Elite Distance Runners and Breastfeeding

Well Established

The literature suggests that moderate physical activity and successful breastfeeding are compatible.

Newly Expressed

We found that elite female athletes have a desire to breastfeed while training and competing. Unfortunately, elite athletes lack relevant information regarding breastfeeding and high-intensity training and the impacts on mother and infant.

Background

Elite athletes as mothers are gaining increasing amounts of media attention^1,2; unfortunately, however, elite sport mothers have been neglected in health-related research.^1,2,3 Researchers have, however, found that having a baby shifts the priorities of the elite athlete,^1,2 as elite sport mothers must mediate their multiple identities, which creates internal tension.^1,2 Further, social expectations of an ethic of care, which includes breastfeeding, create strain for athletic women who choose to train postpartum. ¹ As such, elite breastfeeding athletes may face challenges not faced by their less elite, though high exercising, counterparts.

As social constructionists who recognize the role that one’s positionality may play in one’s research, we note that this research was spurred by the third and fourth authors’, who are both former elite athletes who are now researchers with young children, knowledge of and experience in high-performance sport. In particular, the fourth author struggled with breastfeeding and training, received mixed advice while she was doing both, and still harbors guilt around stopping breastfeeding earlier than planned in order to return to competition. As such, she wanted to know other elite athletes’ duration of and strategies for breastfeeding in order to help other athletes in the same position in the future. The purpose of this research was thus to understand elite female distance runners’ experiences of breastfeeding while training and/or competing at a high performance level. We followed Sloan, Sneddon, Steward, and Iwaniec’s definition of breastfeeding duration as referring to the “length of time infants were breastfed, regardless of when other milks, drinks or food were introduced” (p. 290). ³ We conducted semistructured interviews with 11 elite female athletes from five countries [Australia, Canada, Ireland, the United Kingdom (UK), and the United States of America (USA)].

Infant nutrition is classified as a public health issue due to the dependence on breastfeeding for optimal growth, development, and overall health of children.^4,5,6 Breastfeeding guidelines in Australia, Canada, Ireland, the USA, and the UK (the countries from which our participants hail) all align with the WHO’s current global guidelines.^{5,7,8,9,10,11} The WHO has recommended that infants be exclusively breastfed for 6 months, at which point complementary foods are added to the infants’ diet.^5,12 None of the guidelines in Australia, Canada, Ireland, the USA, or the UK mention alterations to breastfeeding practices based on the mother’s physical activity, which may be an issue for female athletes who are seeking to train, and in some cases compete, at an elite level while breastfeeding, as well as their infants.

Some international physical activity guidelines have suggested that the volume and composition of breast milk is not affected by moderate physical activity. ¹³ Athletes who are breastfeeding may be concerned about the accumulation of lactic acid in breast milk and its consequent impact.^14,15,16 Resting breast milk lactic acid concentration is approximately 0.10 mM; exercise intensity can elevate lactic acid’s concentration in breast milk.^14,16,17,18 Carey, Quinn, and Goodman measured average lactic acid concentration immediately after exercise at 100% of VO2 max to be 0.94 mM, which was a significant increase from resting lactic acid concentration. ¹⁴ These values remained significantly elevated at 30 and 60 min postexercise, but not 90 min. The authors did not find significant increases in lactic acid concentration postexercise at 75% and 50% of VO2 max. Conflictingly, in another study, breast milk lactic acid concentration postmoderate exercise was observed to be 4 to 6 times greater than before exercise. ¹⁹ These authors found a return to resting values at 60 min postexercise.

The lactic acid taste threshold in water is 1.5 mM; it is unlikely that milk with a concentration below this amount would have an altered taste as a result of the lactic acid presence. ¹⁴ Indeed, after controlling for “maternal diet, exercise intensity, and the method, timing, and assessment of infant feeding” (p. 585), Wright and colleagues found that moderate and maximal exercise during lactation had no impact on infant acceptance of breast milk 1 h postexercise. ¹⁸

Nevertheless, concern about breast milk has been found to be a barrier to training and competition for elite breastfeeding female athletes because training and feeding schedules have been reported to be adjusted to avoid higher levels of lactic acid in breast milk.^20,21

Beilock, Fletz, and Pivarnik found that barriers for returning to training postpartum included breastfeeding, a lack of sleep as a result of breastfeeding, and worrying about training too soon. ²² However, most research has lacked applicability to elite athletes, because—as with Beilock et al.’s study—it has been focused on low to moderate intensity exercisers.

