Breastfeeding Concerns With Arthritis

By Linda Rath | March 22, 2022

New parents have a lot to contend with; having a rheumatic disease adds extra challenges. If you’re considering having a baby, you probably have real concerns about breastfeeding, medication and vaccine safety and disease flares – common in the weeks or months after giving birth. Having a baby that’s premature or smaller than normal raises worries about their health and ability to thrive. And you might not get all the family planning and parenting advice and support you need from health care providers.

To ensure that both providers and patients have up-to-date, evidence-based information, the American College of Rheumatology (ACR) released a comprehensive reproductive health guideline in 2020. Among other things, it answers important questions about the postpartum period for people with inflammatory arthritis.

Is It Safe to Breastfeed?

The ACR, American Academy of Pediatrics and World Health Organization (WHO) strongly recommend breastfeeding for people who can and want to, including most women with rheumatic diseases. They suggest feeding breast milk exclusively for the first six months, then supplementing with solid food until the baby is at least a year old.

Here’s why: Breastfeeding boosts your baby’s immune system, helping to prevent many childhood infections, allergies and chronic conditions like asthma, type 2 diabetes and obesity. Mothers who breastfeed have less stress, post-delivery bleeding and a reduced risk of breast and ovarian cancer. Many also say it fosters a deeper connection with their baby.

A study of 265 new mothers with various rheumatic diseases found that most wanted to breastfeed, and two-thirds were breastfeeding at the first postpartum visit – about eight weeks after delivery. Although only a few needed to take methotrexate or other drugs that are not safe in pregnancy, many hadn’t planned to breastfeed because of medication concerns.

Some studies found that people with lupus are less likely to breastfeed than those with inflammatory arthritis; other research shows that while people with lupus start out breastfeeding at high rates, they’re more likely to stop sooner. Those who took hydroxychloroquine were more likely to continue to breastfeed, possibly because they were less likely to have flares or concerns about medication safety.

Not everyone can nurse their baby successfully, and some people choose not to. But formula can’t match breast milk for nutrients, digestibility and healthy antibodies, so consider pumping and storing your own milk for your baby if you don’t breastfeed.

Are Arthritis Drugs Safe During Breastfeeding?

In general, the same medications that are safe during pregnancy are also compatible with breastfeeding, according to Lisa Samaritano, MD, a rheumatologist at Hospital for Special Surgery in New York City and lead author of the ACR guideline. This can vary, though, depending on the drug, your infant’s age, and how much you breastfeed. For most people who are breastfeeding:

• Hydroxychloroquine, colchicine, sulfasalazine, rituximab, and tumor necrosis factor (TNF) inhibitors, such as etanercept (Enbrel) and adalimumab (Humira), are considered compatible with breastfeeding, although sulfasalazine is not a preferred choice.
•  Less than 20 mg of prednisone or other glucocorticoid (corticosteroid) is OK, but the baby should be monitored. If you take a higher dose, avoid breastfeeding (or pump and discard your milk) for four hours after taking the steroid.
• Methotrexate, mycophenolate mofetil, cyclophosphamide, leflunomide or thalidomide are not safe with breastfeeding; they can build up in your baby’s tissues and cause serious harm.
• There’s not enough data to know if small-molecule drugs including tofacitinib (Xeljanz), apremilast (Otezla) and baricitinib (Olumiant) pass into breast milk, but it’s likely they do. The Food and Drug Administration also has heightened warnings about the overall safety of JAK inhibitors like baricitinib and tofacitinib, including for adults.
• If your partner is breastfeeding and you take arthritis drugs, ask your doctor about any necessary precautions.

What About Vaccines?

If you take drugs that suppress your immune system, inactivated vaccines are generally safe while you’re breastfeeding. You should avoid live vaccines, which have the potential to cause infection in you and your baby.

Inactivated vaccines include those for:

• Tetanus, diphtheria, and pertussis (TDaP)
• Haemophilus influenza type B (Hib)
• Inactivated polio vaccine
• Hepatitis A and B
• Pneumonia vaccines
• Inactivated flu vaccine

Live vaccines include those for:

• Measles, mumps, and rubella (MMR)
• Varicella (chickenpox)
• Live flu vaccine (FluMist nasal spray)
• Yellow fever
• Rotavirus
• Bacillus Calmette-Guerin (tuberculosis)

If you took TNF blockers while you were pregnant, avoid giving your newborn live vaccines until about seven months of age to allow the drug enough time to clear the baby’s system.

What About COVID Vaccines?

People who are breastfeeding weren’t included in clinical trials of the COVID vaccines used in the United States, so it’s not known how the vaccine affects nursing infants. Some reports show that antibodies from mRNA vaccines like those from Moderna and Pfizer can pass to babies through breast milk, but it’s not clear how much protection they provide.

Will My Arthritis Flare?

Postpartum flares are common, and though not everyone has them, they’re a major concern for many people planning a family. The fear is that severe disease will prevent moms from breastfeeding, caring for a newborn or going back to work. Making reproductive decisions with so many unknowns, including the possibility and severity of flares, can be profoundly draining psychologically.

It’s not usually possible to predict who will have flares or how long-lived or serious they might be, but you’re less likely to flare if your symptoms are under good control before you become pregnant. The type of medication you take, as long as it’s compatible with pregnancy, doesn’t seem to affect flares.

Research suggests that people with lupus have fewer and milder flares than those with rheumatoid arthritis. One study of 234 people with lupus found a little more than a quarter had mild or moderate postpartum flares and fewer than 2% had severe ones. On the other hand, around 90% of rheumatoid arthritis patients have postpartum flares, usually within the first three months. Your doctor may suggest you restart your meds a few weeks after delivery to try to prevent this.

Still, the best advice is to plan ahead. Line up friends and family willing to help when you need it, and plan your finances in case you can’t go back to work as soon as you thought.