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“Research finds that many women experience increased levels of body dissatisfaction during the postpartum period,” says Dr. Bailey-Straebler, a psychiatric nurse practitioner who is the Clinical Director of the Outpatient Eating Disorders Clinic at NewYork-Presbyterian Westchester Behavioral Health. “Since eating disorders are maintained through feelings of intense dissatisfaction of shape and weight, women who currently have an eating disorder or had an eating disorder in the past are far more vulnerable to feel the impact of further intensification of these feelings postpartum.”
Drs. Susser and Bailey-Straebler began to investigate this possible ED manifestation after observing instances in their clinics. “A patient in our clinic reported ongoing very poor sleep with no identifiable cause,” says Dr. Bailey-Straebler. “After continued exploration with the patient we discovered that that cause of her disturbed sleep was that she was waking frequently throughout the night to pump. She had read online the number of calories burned per ounce of pumped breast milk and was using this behavior more and more [to control her weight].”
“Since eating disorders are maintained through feelings of intense dissatisfaction of shape and weight, women who currently have an eating disorder or had an eating disorder in the past are far more vulnerable to feel the impact of further intensification of these feelings postpartum.” — Dr. Suzanne Bailey-Straebler
Dr. Susser, a reproductive psychiatrist who oversees a perinatal psychiatry clinic, observed similar experiences amongst her patients. “I was seeing women who weren’t enjoying breastfeeding and didn’t want to continue it beyond a year, but they were terrified that they would gain weight if they stopped after one year. They continued waking up multiple times overnight to either pump or feed their child to sustain their milk supply to control their weight,” she says. “We realized discussion of this in the literature was sparse even though women in our practice seemed to use it to control weight in an eating disordered way.”
When Healthy Becomes Unhealthy
Breastfeeding and pumping provide many health benefits both to mother and baby, including protecting babies against some illnesses, reducing the mother’s risk of certain cancers, type 2 diabetes, and high blood pressure, and more. Breastfeeding and pumping can also help some mothers lose the weight they gained during pregnancy. It can be hard to identify whether a mother’s decision to continue breastfeeding or pumping is healthy or unhealthy – the key is the understanding their underlying motivation.
In a recent article published in the International Journal of Eating Disorders, Dr. Susser, Dr. Bailey-Straebler, along with Zafra Cooper, DPhil, BA, DClinPsych, from the Yale School of Medicine, outline a research agenda and screening approach to identify women with a history of or current eating disorder (ED) using breastfeeding and pumping as unhealthy ways to control their weight is needed.
This is the first paper to focus solely on breastfeeding and pumping as a maladaptive weight control method. In it, the authors identify both compensatory and non-compensatory eating disorder behaviors associated with breastfeeding and pumping, such as breastfeeding or pumping after binge eating or to allow for eating avoided foods (compensatory), or “pumping and dumping” and following a rigid schedule with the goal to burn calories rather than meet the infant’s nutritional needs (non-compensatory).
“We want to be cautious in determining when breastfeeding and/or pumping becomes an unhealthy behavior,” says Dr. Bailey-Straebler. “Many mothers are motivated to exclusively breastfeed or extend breastfeeding. When this decision is primarily motivated by reasons unrelated to burning calories that indicates it is a healthy decision for the mother. But if the mother says, ‘I really want to stop breastfeeding, but I know that if I continue to breastfeed or pump, I will continue to burn X number of calories, so I’m going to keep breastfeeding for that reason,’ [that’s when the behavior becomes maladaptive].”
The authors report that breastfeeding and pumping as maladaptive eating disorder behaviors are under-recognized. “…maladaptive breastfeeding and pumping warrant further investigation, as the behaviors may play an important role in maintaining an ED or in contributing to relapse during the postpartum period and may also indirectly harm the infant/child,” they write.
A Call-to-Action for Future Research
In the paper, the authors outline a comprehensive, multi-pronged research agenda to help providers gain a deeper understanding of these behaviors. “We need to get a sense of how common it is occurring, what specifically is happening, and what the impact is on the woman and the child,” says Dr. Susser.
“We need to get a sense of how common [breastfeeding and/or pumping as a maladaptive weight control behavior] is occurring, what specifically is happening, and what the impact is on the woman and the child.” — Dr. Leah Susser
The proposed research agenda includes:
- Conducting case studies of postpartum women with eating disorders who confirm engaging in maladaptive breastfeeding and pumping behaviors
- Developing screening and assessment tools that explicitly ask about excessive or maladaptive breastfeeding and pumping
- Conducting surveys among postpartum women with an active or past eating disorder to obtain prevalence estimates
- Obtaining longitudinal data on women with active or past eating disorders throughout the entire perinatal period to provide a full idea of the impact of these behaviors
“Eating disorder screening tools for use throughout the perinatal period and postpartum are desperately needed – none exist for the postpartum period at all,” says Dr. Bailey-Straebler. “We do not have a standardized way of asking women these questions, which limits the ability to assess for these behaviors.”
She adds that research is greatly needed among perinatal and postpartum women. “Pregnant women are an under-researched group in general because of the impact research interventions may have on the mother, fetus and/or infant. It’s such a vulnerable time,” says Dr. Bailey-Straebler. “Very few longitudinal studies in postpartum women with eating disorders exist, let alone longitudinal studies specifically with breastfeeding women who have eating disorders. There is a lot that we do not yet know, and research is required to fully [understand these issues].”
