This information is also available as a PDF by clicking here.
The information provided is taken from various reference sources. It is provided as a guideline. No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used. Clinical decisions remain the responsibility of medical and breastfeeding practitioners. The data presented here is intended to provide some immediate information but cannot replace input from professionals.
There are many reasons that we become anxious at one point or another in our lives. Anxiety is a normal and healthy emotion which helps to tell us that something in our environment may be threatening, either physically or emotionally to either ourselves or the people we care about. Feeling anxious about these situations encourages us to act to make ourselves safe. Without it we would not be able to recognise danger or keep ourselves safe. It is only necessary to seek help if you find your feelings spiralling out of control. Tell your loved ones how you feel, a hug and an opportunity to express your frustration and worries may be all that you need.
Sometimes though we misinterpret situations and start to believe that they are threatening when they are not. This can be affected by;
- the information we are given by others,
- how confident we feel about coping with a situation,
- our experiences from the past.
If we have been told that something will be difficult or upsetting, or have experienced struggling in a situation in the past we are more likely to be anxious about that situation again now.
It is important to know that 1 in 10 of us will experience a significant anxiety disorder at some point in our lives although this increases during pregnancy and the year after giving birth. It doesn’t mean that you need medication, nor that you are a bad mother or a failure. You may benefit from access to Improved Access to Psychological Therapies (IAPT) services. You may feel better knowing that what you are feeling is perfectly normal and common in many mothers. We hope that this information gives you options to decide what is right for you.
Parenthood is a time when all experiences are new. We are given a lot of information (much of it conflicting) and advice. It feels like there is pressure to get everything ‘right’ every time – to keep our child healthy and to be seen as a ‘good’ mother. Add into the mix the fact that we are usually sleep deprived, exhausted and having difficulty concentrating, and it is very understandable that anxiety is common in mothers, especially those with young babies.
This information sheet is not designed to give a definitive answer that will immediately make the anxiety disappear – we wish it could. Anxiety is very much more complicated and the solutions will be individual to each one of us. Hopefully it will be able to provide some information on what anxiety is and how we may be able deal with this. It will also try to normalise anxiety and consider what a normal reaction to a situation is and when we may want to seek more help. It is important to recognize that anxiety may begin in pregnancy and that it can occur alongside other conditions such as depression and obsessive compulsive disorder (OCD) which can make it less readily recognized by you and your healthcare professionals.
What is anxiety?
Anxiety is a feeling of dread or fear about a real or imagined situation. It is often characterised by excessively worrying and focusing on thoughts and situations that scare or upset you and is accompanied by a range of physical sensations. We will often notice changes in three areas, our thoughts, our physical feelings and our behaviours. Below are listed some of the symptoms in these areas you may experience.
- Racing heart beat
- Changes in breathing (feeling breathless, holding your breath or rapid breathing)
- Tightness or pain in your chest
- Pins and needles or tingling in the arms and legs
- Feeling sick (sometimes, although rarely, also being sick)
- Stomach upsets and needing to go to the toilet frequently or urgently.
- Wobbly legs
- Feeling dizzy and light headed
- Feeling as if things don’t feel real/dream like (depersonalisation)
- Difficulty concentrating
- Head aches
- Muscles tension, especially in the neck, shoulders and jaw
- Disturbed sleep, difficulty getting to sleep or waking frequently
- Feeling exhausted
- Worrying excessively, either about one thing or many things
- Feeling that others are looking at you or judging you
- Thinking that you will be unable to cope with a situation
- Thinking you are not good enough in some way
- Focusing on bad or upsetting experiences from your past Feeling unable to let go or stop thinking about something
- Worrying that something is wrong or will go wrong in the future
- Unpleasant thoughts about bad things happening that pop into our head.
Often these thoughts feel very out of control and we may find it difficult to concentrate on normal daily life because our head is so full of these thoughts. We may also find that no matter how much we think about the problems they don’t get better, and often get worse. When someone asks what you are worrying about you may respond “everything and nothing”. That’s okay, it’s how you feel that you are dealing with your thoughts that is important.
- Reducing normal activities
- Feeling unable to face talking to people
- Avoiding crowded places
- Repeatedly checking things, our children, information, locks, switches etc.
