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.