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To the Editor.
We read with great interest "Lactation Counseling for Mothers of Very Low Birth Weight Infants: Effect on Maternal Anxiety and Infant Intake of Human Milk" by Sisk et al.1 Their objective was to examine whether mothers of very low birth weight infants who initially planned to formula feed were different in terms of their levels of anxiety and maternal stress compared with mothers who had planned to breastfeed their infants. The study showed that counseling mothers of very low birth weight infants increases the incidence of lactation initiation and breast milk feeding without increasing maternal stress and anxiety.
Although hypothesized in their discussion, Sisk et al did not investigate (for ethical reasons) if mothers who received no lactational counseling have more difficulty maintaining lactation during this stressful period.
It is worth clarifying this aspect, because anxiety has been estimated to affect 
30% of women during their lifetime,2 and puerperium is a time of great emotional change for women, often producing increased stress and anxiety,3 with considerable consequences for both mother and infant.4,5
To evaluate the possible relationship between in-puerperium maternal anxiety and failure to maintain lactation over a 6-month period after birth, we currently are performing a prospective study using the State-Trait Anxiety Inventory6 on 204 mothers >18 years of age who had given birth at >37 weeks' gestation to healthy, single infants and who were without neonatal or obstetrical complications precluding discharge. We hypothesized that predischarge maternal anxiety has a negative impact on breastfeeding outcomes.
On average, women were in their 30s, had 10 years of formal education, and had 2 ± 1 pregnancies; 22% delivered by cesarean section; the total lactation initiation rate was 95%; and the mean breastfeeding duration was 114.1 ± 66.8 days. State anxiety age-corrected (T) levels (43.9 ± 6.5) of study-participant mothers were inversely correlated to breastfeeding rate on the third (r = 0.14 and P = .04) and sixth (r = 0.16; P < .01) postnatal months. Instead, trait anxiety levels (41.3 ± 6.7) were not correlated to breastfeeding outcomes.
By studying the relationship between maternal anxiety and lactogenesis, we found that maternal "state" anxiety in puerperium has a negative impact on breastfeeding outcomes. We therefore share the conclusion of Sisk et al that counseling and supporting anxious mothers of healthy and high-risk infants may contribute to increased lactation initiation and maintenance.
REFERENCES
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