- Avoiding thinking or doing things that make us anxious
- Becoming withdrawn
Initially taking some time out may be helpful to give us time to rest and spend time with our baby. However in the long run by reducing enjoyable activities we have little else to distract us or balance the negative thoughts.
What causes anxiety?
Anxiety is normal and a natural part of our biology which we share with all animals. It comes from our fight or flight response that is designed to keep us safe. When we were cavewomen, if we came across a sabre toothed tiger, to keep ourselves safe we would either need to fight it, or run away. In order to do this our brain reacts very quickly to give us the best chance of escaping or winning by making our bodies ready for action by releasing adrenaline. This causes several immediate changes:
- Our hearts beat faster to help pump blood around the body
- Our breathing rate increases to give our muscles oxygen
- We get tingling in our arms, legs and stomach (butterflies) as our blood diverts away from our stomach where it’s not needed and into our arms and legs instead
- Our stomachs are not essential for fighting so we may feel sick or need to go to the toilet
- Our muscles tense ready for actions
- We feel on edge as our senses are on high alert for danger
- We feel the urge to escape or leave a situation
In our modern life we rarely encounter sabre toothed tigers, but the same reaction can still be triggered if a situation or thought feels threatening to us. Our bodies are unable to differentiate whether something we just think is real or not. Even if you are just thinking about an anxiety provoking situation, what may or may not happen, or worrying that something might be wrong, this will still cause all the same physical reactions that a physical threat would.
Anxiety and parenthood
Parents are anxious about doing their best for their child and as a result some level of anxiety is to be expected. Not only do we worry about our children, but we may also be facing massive changes to our lives; changes in our role within a family, greater responsibility, less time to ourselves, less money, less time with our partners and friends. The list is endless but below are some common worries you may experience:
- Is my child eating enough?
- Is my child gaining weight?
- Am I feeding too frequently/frequently enough?
- Is the baby’s poo the right colour?
- Are they safe where they are sleeping?
- Will my baby nap today?
Breastfeeding and anxiety
Everyone loves to give advice about how best we should care for our children, this is especially true when it comes to feeding. Over the past 100 years breastfeeding has become less common than it was and information about what is normal has been lost over time. Instead we are inundated with advice which is often unrealistic and related to old childrearing practices that we no longer regard as helpful or evidence based.
Advice may include ideas that every baby should sleep through the night from x weeks, that they should only be fed every y hours, if they cry or are fussy they are hungry, mums can’t produce enough milk to feed a large baby and a million more opinions that you will be exposed to every day.
With breastfeeding it isn’t as easy to see exactly how much milk a baby has consumed. We may question our ability to sufficiently feed the baby – especially if a healthcare professional questions baby’s weight gain or feeding schedule. Concerns about breastfeeding or perceived lack of support may add to anxiety.
Breastmilk is completely absorbed so breastfed babies will be more likely to wake frequently throughout the night and for longer. This is not a bad thing for the babies, who are feeding effectively and naturally, however this may lead to more disrupted sleep for the parents. Feeling more tired may result in higher levels of anxiety as we struggle to think clearly when tired. Few babies sleep through the night for the first year, but the pressure that is given by society for them to do this may again lead to anxiety and self-doubt.
We may get very conflicting or incorrect advice about what is normal from a variety of sources. Our society also has limited knowledge about healthy breastfeeding practices so we may be more likely to encounter misinformed opinions from others which may make us feel uncertain about what we are doing. You may feel your wishes to breastfeed or indeed to give up, may not be listened to or respected. This may add to your feelings of loss of control.
What can I do to manage my anxiety?
There are several simple things we can do to balance our life and manage anxiety. The focus should be on reducing focus on the worrying thoughts and trying to refocus attention on life activities which are happening at the moment, rather than what may happen in the future.
- Deal with or approach a problem if you can – if you can’t do anything or it hasn’t happened yet – let it go. The Exeter Worry Guide in the link below may give you some ways in which to do this. Mindfulness techniques may also be helpful with this and there are links to some helpful websites in the next section.
