenefitsforthemother arestillinneedoffurtherresearch.Somestudiespointoutthatpregnancydepressionisoneof thefactorsthatmaycontributetobreastfeedingfailure.Othersstudiesalsosuggestan asso-ciationbetween breastfeeding andpostpartum depression; thedirection ofthisassociation isstillunclear. Breastfeedingcanpromotehormonal processesthatprotectmothers against postpartumdepressionbyattenuatingcortisolresponsetostress.Itcanalsoreducetheriskof postpartumdepression,byhelpingtheregulationofsleepandwakepatternsformotherand child,improvingmother’sself-efficacyandheremotionalinvolvementwiththechild,reducing thechild’stemperamentaldifficulties,andpromotingabetterinteractionbetweenmotherand child.
Conclusions: Studiesdemonstrate that breastfeeding canprotect mothers from postpartum depression,andarestartingtoclarifywhichbiologicalandpsychologicalprocessesmayexplain thisprotection.However,therearestillequivocalresultsintheliteraturethatmaybeexplained bythemethodologicallimitationspresentedbysomestudies.
©2013SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.
夽 Pleasecitethisarticleas:FigueiredoB,DiasCC,BrandãoS,CanárioC,Nunes-CostaR.Breastfeedingandpostpartumdepression:state
oftheartreview.JPediatr(RioJ).2013;89:332---8.
∗Correspondingauthor.
E-mail:bbfi@psi.uminho.pt(B.Figueiredo).
0021-7557©2013SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.
http://dx.doi.org/10.1016/j.jped.2012.12.002
Este é um artigo Open Access sob a licença de CC BY-NC-ND
PALAVRAS-CHAVE Amamentac¸ão; Depressãona gravidez; Depressãopós-parto; Hormônios
Amamentac¸ãoedepressãopós-parto:revisãodoestadodearte
Resumo
Objetivo: Revisaraliteraturasobreaassociac¸ãoentreaamamentac¸ãoeadepressãopós-parto.
Fontes: UmarevisãodaliteraturaencontradanabasededadosMEDLINE/Pub-Med.
Resumodosachados: Aliteraturamostra,deformaconsistente,queaamamentac¸ãofornece uma ampla quantidade de benefícios tanto para a crianc¸a quanto para amãe. Ainda são necessáriasmaispesquisassobreosbenefíciospsicológicosparaamãe.Algunsestudosapontam queadepressãonagravidezéumdosfatoresquepodecontribuirparaanãoamamentac¸ão. Outrosestudossugerem,também,umaassociac¸ãoentreamamentac¸ãoedepressãopós-parto, nãoestandoclaraaindaadirec¸ãodessaassociac¸ão.Aamamentac¸ãopodepromoverprocessos hormonaisqueprotegemasmãescontraadepressãopós-partoporatenuararespostado cor-tisolaoestresse.Eissotambémpodereduziroseurisco,porauxiliarnaregulac¸ãodospadrões dosonoevigíliadamãe edofilho,melhorando aautoeficáciaeoenvolvimentoemocional damãecomacrianc¸a,reduzindoasdificuldadesdetemperamentoepromovendoumamelhor interac¸ãoentreeles.
Conclusões: Apesquisaapontaqueaamamentac¸ãopodeprotegerasmãesdadepressão pós-parto e comec¸a a esclarecer que processos biológicos e psicológicos podem explicar essa protec¸ão.Contudo,aindaexistemresultadosambíguosnaliteraturaquepoderãoserexplicados pelaslimitac¸õesmetodológicasapresentadasporalgunsestudos.
©2013SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.
Introduction
Breastfeeding has been associated with the well-being of both the child and the mother. Breastfeeding ben-efits for children’s physical and psychological status include decreased risk of infectious diseases and obe-sity,decreased bloodpressure,lowercholesterollevels,1,2
andincreasedcognitiveandmotorperformance.3,4Positive
health-outcomes for the mother’s physical health include decreased blood pressure and risk of breast and ovarian cancer;5---7forthemother’spsychologicalhealththeyinclude
attenuated stress response8---12 and enhanced sleep.13,14
However,benefitsforthemother’spsychologicalwell-being needmoresupportiveempiricalevidence.15
The World Health Organization (WHO),16 the European
Commission for Public Health (ECPH),17 and the
Ameri-can Academy of Pediatrics (AAP)18 recommend exclusive
breastfeeding for the firstsix months of life. Despite the established benefits of breastfeeding, rates are still low, andeventhoughratesofbreastfeedinginitiationarehigh, thereis amarkeddeclineinbreastfeedingduringthefirst few weeks afterinitiation, and exclusive breastfeedingis rare. In Portugal, despite the high rate of breastfeeding at the time of hospital discharge (91%19 and 98.5%20), an
accentuateddecreaseisobservedinthefollowingmonths, withonly54.7%19to55%20ofmothersbreastfeedingatthree
months postpartum, and 34.1%19 to 36%20 at six months
postpartum. The national health surveys provided by the Portuguese HealthMinistryshowed thatbreastfeeding ini-tiation rates increasedfrom 81.4% in 1995/1996 to84.9% in 1998/1999.21 In 2010/2011, this percentage ascended
to98.5%.22 However,despitetheincreaseinbreastfeeding
rates,thesesurveysalsoshowadecreaseinbreastfeeding overthemonths.In2010/2011,inbaby-friendly hospitals, between65.2%to72.5%ofmothersexclusivelybreastfeed
their babies by the time of hospital discharge. At three months postpartum, the percentage of exclusive breast-feedingwas 40.3%,falling to14.7% at fivemonths.22 The
Europeanratesofbreastfeedinginitiationvaryfrom63%in Belgiumto99%inNorway.23 Afterhospitaldischarge,rates
starttofall andat sixmonths thepercentageof mothers whocontinue tobreastfeed variesfrom10%inBelgium to 80%in Norway.23 Scandinavian countriespresent the
high-estratesofbreastfeedingatsixmonthspostpartum(80%in Norway,72%inSweden,and65%inIceland).23 InBrazil,a
nationalsurveyconductedin2008showedarateof41%of exclusivebreastfeedinginbabiesfrom0to6months.24In thesamesurvey,thepercentageofbreastfeedinginbabies from9to12monthsoldwasapproximately58.7%.24
Therefore,identificationofwomenatriskforearly ces-sation of breastfeeding and implementation of effective breastfeeding promotion strategies are considered health priorities.
