Sunday, 19 February 2017

The Social Nervous System & Breastfeeding (How stress or relaxation impacts breastfeeding)

Mother S Day Clip Art   Images   Free For Commercial UseYou might be surprised at how often during a breastfeeding consultation I talk about mum's current stress levels, and techniques for stress management.   Why do I as an IBCLC think that modern life and daily stresses can physically affect how well a baby breastfeed or perhaps manages the flow of milk at the breast?

The benefits of skin to skin after birth are now very well publicised.  In antenatal education we explain to mums how this skin to skin helps to stabilise the baby and how mum's heartbeat helps to regulate baby's heart rate and how her breathing helps to regulate baby's breathing.  What we don't do is talk about the biology behind it or that our nervous system continues to be affected by others throughout our life.  The only mention of it tends to be in the phrase "happy mum, happy baby" - which unfortunately in my experience tends to be used in terms of justifying substitute milks rather than being used to help with breastfeeding. In this blog I want to try to explain how the nervous system can respond to stress, how it physically translates to the muscles and nerves involved in sucking, swallowing and breathing and how we can use that knowledge both to help mum feel calmer and to help the baby with breastfeeding.

The Social Nervous System
During school you may have learned about animal stress responses to danger as Freeze (think of animals playing dead) or Fight & Flight.  The picture isn't as simple as this in mammals due to a social component in our nervous system.  Humans, like other mammals,  have a social nervous system - meaning that our physiology and behaviours are directly impacted by our social circumstances, our connection to other people, to our environment and our perception of these.  The implications of the social nervous system are vast, and it is really hard to summarise in a couple of paragraphs.  I want this blog to be about practical help with breastfeeding so I will just cover the nervous system in the highest level terms and how you can use it to help with breastfeeding, and I will put links to more detail on the social nervous system / polyvagal theory in the further reading section.

That said, let's look at an example of the social nervous system in action during a perceived threatening situation.  Let's imagine you are sitting in a room, perhaps in a hotel or at a meeting and the fire alarm goes off.  You weren't aware that a test was going to be conducted so you have no idea whether the alarm is a genuine threat to you or not.  So what do you do?  It's unlikely that you are going to freeze e.g. faint.  I think it's also unlikely that you suddenly get up and run out of the door (fight or flight).  What humans typical do is look to each other to gauge the correct response.  You might turn to people around you and ask, "Is that the fire alarm?  Do you think it's real or a test?  Should we go?"  We then get a kind of common consensus of the level of risk and that determines the level of stress we feel and how we respond.  We read safe and unsafe cues from those around us.

The social nervous system is controlled by a series of cranial nerves.  These nerves, and some relevant parts of their function are:
Image from
http://medical-dictionary.thefreedictionary.com/cranial+nerve

  • Cranial Nerve 5 - The Trigeminal Nerve. This nerve is responsible for sensory input in the face and for muscle
    function needed for jaw movements and swallowing
  • Cranial Nerve 7 - The Facial Nerve.  This nerve is responsible for facial expression, for listening, for tongue sensation, taste and production of saliva.
  • Cranial Nerve 9 - The Glossopharyngeal Nerve.  This nerve is responsible for sensation in the tongue, the pharynx and middle ear (so eating and listening)
  • Cranial Nerve 10 - The Vagus Nerve.  This nerve is responsible for huge number of functions in the body.  The name "vagus" comes from the same root as the word "vagrant".  It is the wandering nerve and supplies almost every organ in the body.  The relevant functions here is that it has a responsible role in heart rate, digestion, pharynx and larynx (so back of nose and mouth), and even feeling of satiety after eating.
  • Cranial Nerve 11 - The Accessory Nerve.  This nerve provides motor control to head and shoulders allowing us to turn our head (such as in the rooting reflex) or shrug our shoulders
Hopefully you are starting to see how the nerves involved in the social nervous system are involved in breastfeeding (face, tongue jaw, swallowing, digestion etc), but maybe less so in how it affects a stress response, so lets go back to our fire alarm example.

Let's go back to you sitting in that hotel or meeting room when the alarm goes off.  You hear it (nerves engaged in listening).  You will engage your accessory nerve to look around (in the same way a mouse might look around for a predator).  Your facial expression will change based on this.  Visualise this now.  Really imagine sitting in that room and hearing the alarm.  Notice how your face changes as you try to perceive the level of threat.  You look at other's faces for subtle clues as to their stress levels.  If they are showing fear or anxiety this increases your perception of threat, you will also engage your own facial muscles to echo your own emotional state.  The vagus nerve may then remove what is called the vagal brake from your heart, causing your heart rate to increase (so that you can flee if you need to).  The body becomes able to mobilise against a threat.
Now lets look how the social nervous system works to counteract that stress response.  You heard the fire alarm and looked around.  Someone nearby with a happy facial expression calmly announces to the room that it is a test and that reception had confirmed it earlier.  You look at their facial state, you modulate your inner ear muscles to listen to the changing pitch of the words and it neutralises the level of threat, your own face calms, and the vagal brake is reapplied to your heart which slows your heart and your breathing.  The person engaged you on a social level, changed the perception of the threat and that put your social nervous system to work to calm the body.  