- Talk to people – other mums in similar situations to get an idea of what is normal. This may be via baby groups, helplines, Facebook groups or online forums. However, you may find that the mood of a forum may be negative and make you feel worse. If that happens find somewhere that helps you feel positive. Keep talking to those who love you and let them know how you are feeling.
- Keep doing enjoyable activities. These may need to be adapted to life with a baby but try to do something enjoyable every day e.g. baby groups, walks, playing with your baby or swimming. If you can get someone to babysit you may enjoy getting time out for half an hour to go for a run, have a bath, painting your nails, reading a book or even going to the toilet by yourself.
- Get out of the house – get to the shops for some milk, walk around the block, go for a drive.
- Staring at the same four walls will not help to distract you and your thoughts will go round in circles. Getting out even just for 15 minutes a day can be helpful to clear your head and may help your baby sleep too.
- Focus on positives each day – try and write one positive thing in a daily diary or try 100 days of happiness on Facebook. Maybe if someone asks how things are going, try to think of the positives first before the problems. Also make a list of all the things you are doing well rather than where you might be struggling.
- Take a breath and ignore those giving advice which doesn’t feel comfortable – they are giving their opinion not facts. Their baby might be very different from yours, whatever they did was their choice but you do not have to conform to everyone else’s ideas.
- Stop googling! There is a place for internet searches, but you can also drive yourself mad looking at conflicting, inaccurate and catastrophic advice. Go to reliable sources and once you have found an answer, stop checking further – you will just start to doubt yourself and you keep yourself focused on the worrying thoughts rather than the solutions.
When might you want to seek help?
As we have said, some level of anxiety is normal in parenthood, however if you find that you are anxious most of the day, several days a week for more than 2-3 weeks then this can be signs that anxiety is becoming more of a problem for you. If it is impacting on your ability to continue your normal life then you may wish to seek further help from your GP or other voluntary services. Your health visitor and GP should both be checking on your mental health at each appointment and even if you do not feel you need help yet, if you are starting to feel anxious or low you can still discuss it with them so that they know to check up on you in the future.
What help is available?
Your GP may suggest a period of two weeks of watchful waiting to see whether your mood improves by itself. This is normally the first plan of action if anxiety or low mood is mild. They will normally suggest some self-help guides similar to the ones at the bottom of this page and then book a review appointment in two weeks.
If you and your GP decide you need some support, they may offer you a referral to a talking therapy service or discuss whether medication would be helpful.
Talking therapy services based within mental health teams are very different to how they were 20 years ago. They are designed to support people within the community with common mental health issues such as anxiety, depression and panic attacks. You will be offered an assessment during which you can discuss what difficulties you have been facing and what your goals are. After this you may be offered some treatment, the most common of which is counselling or Cognitive Behavioural Therapy (CBT). Counselling allows you to look at issues more commonly from your past which may be affecting you now, or issues around relationships with other people. Cognitive Behavioural Therapy comes in many forms, most of which is face to face, but it can be offered over the telephone or in group settings. CBT looks at cycles of thoughts, feelings and behaviours which may be keeping you stuck. It aims to help you understand what is happening and may offer practical steps to reassessing whether these thoughts are realistic and changing unhelpful behaviours.
CBT currently has the greatest evidence base for treating anxiety and is widely available within the NHS however there are other therapy options available in some teams such as Cognitive Analytical Therapy (CAT), Interpersonal Therapy and Mindfulness.
Safe medication in breastfeeding
If you and your doctor decide that prescribed medication is the best route for you, there are several options which you can take and continue breastfeeding. They include, in no particular order:
- SSRI antidepressants e.g. sertraline, citalopram, fluoxetine, paroxetine all have anti- anxiety activity. They take 4 to 6 weeks to exert full benefit.
- Tri-cyclic antidepressants e.g. amitriptyline, imipramine.
- Beta blockers e.g. propranolol act to reduce heart rate and slow the body and act very quickly. They can be taken regularly or when required. They cannot be taken if you have asthma.
- Benzodiazepines e.g. diazepam, lorazepam, alprazolam act very quickly to reduce anxiety but cannot be taken long-term because they are addictive and can also accumulate in the breastfed baby leading to drowsiness and poor feeding.