Breastfeeding
and
depression
in
pregnancy
and
postpartum
depression
Recent literature reviews suggest that breastfeeding is lesscommonamongdepressedmothers,eventhoughtheir infants benefit from breastfeeding.25,26 Studies from
dif-ferent socio-cultural contexts show almost unequivocally thatdepressedmotherstend tobreastfeedlessor forless timethannon-depressedmothers.However,theassociation betweenbreastfeedingandpostpartumdepressionremains equivocal.25,27
Whendepressedduringpregnancy,womenarelesslikely toinitiate28,29or tomaintainbreastfeeding,30---32 compared
withthosewithnodepressivesymptoms.Inarecentstudyon theassociationbetween prenatalpsychosocialriskfactors
andbreastfeedingintentionofHispanicwomen,researchers foundthatwomen whoscored higherindepression atthe middle of gestation (about 25.7 weeks) and women who showed persistent depressivesymptoms during pregnancy presented a lower intention tobreastfeed their babies.33
Other studies have shown that 1/5 of pregnant women aredepressedat thethird trimesterofpregnancy,34,35and
thathalfof thesedepressedpregnantwomenwillnot ini-tiateorbreastfeedforthreemonthsormore.30Depression
scoresatthethirdtrimesterwerethebestpredictorsofthe lengthofexclusivebreastfeeding,andwhenconsideringall themothersnotbreastfeedingatthree-monthpostpartum, 37%couldbeeasilydetectedbecauseofdepressionduring pregnancy.30 Results also showeda significant decreasein
depressionscoresfromchildbirthtothreemonths postpar-tuminwomenwhomaintainedexclusivebreastfeedingfor threeormoremonths.30
Exclusivebreastfeedingappearstobesignificantlylower amongdepressedmothers.36---39Motherswhodonotinitiate
or maintainbreastfeeding aremore at-riskfor depression duringthepostpartumperiod.30,40---43Moreover,when
moth-ersaredepressedin the postpartumperiod,they tend to notinitiate28,29ormaintainbreastfeeding.27,36,44---50
Some studies have shown that postpartum depression emergesin the sequence of and may result from breast-feeding interruption,40---43 suggesting that early cessation
of breastfeeding may be involved in the cause of post-partumdepression. For example, an association between negative early breastfeeding experiences and depressive symptomsattwomonthspostpartumwasfound.51 Another
study that aimed to assess the association between the infant feeding method and depressive symptoms showed that breastfeeding initiation among multiparous mothers wasassociatedwithsignificantlydecreasedoddsof postpar-tumdepression.43
Otherstudiessuggestthatpostpartumdepressionmaybe involvedinthecauseofearlybreastfeedingcessation,and thatdepressivesymptomshavebeen observed toprecede the cessation of breastfeeding.27,46,49,52---54 For example, a
recent study screening for depression levels immediately afterdeliverydemonstratedthatmotherswithhigherlevels ofdepressivesymptomshaveahigherlikelihoodto bottle-feed their infants at three months postpartum.38 Results
alsoshowedthattheoddsofbottle-feedingincreasedwith theseverityofmaternaldepression.38Anotherrecentstudy
indicated an association between breastfeeding cessation at four months postpartum and higher depressive symp-toms at one month after delivery, showing that mothers who continued to breastfeed at four months had lower depression scores at one month than those who stopped breastfeeding.36
Research has also been focusing on the association between breastfeeding and depression in pregnancy and postpartumdepression.Arecentstudyshowedthathigher levels of depression and anxiety during pregnancy were associatedwith breastfeeding cessation,and that breast-feeding cessation predicted higher levels of anxiety and depression after birth.55 Moreover, the results showed an
interaction effect between anxiety and depression levels at pregnancy and six monthspostpartum and breastfeed-ingcessation,sothatbaselinelevelsanxietyanddepression are increased at six months postpartum by the effect of
breastfeedingcessation.55Anotherrecentstudyonthe
asso-ciationbetweenbreastfeedinganddepressioninpregnancy and postpartumdepression concludedthat higher depres-sion scores at the third trimester of pregnancy predicted lower exclusive breastfeeding duration.30 This study also
foundadecreaseindepressivesymptomsinwomenwho ini-tiated or maintained exclusive breastfeeding for threeor moremonths.30
The association between breastfeeding and depression hasalsobeenstudied,takingintoaccountbothparents.A studyundertakentotriggertheassociationbetween breast-feeding andmental health of both theparents concluded thatthesimultaneouspresenceofmentaldisordersinboth the mother and the father was not associated with the earlybreastfeedingcessation(beforefourmonths).56
How-ever, motherstended tobreastfeed fora longerperiodof timewhentheyfeltthattheirpartnersactivelysupported breastfeeding.56
Breastfeeding
and
hormonal
protection
to
postpartum
depression
Research has been showing that breastfeeding promotes hormonaland psychological conditionsand processesthat areinverselyassociatedwithpostpartumdepression. How-ever,thesimultaneousstudyofthesedimensionsandtheir potential explanatory value in the connection between breastfeedingandpre-andpostpartumdepressionhasnot yetbeenaccomplished.