The fire alarm example is easy to demonstrate how we react to others, but in fact we are picking up subtle clues about safety or danger from others all the time.  The psychiatrist Stephen Porges who developed the understanding around the social nervous system, calls this subtle detection of risk in others neuroception.  We are constantly using neuroception to determine the safety of our environment and our stress responses.  Given that in today's 21st century world we are surrounded by people rushing around, with constant stimulation you can see how we can constantly be getting low level unsafe signals contributing to our own anxiety.

There is a saying in neuroscience that nerves which fire together wire together, which essentially means that groups of nerves which fire at the same time are wired from the same part of the brain, and that in turn means firing that area of the brain fires off all the nerves which come from that area.  This is true of the social nervous system and our level of social engagement with those around us.  At the most basic level you can think of the social nervous system being online or offline.  When the social nervous system is online the vagal brake is on (heart rate and breathing is relaxed), our social engagement or attachment to others is on and we use our face to communicate that by listening (middle ear muscles constantly readjusting to listen to alternating pitch of speech) smiling, talking etc.  This is what Porges refers to as the face-heart connection. To demonstrate this social engagement think of a time when you were with someone you loved and really enjoying their company and conversation and how you felt relaxed and safe.   
Conversely when we are stressed our vagal brake is off (heart rate and breathing rate increases) and our social engagement is also off.  Think of a time you were feeling a bit hassled.  Maybe you needed to get somewhere and were running late, or perhaps you were working on a project and needed to get something done.  Then someone asks you for something, or maybe a child starts pulling toys out of a box.  You are already a little stressed, your social nervous system is offline, your heart rate and breathing is a little faster than usual.  Think of how you react to the person.  It's quite different to how you react when you are feeling calm.  You aren't socially engaged or attached.  You may be irritated by the interruption, the distraction and your response shows that.  Now imagine that you are the person asking the hassled person for something. Think of how their level of stress and irritation with you causes you anxiety as well, because you aren't correctly socially engaged with each other.


The Social Nervous System & Breastfeeding
Back to the central question..... how can this help with breastfeeding?  Well, babies also have the social nervous system.   They also use neuroception and look to us for subtle safe and unsafe signals.  We know from research that 1 in 6 mothers develop postnatal anxiety (1 in 5 first time mothers).  We know from recent studies that the use of synthetic oxytocin is linked with an increase in anxiety postnatally.  Birth may not have gone how a mother wanted and may have left her traumatised or grieving even though she has a baby in her arms.  Add in the fact that our culture has lots to say about parenting which is in direct contradiction to breastfeeding norms and to breastfeeding instincts, and it's easy to see how parents can feel stressed.  On top of that we generally live in nuclear families, without extended family in the house to help with daily housework and older children. Breastfeeding mums often find themselves isolated at home with a baby, sometimes trying to meet the needs of several children, while the tv, radio and internet tells her what she "should" do regarding parenting.  All the while, life continues with other challenges, house moves, extended family or in-law dynamics, maybe even bereavement, or employment issues.  In short - parents are stressed, and this can affect babies, which can affect feeding and that in itself adds to the stress.   

In very many breastfeeding consultations that I do, I talk about this.  Babies pick up on subtle stress signals. Often we aren't aware of the stress in our bodies but when in consultations the parents and I start to talk about feeding and stress, mums open up and say that they know that the baby feeds better at night and less well when in public or less well when she is busy.  They talk about how difficult it is to meet the needs of the toddler when the newborn feeds constantly.  They talk about how it's so difficult when they are not getting enough sleep and the "helpful advice" they are getting from others and how that is stressful.  How others are questioning their parenting.  How stressed they are that the baby wants to be held so much when others are telling them that babies will be spoiled if not left down.  We talk about the physicality of that stress and often mum's tell me that they are aware of tension in their shoulders and how that changes their posture, or about how they can't seem to relax and nap when the baby is napping even if they were able to lie down.  When these things happen we are giving out signals that just subtly say that the world isn't completely safe right now.  How do our babies and children react to this?  Well let's go back to the social nervous system.  If a baby is getting unsafe signals the social nervous system isn't engaged as well as it could be and we already know that the social nervous system involves muscles and nerves which coordinate latching sucking, swallowing etc.  The baby's breastfeeding just isn't as coordinated as it could be.  The baby may not latch as well, or may not manage the flow of milk as well as they could.   The tongue just doesn't operate as optimally as it should.  Digestion is also affected and you just have a fussier baby in general.  
What about a slightly older baby or toddler?  What happens if they feel unsafe?  Well, they try to get back to feeling safe.  How do they do that?  They go to their safe place - which is you.  So the baby or toddler places greater demands on you just when you are feeling like you can deal with it less.  It can become a vicious circle.