The first thing most mothers prescribed with anti-anxiety medications worry about is whether the drugs will harm the baby in the short or long term. They are also concerned that they are ‘bad’ mothers for needing to take medication but they don’t know how to cope without. They worry about long term use, addiction, withdrawal, development of the baby, whether formula milk may be a better option than breastmilk containing even a small amount of the drug. They ‘google’ madly trying to find the information which supports their concerns, but often don’t trust those sites which support the safety. They may ask lots of people’s opinions which can be even more anxiety provoking according to that person’s experience of breastfeeding and medication. Often they fear that even admitting that they are anxious may lead to their baby being taken into care and them being labelled as an unfit mother. This is not going to happen but can sadly lead to delays in seeking treatment.
Where can I get further support and information?
- Anxiety UK www.anxietyuk.org.uk
- Panda www.pandasfoundation.org.uk
- IND www.mind.org.uk
- Birth Trauma www.birthtraumaassociation.org.uk/
- Self-help guides Centre for Clinical Interventions www.cci.health.wa.gov.au/resources/consumers.cfm
- Mindfulness and other self-help material www.getselfhelp.co.uk
- Exeter Worry Management Guide https://cedar.exeter.ac.uk/media/universityofexeter/schoolofpsychology/cedar/documents/Worry _website_version_colour.pdf
- Northumbria Mental Health Guides www.ntw.nhs.uk/pic/selfhelp/
What if I need emergency help?
Although rarely talked about, when people have been feeling very anxious or depressed for long periods of time, they can feel that they are unable to cope and they can experience thoughts of suicide or self- harm. The intensity of these can vary significantly, some people experience fleeting thoughts of ‘I just don’t want to be here’, for others they can start to imagine more in depth thoughts and plans about what they could do. Most of the time having these thoughts does not mean that you intend to act on them. It can be part of our brain’s way of imagining one possible escape, and often we have many protective factors that would stop us ever acting on them, such as our children, partners, family, friends, faith or hope for the future. Normally once our mood improves, thoughts of harming ourselves reduce and disappear. However they can still be very distressing to experience so it can be helpful to talk to others if you feel able to. Although they may find it upsetting to hear that you feel this low, friends and family can often support you to manage these feelings when they occur and help you not to feel so alone. You can also talk to your GP or health visitor about them and they can decide with you what support would be helpful.
If you ever feel that you may be more seriously thinking about harming yourself or unable to keep yourself safe it is important that you speak to your GP or another health professional as soon as possible. Doctors, midwives and health visitors are aware that these are symptoms of depression and anxiety. They should support you to access help and appropriate treatment.
If you need immediate help you can go to any accident and emergency department or drop in clinics to help. Suicidal or self-harm thoughts are also seen as a priority and would be counted as a reason for an emergency appointment with a GP. You can also call NHS direct on 111 or in an emergency 999.
- Antenatal and postnatal mental health: clinical management and service guidance. NICE guidelines [CG192] December 2014
- Bauer A, Parsonage M, Knapp M, Lemmi V,Adelaja B Costs of perinatal mental health problems. October 2014 www.centreformentalhealth.org.uk/costs-of-perinatal-mhproblems
- British National Formulary
- CG192 Antenatal and Postnatal mental healthcare
- Hale T. W Medications in Mothers Milk
- Health Outcomes Paediatrics; 131(4):2013 http://pediatrics.aappublications.org/content/early/2013/02/26/peds.20122147.full.pdf+html
- Jones W Breastfeeding and Medication 2018 Routledge
- Khan L Falling through the gaps. Perinatal mental health and general practice. March 2015
- Lactmed website http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
- Martindale, the Extra Pharmacopia 2007
- Paul IM, Downs DS, Schaefer EW, Beiler JS, Weisman CS, Postpartum Anxiety and Maternal-Infant
- Royal College of General Practitioners Practical Implications for Primary Care of the NICE guidelines
This information was compiled by Beth Chapman Cognitive Behavioural Psychotherapist and Wendy Jones Pharmacist.
©Dr Wendy Jones MBE, MRPharmS and the Breastfeeding Network Sept 2019