‘‘Itis possible that the positive effects of breastfeed-ingmayoutweighthepositiveeffectsofantidepressants’’.26
Evenwhenthepotentialharmfuleffectsofmedicationare takenintoaccount,somestudiessuggestthatwomenwith postpartumdepressionwhoaretakingantidepressantshould notdiscontinuebreastfeeding.57Lactogenichormones,
oxy-tocinandprolactin,areassociatedwithanti-depressantand anxiolyticeffects.43 Somestudiessuggestthat
breastfeed-ingmayhaveaprotectiveeffectonmaternalpsychological healthbecauseitattenuatesstressresponses.15,58,59
Lacta-tionhasbeenassociatedwithattenuatedstressresponses, especially that of cortisol.8---12 Attenuated cortisol stress
responses,8---10 as well as attenuated total cortisol and
free cortisol stress responses,11 were observed in
lactat-ing motherscompared tothenon-lactating. These results suggestthatlactationattenuatesneuro-endocrineresponses tostress,8afactorthathasbeenrelatedwithfewer
post-partum depressive symptoms.60---62 In a recent study on
maternaladreno-corticotropichormone(ACTH)andcortisol releasepatternsduringabreastfeedingsession,researchers found thatbreastfeedingwasassociatedwithasignificant decreaseinACTHandcortisollevels.63Skin-to-skincontact
beforesuckingthebreastwasshown toplayan important roleinthe reductionof theselevels;the longerthe dura-tionofskin-to-skincontact,thelowerthematernalcortisol levels.63
Additionally,theusualdiurnalpatternofcortisol, consist-ingof highmorning levelsandgradualdeclinethroughout the day (also associated with fewer postpartum depres-sive symptoms),64 was found to be more common in
multiparousbreastfeedingwomencomparedwiththe non-breastfeeding.12 Despite the fact that some studies did
notreportdifferencesin dailycortisollevelsindepressed pregnantorpostpartumwomen,8,65---67cortisolhasalsobeen
foundtobelower,10aswellashigherindepressedmothers
whencomparedwiththeirnon-depressedcounterparts.60,68
A recentstudy suggested that depressedmothers present adownregulatedHPAaxis,showinglowersalivarycortisol levelscomparedwithnon-depressedmothers.62Conversely,
another recent study found significantly higher levels of serumcortisolinthegroupofdepressedmothers.69 A
dif-ferentdiurnalpatternofcortisol,withhighercortisollevels atwakingandnoincreasefromwakingto30minutes (com-paredtoasignificantincreaseincortisollevelsfromwaking to30minutesfoundinnon-depressedwomen),wasreported inpostpartumdepressedwomen.64
These data support the possibility that postpartum depressionmaybeassociatedwithaderegulatedHPAaxis. However,empiricalevidenceisequivocal, probablydueto thepresenceofavarietyofprocedures(forexample, diur-nalpatternordailycortisollevelsinsaliva,blood,orurine) tomeasuredifferentHPAaxisfunctions.
Results suggest that breastfeeding might promote a tighterregulationofdiurnalbasalcortisolsecretion,8---12and
thestabilityofdiurnalcortisolsecretionlowerstheriskof postpartumdepression.64 However,moststudies regarding
postpartum depression do not control for breastfeeding, and most studies about breastfeeding do not control for depression. In addition to the high correlation between breastfeeding and depression in studies, there is a possi-bleeffectofthesevariablesonthefunctioningoftheHPA axis.