The structure of health care systems and national sport organizations can pose additional barriers to breastfeeding. ²³ Specifically, athletes can be financially stressed during pregnancy and postpartum due to a loss of state support (e.g., financial support, rehabilitation support), commercial sponsorship, and their related economic benefits. ¹ The nonguarantee of paid maternity leave also provides incentive for women not to breastfeed. ²¹ To date, researchers have not examined the ways in which the aforementioned factors coalesce to influence elite female runners’ breastfeeding experiences, a gap we sought to address. Therefore, our research question was, How do elite female distance runners manage breastfeeding while training and competing?

Methods

We used a case study approach because we aimed to understand “how” breastfeeding practices were managed. ²³ Yin described descriptive case studies as being appropriate when seeking to follow an interpersonal event with the goal of discovering key phenomena. ²⁴ Our participants are a part of a population that has not received much scholarly attention in the past. The use of a case study approach allowed us a deep understanding of the relationship between the context of high performance sport and breastfeeding experiences to emerge.

The Research Ethics Board at the University of Ottawa reviewed our study protocol and informed consent process and determined that our human research participants would be adequately protected. The third and fourth authors recruited 11 women who met our inclusion criteria: had had at least one pregnancy within the past 5 years (2009–2014) and who had achieved a minimum of the USA Track and Field 2012 Olympic Trials “B” entry standard for the marathon or an equivalent performance for distance running events 1,500 m or longer. ²⁵ We used 5 years as our cutoff because these interviews were part of a larger study that used a 5-year cutoff. This study is part of a larger study in which we sought to understand (through qualitative and quantitative methods) elite female distance runners’ levels of physical activity before, during, and after pregnancy; to determine adherence to gestational physical activity and weight gain guidelines; to examine where women receive advice and support regarding physical activity; and finally to determine what supports or barriers allow women to continue elite competition. The time standard ensured that our participants were elite athletes, while the selected distances are considered to be “distance” events (rather than, for instance, sprint distances), and thus ensured some homogeneity in the participants’ training. The third and fourth authors also asked the participants to identify other potential participants and to pass along the researchers’ contact information if these women were interested in participating.

Our participants came from five countries (Australia, Canada, Ireland, the UK, and the USA) and have participated in 11 Olympic Games and 64 World Championships. As such, the participants comprise a remarkable cohort of athletes. The age at which the remaining 11 athletes gave birth ranged between 25 and 37 years, and they have between one and three children. In this study, we focused on their experiences with their first child.

The third and fourth authors conducted 11 individual semistructured interviews over the telephone, Skype, and in person. ²⁶ While the interviewers knew many of the participants personally, this potential source of bias is usually not of concern in feminist qualitative research, particularly when there are no relations of power between the interviewer and participant. As Campbell and Wasco have noted, “feminist researchers invest their personal experiences and emotions in the research process as means of connecting with their respondents. The advantage of this altered dynamic is increased trust, which may enhance the quality of the data” (p. 786). ²⁷

Semistructured interview questions included, but were not limited to, the following: What do you think are the major barriers to returning to competition after pregnancy? Is there anything you see is not being addressed in athletics with regard to pregnancy? For how long did you breastfeed? Why did you stop breastfeeding? All interviews were transcribed verbatim and returned to the participants for verification. None of participants requested that changes be made to the transcript.

The first, second, and third authors then performed thematic analysis on the transcript data following Braun and Clarke’s six-phase approach. ²⁶ We began by familiarizing ourselves with the dataset. We then actively read the data multiple times while taking preliminary notes to stimulate analysis. Next, we created initial codes, which allow for the arrangement of data extracts (quotations) into groups. ²⁶ Multiple codes were then clustered to form the broader concept of a theme. The second, third, and fourth authors corroborated the themes identified by the first author by reviewing the data’s (i.e., selected quotes’) consistency within each theme and by comparing the themes with the full dataset (i.e., all interview transcripts). The use of member-checking, peer debriefing, and the use of numerous coders helped to ensure our results’ credibility and dependability. ²⁸

Results

Breastfeeding as barrier to returning to training and competition was the first theme identified. It includes the subthemes of lack of sleep, injury risk, possible personal health risk, logistics (e.g., scheduling), and the use of breast pumps to facilitate training or competition. The second theme, limited access to breastfeeding information specific to the population, was compromised of four subthemes: seeking advice from the Internet, peers, and health care providers. The subthemes of the need for prolonged breastfeeding and the worry of lactic acid accumulation in milk were clustered to form the third and final theme: a concern for the baby’s health.

