At #ILCA17, the Journal of Human Lactation awarded the JHL Best Research Article with a Practice Focus Award to Vicky Fallon and her colleagues, Rachael Groves, Jason Christian Grovenor Halford, Kate Mary Bennett, and Joanne Allison Harrold,  for their paper “Postpartum anxiety and infant-feeding outcomes: A systematic review.” This award, given for the first time at this year’s conference, honors a paper which facilitates the development of the evidence-base in lactation practice. The winner is chosen by the JHL Editorial Review Board from all articles published in the JHL having a practice focus, based on the quality of the science and the contribution to the field of lactation. We recently caught up with Dr. Fallon to find out more about her paper and how she came to be interested in lactation research.

Share with us your research interests and what led you to focus your efforts in this area.

My research interests concern maternal mental health (prenatal and postpartum) and its impact on infant health and behaviour, in particular infant nutrition. My interests in this area were initially sparked by my experiences with my own children, who I have raised alongside my psychology studies. My interests have been further refined through my PhD studies which examined maternal anxiety and infant feeding from pregnancy to parenthood. In the US, over 25% of new mothers – over 1 million women a year – suffer from depression, anxiety, obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder following the birth of an infant. The consequences of these disorders are far reaching for the mother, her infant, and the wider society. Yet research examining many of these mental health problems is insufficient. I try to bridge the gap between research and practice and increase awareness of the impact of poor maternal mental health to influence policy and practice.

Your award-winning paper addresses postpartum anxiety and how it impacts infant feeding. What do you think the key takeaways are for individual IBCLCs® working directly with families?

The paper reports a systematic review synthesising all of the available evidence regarding postpartum anxiety and infant feeding. It includes data from 33 studies across 11 different countries. Firstly, IBCLCs should be aware of the specific manners in which anxiety can impact upon infant feeding outcomes in order to provide appropriate support. The findings demonstrate that women with symptoms of postpartum anxiety are less likely to breastfeed exclusively and more likely to terminate breastfeeding earlier. In those who do breastfeed, symptoms of anxiety reduce breastfeeding self-efficacy, and increase breastfeeding difficulties. Given that anxious women may also have a stronger negative emotional response to breastfeeding cessation, providing sensitive, non-judgmental support for those who supplement with formula is also advised to minimize further maternal distress. IBCLCs should also be mindful that postpartum anxiety remains among the most underdiagnosed and undertreated complications of childbirth and that this is largely due to the “shadowing effect” of postpartum depression. IBCLCs should be encouraged to be vigilant for symptoms of anxiety occurring in mothers. This is particularly necessary when symptoms present independently of depression; to minimise the risk of symptoms being undetected, and to ensure timely treatment. Finally, the review highlights that women with postpartum anxiety may negatively perceive infant feeding behaviours. Educating women about responsive feeding practices such as timely recognition of infant cues of hunger, and feeding on-demand is advised. Normalising other typical infant feeding behaviours, including cluster feeding, frequent night feeding, and day-to-day variability in infant hunger and/or satiety is also recommended.

And what do you think the policy implications are for this research?

The findings have important applications for those involved in the design and implementation of maternal and infant health policies. First, policy makers are urged to raise awareness of postpartum anxiety as a disorder that can occur independently of postpartum depression. The review highlights literature which finds that despite high comorbidity, postpartum anxiety occurs independently, and at a higher rate than postpartum depression. Currently, postpartum anxiety is not recognised as a distinct disorder, and symptoms of anxiety are subsumed within guidelines on postpartum depression. Consequently, there is no current guidance which exclusively addresses postpartum anxiety and its impact upon infant health outcomes such as infant feeding for either health professionals or mothers. This under-recognition leaves mothers who are anxious and depressed, diagnosed with depression. It also leaves mothers with pure anxiety misdiagnosed with depression. Worse, it raises the potential for both mother and health professional to assume that they are functioning normally as they are not depressed. All of these scenarios delay or prevent the appropriate management and treatment of symptoms of anxiety which may have serious consequences for both mother and child and contribute to suboptimal feeding outcomes. Mandatory screening for symptoms of anxiety in the perinatal period may negate the potential for these outcomes.

Our congratulations on the award! What research should we watch for coming up from you?

Thank you. It is a real privilege to receive such a prestigious award at this stage in my career. In terms of future work, there are a number of avenues we are currently exploring based on some of the review findings. For instance, the paper highlighted wide variability in anxiety measurement. I have been recently working on developing and validating a measure of postpartum specific anxiety (Fallon et al. 2016). Regular use of similar measures of anxiety would allow future replication of the review with the addition of a meta-analysis allowing a more precise estimate of the effect of anxiety upon infant feeding outcomes. The bidirectional nature of the relationship between maternal anxiety and infant feeding is also yet to be explored. Dennis and McQueen (2007) used a time-sequenced analysis to examine the bidirectional nature of the relationship between postpartum depression and diverse infant feeding outcomes. Although their findings indicated that infant feeding method did not predict the development of depressive symptoms, a similar study is necessary to examine this hypothesis in relation to postpartum anxiety. Finally, the paper recommends a funding proposal for a non-pharmacological intervention designed to simultaneously reduce postpartum anxiety and increase breastfeeding rates. We are currently looking into funding opportunities to take this recommendation forward.

 Congratulations Dr. Fallon!

Vicky Fallon is a Lecturer in the School of Psychology at the University of Liverpool. She is affiliated with the Appetite and Obesity research group in the Department of Psychological Sciences and holds a doctorate in Psychology. Her research interests concern perinatal mental health and early infant development, in particular infant nutrition. Her PhD examined maternal anxiety and infant feeding from pregnancy to parenthood.

The University of Liverpool has a long history of psychological research and was one the first Universities in the UK to establish a Department on the subject. The Department of Psychological Sciences has over 100 staff, including Chairs, Lecturers and Researchers, with expertise in experimental, applied and clinical domains.  These experts are brought together across several research groups that drive research of value to developments in psychology, psychiatry and behavioural medicine. The work of the Appetite and Obesity research group encompasses a broad spectrum of basic and applied research, addressing behavioural and psychological processes that govern appetite expression at a variety of levels from the molecular to the whole person.  Key research themes in this area include examining the influence of food advertising on food choice, consumption and bodyweight in children and the development of food preference and weight gain in infants.