Breastfeeding
and
psychological
protection
from
postpartum
depression
Anotherimportantassociatedchange duringbreastfeeding relatestotheregulationofsleepandwakepatternsforboth themotherandthe child,helpingthe mothertofeelless tired, which could also prevent symptoms of depression. Parentsofinfants whowereexclusivelybreastfedsleptan averageof40-45minutesmoreandself-reportedlesssleep disturbancethanparentsofinfantsgivenformula.14Women
withpostpartumdepressionexperiencedpoorersleepthan women without postpartum depression, andsleep quality worsened withincreasingpostpartum depressionsymptom severity.61,70,71 Maternal sleep patterns are enhanced by
breastfeeding,13whilethisderegulationmaycause
postpar-tumdepression.61,70,71
Research alsoshows that breastfeedingimproves some psychological conditions and processes that can protect mothers from emerging postpartum depression. Mater-nal self-efficacy, a condition inversely associated with postpartum depression,72 is improved in mothers who
breastfeed.45,73 Regardless of maternal depression,
moth-erswhobreastfedratherthanbottle-fedtheirinfants had higher confidence levels and rated their infants as less alertandlessirritableduringfeedings.45 However,
breast-feedingself-efficacyappears toplayan importantroleon postpartumdepression;motherswhoshowhigherlevelsof breastfeedingself-efficacypresentlowerlevelsof postpar-tumdepressionsymptoms.74
Maternal emotional involvement with the infant is also improved by breastfeeding75 and is negatively
cor-related with postpartum depression.65,76 In fact, feeding
patterns appear to influence mother-child bonding, with non-breastfeedingmothers presenting more difficulties to establish an emotional involvement with the infant than breastfeeding mothers.77 Regarding the relationship with
the partner, studies relate breastfeeding initiation with strongerparentalbonds.78
Temperamental difficulties and sleep problems are reducedwhenthechild isbreastfed,79 whilethepresence
of those problems has been associated with postpar-tum depression.72,80 Depressed breastfeeding mothers
were less likely to have infants with highly reactive temperaments.45,79 Infant competencies are enhanced by
breastfeeding,4,81 and are adversely affected in the
pres-enceofpostpartumdepression.80,82
Breastfeeding also facilitates mother-infant interaction,45,83 which is poorer when the mother is
depressed.78 Breastfeeding is associated with better
mother-infant interactions, with breastfed infants show-ing more physical contact, vocalizations, and positive play, and mothers exhibiting more proximity towards the infant.68,79,83,84Dataalsospecificallysuggeststhatdepressed
mothersandtheirinfants,notunlikenon-depressed moth-ers and their infants, may benefit from breastfeeding: depressed mothers and infants are more relaxed during breastfeeding versus bottle-feeding interactions.83
Fur-thermore, studies also showed that breastfeeding may act as a protector against maternal child maltreatment, especially child neglect.85 This association may depend
on the protective effect of breastfeeding on maternal depression, as depression is the best predictor of child maltreatmentandneglect.Theimpactofbreastfeedingon the maternal attention sensitivity towards infant distress wasalsorecentlyshown.86
Discussion
Literatureconsistentlyshowsthatbreastfeedingprovidesa wideamountofbenefitsforboththechildandthemother. Thepsychologicalbenefitsforthemotherarestillinneed offurtherresearch.
Despitethehighrateofbreastfeedinginitiation,alarge decreasein the number of mothers who breastfeed from thefirstfew weekspostpartum isobserved. Publichealth authorities’effortstopromotebreastfeedinginitiationhave beensuccessful;however,thesamehasnotbeenobserved regarding its maintenance for a recommended period of time,whichisfortwoyearsormore,andexclusivelyduring thefirstsixmonths.16---18Identifyingthepossibleunderlying
factorstothissituationis agoalforresearchinthisfield. Maternalmental healthmaybeoneofthereasonsbehind thisreality. A recent empiricalstudy conducted in Portu-galsuggeststhatscreeningfordepressionsymptomsduring pregnancycan help identifywomen at risk for early ces-sationofexclusivebreastfeeding.30Thereisnowempirical
evidencethat pregnancydepression is one of the factors thatmaycontributetobreastfeedingfailure.29,30,32,33,45,56
Studies suggest an association between breastfeeding and postpartum depression, and the direction of this
association is still unclear. While some suggest a negative association between breastfeeding and postpartum depression,40---43 others point to a
nega-tive association between postpartum depression and breastfeeding.27,46,49,52---54
Results from several studies provide empirical evi-dence that breastfeeding may act as a protective factor for depression during the postpartum, improving both maternalpsychologicalwell-being(namelythroughthe reg-ulation of sleep and awake patterns13,14 and increased
self-efficacy)45,73 and adequate parenting, through the
enhancement of the emotional involvement with the infant,75,77 mother-infant interaction,45,83 attention
sensi-tivitytowards infantstress,86 and protectionagainstchild
neglect.85 Breastfeeding can also protect women from
depressivesymptoms,byaiding the regulationof the HPA axis (throughout the regulation of diurnal basal cortisol secretion),8---12 which has been consistently shown to be
deregulatedinthepresenceofdepressivesymptoms.62,64,69
Other relevantvariables significantlyrelatedwithboth breastfeeding and postpartum depression that may play a part on this association are also highlighted in the literature:parity,relatedwithbreastfeeding12,43and
post-partum depression;35,70 quality of the relationship with
thepartner,relatedwithbreastfeeding75,87,88and
postpar-tumdepression;89,90 andanti-depressantuse, relatedwith
breastfeeding26,91 and postpartum depression.92 It is also
importantcontrolfor potentialconfoundingvariablessuch asparity,qualityoftherelationship withthepartner,and medicationuse,andthishasnotalwaysbeenaccomplished. Moreover,fewstudieshavedefinedbreastfeedingaccording to standardized categories, few studies included a clini-cal diagnosis of postpartum depression, and few studies wereprospectiveandcompletedadequatestatistical analy-sistocaptureasequentialrelationshipbetweendepressive symptomsandbreastfeedinginitiationandduration.These may be some of the reasons for equivocal results in the literature.