Breastfeeding as a Barrier to Training and Competition

All participants breastfed their babies for a duration of between 1.5 and 18 months; the mean was 9.73 months (SD 3.88), and the median was 10 (see Table 1).

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Table 1.

Participant Characteristics (N = 11).

	Pseudonym	Olympics	World Championships	Race	No. of Children	Breastfeeding Duration
1	Riley	Yes	Yes	White	2	7.5 months
2	Caitlyn	Yes	Yes	White	2	12 months
3	Carina	Yes	Yes	White	2	13 month
4	Sally	Yes	Yes	White	2	1.5 months
5	Maggie	Yes	Yes	White	1	10 months
6	Kallie	No	Yes	White	3	15 months
7	Sandra	Yes	Yes	White	3	10 months
8	Larissa	No	Yes	White	1	8.5 months
9	Karen	Yes	Yes	White	1	14.5 months
10	Siena	No	Yes	White	1	8 months
11	Heather	Yes	Yes	White	1	7 months

All participants are white and had obtained at least an undergraduate degree. The participants identified the way that breastfeeding influenced their ability to return to training and competition. Karen described mixing training and breastfeeding as “kind of not to be done.” Larissa explained the difficulties associated with breastfeeding as including “scheduling around another person that you’re not used to scheduling around.” Scheduling was cited as a logistical concern; thus, pumping breast milk was a common way for the athletes to manage feeding schedules. Larissa also mentioned, “Sleep is huge, feeling sleep deprived … it reduces your recovery rates. … I felt like I had to reduce my training load to accommodate for my reduced recovery capacity or I was going to be asking for trouble.” Lack of sleep limited the ability of breastfeeding athletes to participate in a high-intensity training regimen due to fatigue. As a result, they reported that it took them longer to return to competition-level fitness.

The physical changes that occur in the body during breastfeeding presented an additional challenge to breastfeeding athletes trying to return to training and competition. Heather explained her reservations regarding training while breastfeeding, which she attributed to the body’s ligament laxity postpregnancy: “I have never really been in this position where I had to be so careful about my body.” Riley noted, “I wasn’t sure about … when I was getting back to training and stuff, like, was breastfeeding affecting me? … If…I was getting depleted or my bones were?” As elite athletes, the women were not able to make decisions regarding breastfeeding practices without considering the implications on their ability to train and perform. For example, when asked about barriers to returning to training and competition, Heather mentioned the increased training required to reduce injury risk during nursing: “Knee injury and instability was the biggest thing, so retraining transverse abs and things like that because your body is still relaxing, still nursing.” Certainly, the injury prevention routine was an additional time constraint for these busy mothers.

Riley noted that she experienced a difficult personal dilemma in trying to decide whether or not to stop breastfeeding, as she felt that it might affect not only her health but also her performance:

I was like, if I don’t stop breastfeeding now, I’m definitely not giving myself a chance … I wasn’t sure if the really, really hard workouts and races that were just about to come … [were] going to be really bad if I hadn’t stopped breastfeeding … I … kind of had to make peace with it and say, like, “look it, you’re trying to do the Olympics.” … I had to kind of convince myself that it was a good enough reason to stop breastfeeding at like 7 months or so, but it was really hard—that was the hardest dilemma.

Not all participants, however, experienced physical changes or difficulties in training related to breastfeeding. Marcie noted, “It wasn’t an issue. I never had any issues about it I was training and it all worked fine.” Thus, although many of the mothers had injury concerns related to breastfeeding and training, breastfeeding-related physical changes did not negatively impact all mothers’ return to elite-level training and competition.