Unfortunately this is ripe territory for mums being given all sorts of advice for fussy babies  - diagnoses of colic, reflux, need for alternative milks, allergy etc.   On the other hand some mums are just dismissed as anxious mothers, particularly common with first time mothers.  Both approaches fail mothers and babies. These stresses are real.  A new baby is overwhelming.  That sense of loss of control is real.  It is stressful. The cultural clash between baby's needs and society's idea of parenting is real.  All the other stresses mentioned earlier are real and they have real effects in our bodies.  Dismissing them with a label of "anxiety" is unhelpful.  It may indeed be that the baby does have colic, reflux or allergy - but in my experience colic, reflux and allergy are often diagnosed where it is not appropriate, and even where those things are present, working on the social nervous system helps both mum and baby.  What we can do is help mothers to manage stresses better and a simple way to do that is engaging the social nervous system, because nerves that wire together, fire together.   If we can bring the social nervous system online it calms both mother and baby and that helps the baby to feed better.  A less fussy baby who is feeding better in turn, makes parents feel calmer.

Engaging the Social Nervous System

The good thing about the social nervous system is that very simple strategies can be used to bring our social engagement and the social nervous system online.  These are techniques and thoughts that I often discuss with mothers who are feeling stressed:
  1. Shoulders - think about your shoulders.  We tend to hold a lot of tension in our shoulders and that brings them up and forwards towards our ears.  How are you sitting when you go to breastfeed?  Can you feel your shoulder blades against the back of the seat or couch?  Are you using laid back breastfeeding positions, which tend to help us relax all our muscles.  Stop during the day at various points and check in with your body - are you holding tension?  Can you consciously relax?
  2. Breathing - we can consciously slow our rate of breathing to help apply the vagal brake.  Long slow out breaths are the key to this.  A technique I often suggest is breathing in for a count of 4, and out for a count of 7.  Doing this for a very short time really calms the body very effectively.  I also suggest this to mums who are struggling to get older children or toddlers to sleep and again it is very effective as the child can start to mirror your breathing and relaxes.
  3. Engage the ears - the middle ear muscles which help us to focus on different sounds are part of social engagement, and there are a few ways that this can be used.  Music is very helpful.  This might be playing relaxing music or it may be singing.
  4. Speech - the muscles involve in speech and singing are those in the pharynx and larynx.  Talking and really engaging with someone helps to relax us - this is one reason why talking therapies work.
Now see how these fit together.  Think about baby talk, when people coo at babies, "Hello baby".  They are using speech, and generally speech which varies in pitch - almost like singing.  This constant changing pitch involves the middle ear muscles to work hard.  Take that one step further to singing.  Studies have shown that babies suck better when mum is singing lullabies.  I think this is because it engages the social engagement system. Mum is using speech (during the singing), using long out breaths (from the singing) and her middle ear to give her feedback on the sound.  This relaxes mum and she gives safe cues to the baby.  Baby in turn is listening to the sound and engaging her middle ear muscles, and the social engagement brings her social nervous system online and helps with sucking and swallowing.

If you are having problems with breastfeeding or a fussy baby I recommend that you see a breastfeeding counsellor or IBCLC to look at the the dynamics that are happening at the breast, and to work on optimising positioning, attachment, frequency of feeds, milk transfer, and to look at causes of reflux or weight gain problems etc, however I also think that it's worth the time to think about how you are doing in addition to that.  Breastfeeding isn't all about the baby latching on and transferring milk.  A breastfeeding mother and baby are a dyad.  They impact each other and they respond to each other and when breastfeeding isn't going as you wanted, or if other parts of your life are challenging as well that affects our babies too.  Babies are one half of the breastfeeding equation and we are the other half.  

I know that slowing down your breathing or singing to your baby seems like a facile solution for a fussy baby.  It's too simple in a world where we are confronted with a myriad of reasons and solutions for fussiness.  Sometimes though, it is the solution, and even where it isn't the only solution - it helps.  I have known mothers dealing with babies with diagnosed allergy and reflux who have put some of these techniques to work and after a few days told me that the baby's "body felt softer"; mothers who felt baby wasn't vomiting as much, mothers who said that the baby was managing the letdown better and not choking or gagging on milk.  Of course we worked on optimising breastfeeding in the consultation but relaxing was part of it, and often mothers tell me that she felt that working on relaxation made a huge difference.  

If you find that you are aware of feeling anxiety on a frequent basis and it continues more than a week or two, consider talking to your G.P, or other HCP.  For very many new parents however, we're are not even aware of the low level anxiety that might be impacting us.  The expectations that society sets upon new parents are enormous.  The expectations that we set on ourselves as new parents (even if not first time parents) are enormous, and post partum what we really need to do is to slow down.  To spend time just being and adjusting to the new family member, to the physical recovery after birth and the establishment of this new breastfeeding relationship.  Our modern life and environment often doesn't make that easy for us, and that makes it all the more important to pay attention to it.  Remember to just stop and breathe.....slowly.  See what it changes.  You might be surprised.
www.carolsmyth.co.uk


Further Reading
1.  NICE guidance on Antenatal and Postnatal mental health - https://www.nice.org.uk/guidance/cg192/chapter/Introduction
2.  Breastfeeding Network Factsheet on Anxiety - http://www.breastfeedingnetwork.org.uk/wp-content/dibm/anxiety%20and%20breastfeeding.pdf
3.  Interview with Porges - https://blog.bulletproof.com/stephen-porges-the-polyvagal-theory-the-vagal-nerve-264/


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