Data, in a general way, demonstrate that breastfeed-ingfailureisunequivocallyassociatedwiththepresenceof depressionduringpregnancyandpostpartum.Somerecent prospectivestudiesclarifythatdepressionduringpregnancy is a risk factor for unsuccessful breastfeeding, and that breastfeedingisaprotectivefactorforpostpartum depres-sion.Researchisalsostartingtoclarifywhichbiologicaland psychologicalprocessesmayexplainthisprotection. How-ever,therearestillequivocalresultsintheliteraturethat may be explained by the methodological limitations pre-sentedbysomestudies.
Funding
This work was supported by Portuguese fundings from theFCT/MCTES(PIDDAC)andbytheEuropeanCommunity (FEDER COMPETE): Breastfeeding and Postpartum Depres-sion(PTDC/SAU-SAP/116738/2010).
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.HortaB,BahlR,MartinesJ,VictoraC.Evidenceonthe long-termeffectsofbreastfeeding:systematic reviewsand meta-analyses.Geneva:WorldHealthOrganization;2007.
2.ShieldsL,O’CallaghanM,WilliamsG,NajmanJ,BorW. Breast-feedingandobesityat14years:acohortstudy.JPaediatrChild Health.2006;42:289---96.
3.KramerMS,AboudF,MironovaE,VanilovichI,PlattRW,Matush L,etal.Breastfeedingandchildcognitivedevelopment:new evidencefromalargerandomizedtrial.ArchGenPsychiatry. 2008;65:578---84.
4.SackerA,QuigleyM,KellyY.Breastfeedinganddevelopmental delay:findingsfrom theMillenniumCohortStudy. Pediatrics. 2006;118:682---9.
5.Jonas W, Nissen E, Ransjö-Arvidson AB, Wiklund I, Henriks-sonP,Uvnäs-MobergK.Shortandlong-termdecreaseofblood pressure in women during breastfeeding. Breastfeed Med. 2008;3:103---9.
6.InumaruLE,daSilveiraEA,NavesMM. Fatoresde riscoede protec¸ãoparacâncerdemama:umarevisãosistemática.Cad SaudePublica.2011;27:1259---70.
7.ReaMF.Osbenefíciosdaamamentac¸ãoparaasaúdedamulher. JPediatr(RioJ).2004;80:142---6.
8.AltemusM,DeusterP,GallivenE,CarterC,GoldP. Suppres-sionofhypothalmic-pituitary-adrenalaxisresponsestostress inlactatingwomen.JClinEndocrinolMetab.1995;80:2954---9.
9.AmicoJA,JohnstonJM,VagnucciAH.Suckling-induced attenu-ationofplasmacortisolconcentrationsinpostpartumlactating women.EndocrRes.1994;20:79---87.
10.Groer MW, Davis MW. Cytokines, infections, stress, and dysphoricmoodsinbreastfeedersandformulafeeders.JObstet GynecolNeonatalNurs.2006;35:599---607.
11.HeinrichsM,MeinlschmidtG,NeumannI,WagnerS,Kirschbaum C, Ehlert U, et al. Effects of suckling on hypothalamic-pituitary-adrenal axis responses to psychosocial stress in postpartumlactatingwomen.JClinEndocrinolMetab.2001;86: 4798---804.
12.Tu M,Lupien S, WalkerC. Diurnal salivarycortisol levels in postpartummothersasafunctionofinfantfeedingchoiceand parity.Psychoneuroendocrinology.2006;31:812---24.
13.DoanT,GardinerA,GayCL,LeeKA.Breast-feedingincreases sleep duration of new parents. J Perinat Neonatal Nur. 2007;21:200---6.
14.Gay CL,Lee KA, Lee SY. Sleep patterns and fatigue in new mothersandfathers.BiolResNurs.2004;5:311---8.
15.Heinrichs M, Neumann I, Ehlert U. Lactation and stress: protective effects of breast-feeding in humans. Stress. 2002;5:195---203.
16.WorldHealthOrganization.Globalstrategyforinfantandyoung childfeeding.Geneva:WHO;2003.
17.EUProjectonPromotionofBreastfeedinginEurope. Promot-ing,protectingandsupportingbreastfeeding:anactionplanfor Europe.Luxembourg:EuropeanCommissionDirectoratePublic Health;2002.
18.AmericanAcademyofPediatrics.Breastfeedingandtheuseof humanmilk.Pediatrics.2005;115:496---596.
19.SandesAR, Nascimento C,Figueira J,Gouveia R, Valente S, MartinsS,etal.Aleitamentomaterno:prevalênciaefactores condicionantes.ActaMedPort.2007;20:193---200.
