Discussion
The present study showed that FA is negatively linked to psychosocial states of breastfeeding mothers. Psychosomatic symptoms, depression and anxiety were more frequent in breastfeeding mothers of infants with FA than healthy controls. The negative psychosocial changes were more severe in mothers with Indecisive symptoms for FA than those of mothers of infants with Diagnosed FA. The scores were also higher in non-IgE-mediated FA than those of IgE-mediated. Doctor recommendation was the most frequent reason for dietary elimination for the breastfeeding mothers.
The importance of the link between feeding and bonding have long been explored (16). It has been shown that mothers’ attachment style was associated with postpartum psychological well-being and feeding preferences (17). When putting these points into consideration, it is not surprising that FA has many impacts on multiple aspects of psychological well-being. The diagnosis of FA, daily management of allergen avoidance, anxiety and fear about an unpredictable risk of allergic reactions bring a greater psychological burden to both the patients and their families (18-21). The negative impact of FA on QoL as well as emotional states such as anxiety and depression has been shown on several studies conducted on children, adolescents, adults and their families (3, 18). However, the impact of FA on psychosocial aspects in the first year of life was not investigated, previously.
This study evaluated FA in the first year of life which was a very sensitive and vulnerable period of mother-to infant bonding and showed that the diagnosis of FA was related to the psychosocial well-being of breastfeeding mothers, negatively. When compared with the healthy controls, the consideration of FA, irrespective of the diagnosis is FA- or Indecisive symptoms for FA caused anxiety, depression, anger, phobia, somatization symptoms, feeling of inadequacy with increased expectation of rejection and criticism. Furthermore, this study showed that FA affected mother-to-infant bonding inducing anxiety and anger in the mother and also increased interpersonal sensitivity of the mothers.
In QoL research on FA, mothers reported a significantly greater impact on psychological and physical QoL than fathers (3, 23-25). Various studies also showed that mothers felt the pressure of being primarily responsible for the state of health and safety of their children (25, 26). Therefore, it is highly likely that breastfeeding mothers may feel guilty themselves due to food allergens passing via their breast milk. When the possibility of harming their infants come together with the great responsibility of feeding, mothers may experience stress and feel helpless. They may be afraid of harming their infants and begin extensive elimination diets with great desperation. There may be such a huge intra-psychic conflict among mothers that they may develop some psychotic and somatic symptoms, which disturb mother-to-infant bonding. Dieting can also play a negative role in mother and infant relationship due to its difficulty in implementing through the daily routine for a breastfeeding mother (27).
According to a previous study, anxiety and depression of parents began even before the establishment of the FA diagnosis (28). The psychosocial scores in this study were higher in the Indecisive symptoms for FA group than in the Physician Diagnosed FA group. The Indecisive symptoms for FA group consisted of parents with higher education levels. And also, a higher ratio of the mothers in the Indecisive symptoms for FA group were the primary caregivers. These results may be related with the oversensitivity of the mothers about the symptoms in their infants actually not related with FA. Another possibility may be the psychological factors intrinsic to these mothers that may lead them to think that their children had FA (29).
The scores were also higher in non-IgE-mediated FA than those of IgE-mediated. This result may be related with the absence of a laboratory test to confirm non-IgE-mediated FA or diagnostic delays with the longer periods waiting in anxiety for the mothers. This may also be associated with the nature of symptoms. Seeing blood in stool may be very worrisome for a mother. In a study which found poorer physical QoL in non-IgE-mediated FA than that in IgE-mediated, the authors concluded that extra manifestations such as pain, hypermobility and fatigue and delays in diagnosis due to absence of laboratory tests may had an impact on the emotional psychological health of children (30). In another study, poor physical and emotional functioning associated with non-IgE-mediated FA was thought to be related with poor symptom recognition, delay in diagnosis and noxious symptoms such as sleep deprivation due to abdominal pain and feeding difficulties (31).
External stimuli affecting maternal feelings may affect the breastfeeding period. Nearly 50% of mothers reported that their breast milk had a change in color, volume, consistency and even more than two thirds of mothers in this study stated that their breast milk were decreased. Changes in breastmilk may also be due to extensive dietary eliminations. Almost half of True-FA group and 1/3 of False-FA group said to exclude >20 nutrients from their diets. Moreover, uncommon allergens such as vegetables and fruits were excluded by almost 20-30% of mothers. The ultimate allergens responsible for the reactions were actually just one type of food, for many it was only milk and not more than two in the majority of the cases. As thought from the perspective that relatively small number of allergens cause a high proportion of FA, it was obvious that mothers followed extensive unnecessary elimination diets (2). Extensive number of foods being avoided may also be a factor increasing maternal stress (32).
The evaluation of breastfeeding mothers with infants <1 year separately from older ages, comparison with a healthy control group, comparisons between Physician diagnosed FA vs Indecisive symptoms for FA, IgE- vs non-IgE-mediated FA using multiple standardized validated tools were the strengths of the study. The small number of patients within subgroups and lack of re-evaluation after remission of FA were the limitations. It is not well-known that the negative psychosocial functioning is caused by FA itself or by dietary elimination. Even though it was planned to include the cases with FA but without dietary elimination, this group is missing in the study due to the very few numbers of cases admitted to the study clinics.
In further studies, re-assessment of the mothers after remission of FA may answer the question of whether the psychosocial problems in mothers are pertinent to mothers themselves or related with burdensome aspects of FA.
In conclusion, breastfeeding mothers having children with FA were anxious, depressive and had many psychosocial symptoms which affected mother-to-infant bonding and interpersonal relationships. The Indecisive symptoms for FA and non-IgE-mediated FA groups had worse scores that the physician diagnosed FA and IgE-mediated FA groups, respectively.
Psychologic and social support and changes in the attitude of the physicians to the mothers who avoid major foods form their diet to care their infants in allergy clinics should be re-visited.