Rheumatologists Promote Breastfeeding by Women with Inflammatory Disease

Duke pregnancy registry offers data to encourage lactation

Counseling a pregnant patient

Duke rheumatologists want to encourage breastfeeding among women with rheumatic disease by identifying and addressing factors that limit these women from breastfeeding based on a new analysis of data from the Duke Autoimmunity in Pregnancy Registry.

While the large majority of women with rheumatic disease want to breastfeed, some choose not to do so because of unfounded concerns about side effects of medications, says Megan E. B. Clowse, MD, MPH, leader of a regional referral practice dedicated to treating pregnant women with rheumatic disease. The team operates as part of the Duke Autoimmunity in Pregnancy Clinic.    

Many rheumatologists and patients are aware that most medications prescribed to treat rheumatic disease are compatible with breastfeeding with little, if any, transfer to breastmilk. Antimalarials, glucocorticoids, ibuprofen—all commonly prescribed—as well as immunosuppressants and biologics are safe for use during breastfeeding,

Clowse warns that a few medications should be avoided by women who are breastfeeding primarily because no clinical measures exist regarding their transfer into breastmilk. “There is a possible risk to the infant,” Clowse says.  Medications to avoid are mycophenolate, cyclophosphamide, and tofacitinib.

“We know from our prior research surveying women with inflammatory arthritis across the country that many new mothers do not breastfeed in order to take their medication or initiate breastfeeding but stop their medications and suffered terribly as a result," Clowse says. “My message is that suffering is not necessary. Women can manage their rheumatic disease and breastfeed at the same time. They do not need to choose between medication and breastfeeding.”

Duke Autoimmunity in Pregnancy Registry

To analyze lactation trends among women with rheumatic disease, the team analyzed data from the Duke Autoimmunity in Pregnancy Registry. Clowse launched the registry in 2008 with funding from the Arthritis Foundation; the registry now includes more than 600 pregnancies in women with a range of rheumatic diseases.

Of the 265 women who delivered a live baby and reported their breastfeeding activity, 79% planned to breastfeed, 87% started to breastfeed at delivery, and 67% were still breastfeeding at their follow-up visit.  “The rate of breastfeeding initiation among pregnant women in our registry after delivery was exactly the same as general population in North Carolina, about 87%,” Clowse says. “But when these patients returned six to eight week later, the rate had dropped to 67%.”

Comparing these the women to those that were or were not breastfeeding at follow up, the analysis found that older women, those with a college degree, and those who delivered at term were more likely to be breastfeeding. Importantly, only 5% of all women were taking an anti-rheumatic medication that was not compatible with breastfeeding, Clowse says.

In addition to Clowse, the research team included Amanda Eudy, PhD, an epidemiologist, and Naira Ikram, a Duke University undergraduate.