20.SarafanaS,AbecassisF,TavaresA,SoaresI,GomesA. Aleita-mentomaterno:evoluc¸ãonaúltimadécada.ActaPediatrPort. 2006;37:9---14.
21.Branco MJ, Nunes B. Uma observac¸ão sobre aleitamento materno. Lisboa: ONSA and Instituto Nacional de Saúde Dr. RicardoJorge;2003.
22.Direc¸ão-Geral de Saúde. Registro do aleitamento materno: relatórioJulhode2010aJunhode2011.Lisboa:DGS;2012.
23.Cattaneo A, Yngve A, Koletzko B, Guzman LR. Protec-tion, promotion and support of breast-feeding in Europe: current situation. Public Health Nutr. 2005;8(1):39---46.
24.VenancioSI,EscuderMM,SaldivaSR,GiuglianiER. Breastfeed-ing practice in the Brazilian capital cities and the Federal District: current status and advances. J Pediatr. 2010;86: 317---24.
25.DennisC,McQueenK.Therelationshipbetweeninfant-feeding outcomesandpostpartumdepression:aqualitativesystematic review.Pediatrics.2009;123:736---51.
26.FieldT.Breastfeedingand antidepressants.InfantBehavDev. 2008;31:481---7.
27.Henderson J, Evans S, Straton J, Priest S, HaganR. Impact of postnatal depression on breastfeeding duration. Birth. 2003;30:175---80.
28.GreenJM,MurrayD.TheuseoftheEdinburghPostnatal Depres-sion Scale in research to explore the relationship between antenatalandpostnataldysphoria,inperinatalpsychiatry:use andmisuseoftheEdinburghPostnatalDepressionScale.Royal CollegeofPsychiatrists.1994:180---98.
29.SeimyrL,EdhborgM,LundhandW,SjögrenB.Intheshadowof maternaldepressedmood:experiencesofparenthood during thefirstyear afterchildbirth. JPsychosom ObstetGynaecol. 2004;25:23---34.
30.FigueiredoB, CanárioC,Field T. Breastfeeding isnegatively affectedbyprenataldepressionandreducespospartum depres-sion.PsycholMed.2013:43,inpress.
31.GallerJR,HarrisonRH,BiggsMA,RamseyF,FordeV.Maternal moodspredictbreastfeedinginBarbados.JDevBehavPediatr. 1999;20:80---7.
32.KehlerHL,ChaputKH,ToughSC.Riskfactorsforcessationof breastfeedingpriortosixmonthspostpartumamonga commu-nitysampleofwomeninCalgary.AlbertaCanJPublicHealth. 2009;100:376---80.
33.InsafT,FortnerRT,PekowP,DoleN,MarkensonG,Chasan-Taber L.Prenatalstress,anxiety, and depressivesymptoms as pre-dictorsofintentionto breastfeedamongHispanic women.J WomensHealth.2011;20:1183---92.
34.Figueiredo B, Pacheco A, Costa R. Depression during preg-nancy and the postpartum period in adolescent and adult Portuguese mothers. Arch Womens Ment Health. 2007;10: 103---9.
35.Figueiredo B,Conde A. Anxiety and depression symptoms in women and men from early pregnancy to 3-months post-partum: parity differences and effects. J Affect Disord. 2011;132:146---57.
36.AkmanI,KuscuMK,YurdakulZ,OzdemirN,Solako˘gluM,Orhon L, et al. Breastfeeding duration and postpartum psychologi-caladjustment:roleofmaternalattachmentstyles.JPaediatr ChildHealth.2008;44:369---73.
37.McCarter-Spaulding D, Horowitz JA. How does postpartum depressionaffectbreastfeeding?MCNAmJMaternChildNurs. 2007;32:10---7.
38.Gagliardi L, Petrozzi A, Rusconi F. Symptoms of maternal depression immediately after delivery predict unsuccessful breastfeeding.ArchDisChild.2012;97:355---7.
39.ThomeM,AlderEM,RamelA.Apopulation-basedstudyof exclu-sivebreastfeedinginIcelandicwomen:istherearelationship withdepressivesymptomsandparentingstress?IntJNursStud. 2006;43:11---20.
40.AstburyJ,BrownS,LumleyJ,SmallR.Birthevents,birth expe-riencesandsocialdifferencesinpostnataldepression.AustJ PublicHealth.1994;18:176---84.
41.HannahP,AdamsD,LeeA,GloverV,SandlerM.Linksbetween earlypost-partummoodandpost-nataldepression.BrJ Psychi-atry.1992;160:777---80.
42.Mezzacappa ES,Katkin ES.Breast-feeding is associated with reducedperceivedstressandnegativemoodinmothers.Health Psychol.2002;21:187---93.
43.Mezzacappa ES, Endicott J. Parity mediates the associa-tionbetweeninfantfeedingmethodand maternaldepressive symptoms in the postpartum. Arch Womens Ment Health. 2007;10:259---66.
44.Dunn S, Davies B, McCleary L, Edwards N, Gaboury I. The relationship between vulnerabilityfactors and breastfeeding outcomes.JObstetGynecolNeonatalNurs.2006;35:87---97.