Discussion

This research enriches the current body of knowledge by providing qualitative data and analysis that highlight the physical and emotional ramifications of the lack of breastfeeding information for elite female distance runners. Our participants reported often stressful experiences and intrapersonal conflicts while worrying about the health impacts for both themselves and their infants of breastfeeding while training. Breastfeeding advice for these women came primarily from their peers, as they were left dissatisfied with information received from other sources such as health care providers and the Internet.

Several participants mentioned their concerns with lactic acid accumulation in breast milk during exercise. Yet none identified an issue with the infant’s acceptance of her breast milk. Nevertheless, many athletes who did decide to return to competition reported using breast milk pumps to pump milk in order to bottle feed their babies with milk that was not expressed immediately postworkout and was thus less likely to contain lactic acid. Pumping also enabled them to maintain their sleeping, training, and competition schedules.

Although issues such as lack of sleep and scheduling challenges are not unique to breastfeeding elite athletes, these challenges were significant for the participants due to their ramifications on their abilities to train and compete at high levels. What is especially interesting is that despite these challenges, the participants breastfed their babies for an average of 9.2 months, with all by one participant breastfeeding for a minimum of 6 months. The countries from which the participants hail report much lower rates of breastfeeding. For example, percentages of infants breastfeeding at 6 months of age in participants’ countries were Australia, 46.2% ²⁹ ; Canada, 51% ³⁰ ; Ireland, 1% were exclusively breastfeeding at 6 months (data on all forms of breastfeeding were unavailable) ³¹ ; UK, 34% ³² ; USA, 49%. ³³ Our participants’ high rates of breastfeeding are similar to results reported by Tenforde, Toth, Langen, Fredericson, and Sainani. They studied 110 female distance runners who ran competitively prior to pregnancy and completed a self-administered online questionnaire. ³⁴ Tenforde et al. reported that “almost all” of their participants breastfed (exact numbers not provided). ³⁴ These high rates of breastfeeding in both studies could, nevertheless, be a result of the demographic characteristics of both groups of participants, members of which had high levels of education attainment (104/110 in Tedforde et al.’s study had at least a 4-year college degree, and 11/11 of our participants had at least a 4-year college degree). Education attainment has been shown to have a positive relationship with breastfeeding duration.^3,35 Although it is possible that competitive distance runners in general breastfeed for longer periods of time, it is also possible that this group is also more health conscious than the general public and is thus more familiar with the health benefits—for both mother and baby—of breastfeeding. Additional research in this area would be beneficial for further examining this relationship.

Although we did not collect data on injury during breastfeeding, our participants were very concerned about preventing injury. The hormone relaxin is “present when a woman is pregnant or breastfeeding, [and] softens joints all over the body” (p. 39). ³⁶ Many ascribed their injury concerns to their postpregnancy ligament laxity, which they felt endured throughout breastfeeding, and took specific measures to address these weaknesses. Further research on specific injury prevention routines for postpartum high-performance distance runners would enable these athletes to have more confidence and less worry in their return to elite athletics.

One important difference between our findings and those of Tedforde et al.’s is that 84.4% of Tedforde et al.’s participants reported that their running had no effect on their breastfeeding, ³⁴ whereas only one of our participants reported feeling that way. The participants in our study were considerably more elite than those in Tenforde et al.’s, which could account for the discrepancy. Additional research in this area would be helpful in providing further clarification.

Conclusion

When breastfeeding, elite female distance runners have a unique set of characteristics that should be considered by those who provide them advice. Our participants sought advice from health care providers but were often left without answers. A synthesis of the limited existing literature on high-level physical activity and breastfeeding ought to be compiled so that evidenced-based guidelines can be identified and drawn upon. Further research should also be conducted to determine the levels of exercise that are the safest in terms of injury prevention for elite athletes who are breastfeeding. Moreover, knowledge translation efforts regarding breastfeeding need to focus on elite athletes, coaches, and healthcare professionals to meet the unique needs of this population. Despite relatively high levels of breastfeeding among this community, there exists a great deal of insecurity for women around the practice of breastfeeding and training. Well-researched, evidence-based guidelines could permit less uncertainty for all athletes—not just distance runners—trying to make decisions with regard to breastfeeding while training and competing at an elite level and also enable health care providers to offer the best possible advice.