Pediatricians: They’re Not Just For Kids Anymore

Last week I explored the potentiality of perinatal mood disorder interventions occurring within the context of the expectant mother-obstetrician/midwife relationship.  Given the inherent intimacy in this ongoing relationship through pregnancy and beyond, there are myriad opportunities for informative bidirectional conversations about mental health issues related to pregnancy, postpartum mood disorder risk factors, research, and resources.  However, if new mothers and their families do not receive this kind of care from their obstetrician/midwife, there are additional medical professionals who come into contact with infants from the moment they are born and have the opportunity to screen for postpartum mood disorders—namely the pediatrician.

Burgeoning families arm themselves with a community of healthcare practitioners with whom they feel aligned.  Some women opt to surround themselves with a throng of prenatal wellness providers in an effort to bolster inner calm, connectivity, and support whereas others may desire a more private experience throughout pregnancy.  These wellness practitioners may include: acupuncturists, doulas, massage therapists, chiropractors, prenatal yoga instructors, nurse practitioners, midwives, obstetricians, and pediatricians.  All of these practitioners have the opportunity to positively impact the mother and her feelings about pregnancy and the postpartum period in their own unique way.  The pediatrician may encounter mothers during the post-pregnancy transition more frequently than any other healthcare provider.  Typically pediatricians will see the baby and mother for at least six appointments at 2 to 4 weeks, followed by visits at 2, 4, 6, 9, and 12 months.  In addition to expectable appointments, mothers of firstborn babies tend to make contact by phone multiple times during the first year.  The mother-baby-pediatrician relationship that develops within the infant’s first year of life provides multiple opportunities for identifying postpartum mood disorders, which invariably impact attachment, bonding, and relational attunement.

Eight Ways the Pediatrician Can Make Strides Toward Better Serving Pregnant Women and their Families

1. A Family-Oriented Approach.  The American Academy of Pediatrics Task Force on the Family (2003) underscores the importance of “family-oriented” pediatric care with the aim of improving family outcomes.  The “health and well-being of children is inextricably linked to their parents’ physical, emotional, and social health.”  Emotional development is greatly impacted by the quality of mother-infant attachment and bonding.  When a new mother suffers with an untreated postpartum mood disorder, it is likely that her children will suffer in a multitude of ways.  Pediatricians must consider both the child and the mother as patients.
2. Prenatal Information. If the pediatric practice distributes information about postpartum mood disorders at the prenatal visit, expectant mothers and their families will have the opportunity to discuss any perinatal anxiety, family history of mood disorders, or ambivalences regarding parenthood.  Prenatal discussions about postpartum struggles may also help encourage the patient to feel safe revealing herself if she does in fact find she is suffering in uncharted territory.
3. Assessment of the Birth Experience. After delivery, pediatricians typically have contact with mothers and their newborn within the first 1-3 days postpartum.  This is an important time for doctors to assess how the labor and delivery process went and if there was any significant trauma incurred.  Trauma may be felt when there is a highly difficult labor and delivery experience, the new mother was not able to have the birth she envisioned, medical complications occurred, and/or there were unexpected medical issues and concerns related to the newborn.  In addition, women with a history of sexual abuse or other physical or relational traumas may find that the birth process reignited memories that are re-traumatizing.  Though it is quite common for new mothers to experience postpartum blues within the first 2 weeks due to hormonal shifts and utter exhaustion, birth trauma is a noteworthy risk factor in the development of postpartum mood disorders.  Pediatricians can discuss referral sources and assure the patient that there are resources available for processing traumatic and non-traumatic births.
4. Checking Up… On Moms Too. The most critical time for the pediatric staff to identify a postpartum mood disorder is at one of the first three postpartum visits- 2-weeks, 2-months and 4-months.  Symptoms usually peak at about 3 months.  Postpartum mood disorders tend to worsen during this time.  The 4-month pediatric visit is an important milestone appointment in identifying postpartum mood disorders because unless the baby has severe medical, sleep, or feeding issues, new mothers tend to feel less tired, more confident, and less anxious.  The pediatrician may need to rely on clinical judgment when differentiating between expected challenges in new motherhood versus ongoing, worsening, or potentially worrisome difficulties that may be symptoms of a postpartum mood disorder.  Asking the new mother how she is feeling and sensitively attuning to her affective response as well as her interactions with her child may provide important insight into her current emotional world and overall functioning.
5. Universal Screening. Research has shown the value of universal maternal screening.  One study revealed that without the use of screening tools, 50% of women with clinically significant symptoms of depression went undetected by clinicians (Chaudron, 2003).  During the first year of the life, identification of at-risk mothers improved from 1.6% to 8.5% (Chaudron et al, 2004) and from 29% to 40% in another study (Heneghan, Silver, & Stein, 2000).  Screening tools must be simple and accessible.  Optimally, screenings are used in combination with clinical evaluation through the process of getting to know the mother, her newborn, and witnessing their interactions over time.
6. Know More to Support More. Lack of confidence in educational breadth and depth about postpartum mood disorders as well as a shortage of time during well-baby appointments are two contributing roadblocks within the pediatrician-patient dyad.  These obstacles may inhibit identification, diagnosis, and timely treatment of postpartum mental health complications.  Taking strides to overcome these potential barriers should be a priority given the glaring postpartum mood disorder statistics and their impact on developing children.  Fortifying the health of the mother-infant relationship is a central theme in family-oriented care.  As such, pediatricians should feel conversant in postpartum mood disorder risk factors, signs, symptoms, treatment options, and medication regimens that can safely be used in concert with breastfeeding.
7. Holistic Help. Creating office-wide postpartum mood disorder screening protocols in pediatric practices would streamline identification.  Referring identified patients to mental health professionals for diagnosis and treatment can benefit both mother and baby.
8. Follow-Up. Studies have found that many women who have been identified with postpartum mood disorders through the use of screening tools are not necessarily referred to mental health professionals.  Following up with a mother who is struggling in her newfound role as a parent is paramount.  All too often, friends and family members encourage new mothers to “think positively” or normalize feelings that are actually not part of the expectable course of new motherhood.  Minimizing profound struggles only furthers the silence and sequesters the suffering.

Sources:

Perinatal and Postpartum Mood Disorders: Perspectives and Treatment Guide for the Health Care Practitioner (2008) edited by Susan Dowd Stone and Alexis E. Menkins

Jessica Zucker, Ph.D. Bio

Dr. Zucker specializes in women’s health, postpartum mood disorders, and early parent-child bonding.

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