45.FieldT,Hernandez-ReifM,FeijoM.Breastfeedingindepressed mother-infantdyads.EarlyChildDevCare.2002;172:539---45.
46.GallerJR,HarrisonRH,RamseyF,ChawlaS,TaylorJ. Postpar-tumfeedingattitudes,maternaldepression,andbreastfeeding inBarbados.InfantBehavDev.2006;29:189---203.
47.HasselmannM,WerneckG,SilvaC.Symptomsofpostpartum depressionandearlyinterruptionofexclusivebreastfeedingin thefirsttwomonthsoflife.CadSaudePublica.2008;24:341---52.
48.Hatton D, Harrison-Hohner J, Coste S, Dorato V, Curet LB, McCarronDA.Symptomsofpostpartumdepressionand breast-feeding.JHumLact.2005;21:444---9.
49.TaverasE,CapraA,BravemanP,JensvoldN,EscobarG,LieuT. Cliniciansupportandpsychosocialriskfactorsassociatedwith breastfeedingdiscontinuation.Pediatrics.2003;112:108---15.
50.YonkersK,RaminS,RushA,NavarreteCA,CarmodyT,March D,et al. Onsetand persistenceof postpartum depressionin aninner-citymaternalhealthclinicsystem.AmJPsychiatry. 2001;158:1856---63.
51.Watkins S, Meltzer-Brody S, Zolnoun D, Stuebe A. Early breastfeedingexperiencesandpostpartumdepression.Obstet Gynecol.2011;11:214---21.
52.CooperPJ,MurrayL,SteinA.Psychosocialfactorsassociated withtheearlyterminationofbreast-feeding.JPsychosomRes. 1993;37:171---6.
53.DennisCL,McQueenK.Doesmaternal postpartumdepressive symptomatologyinfluenceinfantfeedingoutcomes?Acta Pae-diatr.2007;96:590---4.
54.Misri S, Sinclair DA, Kuan AJ. Breast-feeding and postpar-tum depression: is there a relationship? Can J Psychiatry. 1997;42:1061---5.
55.YstromE.Breastfeedingcessationandsymptomsofanxietyand depression:alongitudinalcohortstudy.BMCPregnancy Child-birth.2012;12:12---36.
56.FalcetoOG,GiuglianiER,FernandesCL.Influenceofparental mentalhealthonearlyterminationofbreast-feeding:a case-controlstudy.JAmBoardFamPract.2004;17:173---83.
57.BerleJO,SpigsetO.Antidepressantuseduringbreastfeeding. CurrWomensHealthRev.2011;7:28---34.
58.Kendall-TackettK.Anewparadigmfordepressioninnew moth-ers:thecentralroleofinflammationandhowbreastfeedingand anti-inflammatorytreatmentsprotectmaternalmentalhealth. IntBreastfeedJ.2007;2:6.
59.MezzacappaES.Breastfeedingandmaternalstressresponseand health.NutrRev.2004;62:261---8.
60.Nierop A, Bratsikas A, Zimmermann R, Ehlert U. Are stress-inducedcortisolchangesduringpregnancyassociatedwith post-partumdepressivesymptoms?PsychosomMed.2006;68:931---7.
61.Goyal D,Gay C,Lee K. Fragmented maternal sleep is more stronglycorrelatedwithdepressivesymptomsthaninfant tem-perament at three months postpartum. Arch Womens Ment Health.2009;12:229---37.
62.Groer MW, Morgan K. Immune, health and endocrine char-acteristicsofdepressedpostpartummothers. Psychoneuroen-docrinology.2007;32:133---9.
63.HandlinL,JonasW,PeterssonM,EjdebäckM,Ransjö-Arvidson AB,NissenE,etal.Effectsofsuckingandskin-to-skincontact on maternalACTH and cortisollevelsduring thesecondday
postpartum-influenceofepiduralanalgesiaandoxytocininthe perinatalperiod.BreastfeedMed.2009;4:207---20.
64.TaylorA,GloverV,MarksM,KammererM.Diurnalpatternof cor-tisoloutputinpostnataldepression.Psychoneuroendocrinology. 2009;34:1184---8.
65.Figueiredo B, Costa R. Mother’s stress,mood and emotional involvementwiththeinfant: 3 monthsbefore and 3months afterchildbirth.ArchWomensMentHealth.2009;12:143---53.
66.O’Hara MW,Schlechte JA, Lewis DA,Wright EJ. Prospective studyofpostpartum blues:biologicandpsychosocialfactors. ArchGenPsychiatry.1991;48:801---6.
67.Hendrick V, Altshuler LL, Suri R. Hormonal changes in the postpartum andimplications forpostpartum depression. Psy-chosomatics.1998;39:93---101.
68.Field T, Diego M, Hernandez-Reif M, Figueiredo B, Ezell S, Siblalingappa V. Depressed mothers and infants are more relaxedduringbreastfeedingversusbottlefeedinginteractions: briefreport.InfantBehavDev.2010;33:241---4.
