AAP Voices Blog

We were seeing Nicole again when she brought her baby for her 2 month well-visit. She completed an Edinburgh Postnatal Depression Scale questionnaire, and we were discussing her responses. She recalled answering the questionnaire at her baby’s one-month visit, too.

“I was tired and sleep deprived then, so I dismissed the questions,” she said. “Today, the nurse told me that you give this questionnaire to all moms of young infants because how I feel can affect my baby’s health and mine.”

Nicole’s score on the Edinburgh was just above the cutoff, and she was tearful as we continued our discussion. I reassured her that postpartum depression is common and asked if she had support so she could get sleep and a break for herself. I also showed her the growth chart, explaining that her baby was growing well and encouraging her to continue breastfeeding. I pointed out her baby’s social smile.

Our practice explored community resources for maternal depression when we decided to implement screening, and I was able to link Nicole with a local postpartum support group we had identified through Postpartum Support International. We agreed on a follow-up visit to check on her baby ‘s social-emotional development and how she and her baby were bonding. At that follow-up, Nicole expressed gratitude and said she had chosen the right practice for her baby and family.

Perinatal depression, of which postpartum depression is a subset, is the most common obstetric complication in the United States. It affects as many as 12 percent of all women who are pregnant or new mothers, while an estimated 11-18 percent of women report postpartum depressive symptoms.

Effects of the condition can be far-reaching, adversely affect a child’s critical early period of brain development. Left untreated, perinatal depression can interfere with healthy parent-child attachment and lead to inappropriate medical treatment, family dysfunction, and impaired attention to and judgment concerning safety. An estimated 50 percent of women who are depressed during and after pregnancy are undiagnosed and untreated.

It’s important to respond to postpartum depression as early as possible, since potential developmental issues may be less responsive to interventions over time. Maternal depression in infancy are predictive of increased cortisol levels in preschoolers, and this, in turn, is linked with anxiety, social wariness, and withdrawal. As they get older, children of mothers with untreated postpartum depression often have poor self-control, poor peer relationships, school problems, and aggression.

​"Pediatricians have long recognized the two-generational nature of providing care for children. Addressing perinatal depression is an example of this—one that has a long term impact on the health of the child, the mother-infant relationship, and the whole family.”

Pediatric primary care clinicians have the opportunity to identify depression and give support to the mother-infant dyad, as the American Academy of Pediatrics (AAP) emphasizes in the policy statement, “Incorporating Recognition and Management of Perinatal and Postpartum Depression into Pediatric Practice.” The statement, and its accompanying technical report, updates the AAP’s 2010 clinical report on the topic.

Incorporating perinatal depression screening into pediatric practice aligns with our recognition of toxic stress, adverse childhood experiences, resilience, and the need for trauma-informed care. Screening is also recommended by the U.S. Preventive Services Task Force and Centers for Medicare and Medicaid Services.

Based on when postpartum depression is most likely to occur, AAP recommends that screening be done at the 1, 2, 4, and 6 month infant visits. The AAP recommends coordinating care with prenatal providers for women diagnosed with depression during pregnancy, as does the American College of Obstetrics and Gynecology.

When screening shows depression concerns, pediatricians can help prevent it from leaving a lasting mark.

• Provide primary care intervention. Begin by acknowledging that postpartum depression happens to many new parents, that the mother is not at fault or a “bad” mother, and that it is treatable. A brief intervention at the visit also would involve:
  • Promoting the strength of the mother-infant relationship, such as reading and/or singing to the infant.
    
    
  • Encouraging the mother to breastfeed and recommending lactation support if needed. Evidence suggests breastfeeding may protect against postpartum depression or help women recover from its symptoms more quickly.
    
    
  • Encouraging the mother to make time to meet other new parents and increase social connections
    
    
  • Facilitating connections with community resources, support and/or mental health services for the mom.
    
    
  • Providing a referral for evidence-based treatment such as Child-Parent Psychotherapy.
    
    
  • Referring to Early Intervention programs for targeted support of social-emotional development.
• Beyond the clinic, there are many opportunities for advocacy. Pediatricians, working with their AAP Chapters can:
  • increase awareness of the need for screening (both in pediatric and obstetric care);
    
    
  • advocate with payers to ensure payment for screening and services;
    
    
  • advocate for creation of postpartum support resources in local communities; and
    
    
  • promote workforce development of mental health providers who care for very young children and the parent-infant dyad.

Pediatricians have long recognized the two-generational nature of providing care for children. Addressing perinatal depression is an example of this—one that has a long term impact on the health of the child, the mother-infant relationship, and the whole family.