69.Lommatzch M,HornychK,Zingler C,Schuff-WernerP, Höpp-nerJ,VirchowJC.MaternalserumconcentrationsofBDNFand depressionintheperinatalperiod.Psychoneuroendocrinology. 2006;31:388---94.
70.Dørheim SK, Bondevik GT, Eberhard-Gran M, Dorheimer BB. Sleepanddepressioninpostpartumwomen:apopulation-based study.Sleep.2009;32:847---55.
71.Posmontier B. Sleep quality in women with and without postpartum depression. J Obstet Gynecol Neonatal Nurs. 2008;37:722---37.
72.CutronaCE,TroutmanBR.Socialsupport,infanttemperament andparentingself-efficacy:amediationalmodelofpostpartum depression.ChildDev.1986;57:1507---15.
73.DennisC.Identifyingpredictors ofbreastfeedingself-efficacy in the immediate postpartum period. Res Nurs Health. 2006;29:256---68.
74.HagaSM,UllerberP,SlinningK,KraftP,SteenTB,StaffA.A longitudinalstudyofpostpartumdepressivesymptoms: multi-levelgrowthcurveanalysesofemotionregulationstrategies, breastfeedingself-efficacy,and social support.ArchWomens MentHealth.2012;15:175---84.
75.Ekström A, NissenE. A mother’s feelings for her infant are strengthenedbyexcellentbreastfeedingcounselingand con-tinuityofcare.Pediatrics.2006;118:309---14.
76.TaylorA,AtkinsR,KumarR,AdamsD,GloverV.Anew mother-to-infantbondingscale:linkswithearlymaternalmood.Arch WomensMentHealth.2005;8:45---51.
77.Nishioka E, Haruna M, Ota E, Matsuzaki M, Murayama R, Yoshimura K, et al. A prospective study of the relationship between breastfeedingand postpartumdepressive symptoms appearing at 1-5 months after delivery. J Affect Disord. 2011;133:553---9.
78.Kiernan K, Pickett KE.Marital status disparities inmaternal smokingduringpregnancy,breastfeedingandmaternal depres-sion.SocSciMed.2006;63:335---46.
79.JonesN,McFallB,DiegoM.Patternsofbrainelectrical activ-ityininfantsofdepressedmotherswhobreastfeedandbottle feed:themediatingroleofinfanttemperament.BiolPsychol. 2004;67:103---24.
80.MurrayL,CooperP,editors.Postpartumdepressionand child development.NewYork:TheGuilfordPress;1997.
81.HartS,BoylanML,CarrollS,MusickYA,LampeRM.Briefreport: breast-fed one-week-olds demonstrate superior neurobehav-ioralorganization.JPediatrPsychol.2003;28:529---34.
82.FigueiredoB,PachecoA,CostaR,CondeA,TeixeiraC.Mother’s anxiety and depressionduringthe thirdpregnancy trimester andneonate’smotherversusstranger’sface/voicevisual pref-erence.EarlyHumDev.2010;86:479---85.
83.FieldT,DiegoM,Hernandez-ReifM,FigueiredoB,AscencioA, SchanbergS,etal.Prenataldysthymiaversusmajordepression effectsonmaternalcortisolandfetalgrowth.DepressAnxiety. 2008;25:E11---6.
84.WidströmA,WahlbergV,MatthiesenA,EnerothP,Uvnäs-Moberg K, Werner S,et al. Short-term effects ofearly sucklingand touch of the nipple on maternal behavior. Early Hum Dev. 1990;21:153---63.
85.Strathearn L, Mamum AA, Najman JM, O’Callaghan MJ. Doesbreastfeedingprotectagainstsubstantiatedchildabuse and neglect? A 15-year cohort study. Pediatrics. 2009;123: 483---93.
86.PearsonR,LightmanS,EvansJ.Theimpactofbreastfeedingon mothers’attentionalsensitivitytowardsinfantdistress.Infant BehavDevel.2011;34:200---5.
87.ScottJA,LandersMC,HughesRM,BinnsCW.Psychosocial fac-torsassociatedwiththeabandonmentofbreastfeedingpriorto hospitaldischarge.JHumLact.2001;17:24---30.
88.MeedyaS, FahyK,Kable A.Factors thatpositively influence breastfeedingdurationto6months:aliteraturereview.Women Birth.2010;23:135---45.
89.Figueiredo B, Field T, DiegoM, Hernandez-Reif M, DeedsO, AscencioA.Partnerrelationshipsduringthetransitionto par-enthood.JReprodInfantPsych.2008;26:99---107.
90.O’HaraM,SwainA.Ratesandriskofpostpartumdepression:a meta-analysis.IntRevPsychiatry.1996;8:37---54.
91.BattleCL,ZlotnickC,PearlsteinT,MillerIW,HowardM, Salis-buryA,etal.Briefreport:depressionandbreastfeeding:which postpartumpatientstakeantidepressantmedications?Depress Anxiety.2008;25:888---91.
92.Cohen LS, Altshuler LL, Harlow BL, Nonacs R, NewportDJ, Viguera AC,et al.Relapse ofmajor depressionduring preg-nancyinwomen whomaintainor discontinue antidepressant treatment.JAMA.2006;295:499---507.
