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August 20, 2011. Posted in: After the First Year,Breastfeeding during pregnancy,Older
Infant,What is Normal?
PDF version (great for printing)
By Hilary Flower, author of
Adventures in Tandem Nursing: Breastfeeding During Pregnancy and Beyond, published by La
Leche League International
So youre breastfeeding and dreaming of a new baby? Good news! Lots of moms are able to
conceive a new baby without having to wean their current nursling. Lets look at seven of the
most common questions.
If you wish to know more about your fertility status, you can gain remarkable insights using
simple family planning methods. Toni Weschler, MPH, includes a section on charting during
breastfeeding in her wonderful guide Taking Charge of Your Fertility.
REFERENCES
1. McNeilly, AS, Glasier, AF, Howie PW, Houston MJ, Cook A, Boyle H. Fertility after
childbirth: Pregnancy associated with breastfeeding. Clinical Endocrinology (1983)
18:167-173.
2. Hale, Thomas, MD, personal communication 2002.
3. McNeilly, Alan, PhD, personal communication, 2002. McNeilly is the worlds leading
researcher on the return of fertility during lactation.
More:
All women's bodies are different, but many find they can conceive even while they are
breastfeeding. Sometimes introducing solids or other supplements to breastmilk is enough to
trigger ovulation. With other women, it takes long breaks between feeds, of four or more hours,
or their baby starting to sleep through the night.
You may be concerned about the viability of the pregnancy if you continue to feed. In a normal,
healthy pregnancy, with no previous history of miscarriage in the first 20 weeks or preterm
labour after 20 weeks, there is no evidence to suggest breastfeeding is threatening to a
pregnancy.1,2 If you do miscarry, it is unlikely to be because you are breastfeeding.
Sometimes you may be told that breastfeeding is taking 'the goodness away from the unborn
baby'. The reality is your unborn baby has first call on all the nutrients it needs, and may even be
healthier than normal, as you may eat better and take better care of yourself during the
pregnancy. The other worry people may have is your newborn may be deprived of colostrum.
Some mothers do restrict their toddler to one side only during late pregnancy, but it appears the
breast reverts to making colostrum automatically without mum having to do anything to help it
do so.3
Your body may start to make colostrum during the pregnancy of its own accord, or this may
occur if your child stops feeding for a while. The taste of colostrum may encourage weaning, at
least temporarily, as it is saltier than mature milk. Other breastfeeding children don't mind at all.
Be aware that colostrum is a natural laxative (to help the newborn pass the meconium), so bowel
motions may become far more liquid. This won't harm your child at all.
As you are normally advised to adjust your diet to allow for additional nutritional needs during
pregnancy or breastfeeding, obviously, it is important to do so while doing both. There is little
research on the requirements of a tandem breastfeeding mum, but we understand that our bodies
are able to adjust metabolism so we don't need to consume extra large quantities of vitamins and
minerals etc. The Australian Breastfeeding Association booklet Looking after Yourself contains
the guidelines for healthy eating. ABA booklets are available from Mothers Direct.
You may have read or been told that 'mothers only feed older children for their own sake'. Of
course, this isn't true (except perhaps in an emotional and health sense). It can be a wonderful
experience tandem feeding or feeding an older child. There are few things more satisfying than
watching your children holding hands while breastfeeding together. The Australian Breastfeeding
Association's booklet Breastfeeding through Pregnancy and Beyond and Norma Jane
Bumgarner's Mothering your Nursing Toddler are good sources of information, encouragement
and support. Both are available for purchase from Mothers Direct.
References
1. Ishii H 2009, Does breastfeeding induce spontaneous abortion? J. Obstet. Gynaecol
45(5): 864-868.
2. Moscone SR, Moore MJ 1993, Breastfeeding during pregnancy. J Hum Lact 9(2):83-88.
3. Marquis GS, Penny ME, Diaz JM, Marin RM 2002, Postpartum consequences of an
overlap of breastfeeding and pregnancy: reduced breast milk intake and growth during
early infancy. Pediatrics 109(4):e56-e56.
Australian Breastfeeding Association Reviewed October 2012
You may worry that you won't be able to eat enough to both nourish the baby growing inside and
produce enough breast milk for the nursling, but our bodies are amazing and know exactly what
to do. Eating a healthy, well-balanced diet eating when you're hungry and drinking when you're
thirsty is all that's needed.
Here are some other things to be aware of as you nurse during pregnancy. All of these are
perfectly normal:
Your nipples and breasts may be more tender during pregnancy.
Your milk supply may diminish a bit.
Verbal toddlers may announce that your breast milk tastes different. Why? Because toward the
end of pregnancy, breast milk changes to a colostral type of milk. (Colostrum is the thick,
yellowish milk your body produces while you're pregnant and for the first few days after your
baby is born.)
Some moms are concerned that nipple stimulation during breastfeeding will lead to premature
labor. Nipple stimulation does trigger your body's production of the hormone oxytocin, which
helps with milk letdown and also plays a role in the contractions you have during labor.
Fortunately, the amount of oxytocin released isn't enough to stimulate labor under normal
circumstances.
The relase of oxytocin is only a concern if you're at risk for early labor and your doctor or
midwife has put you on strict bedrest, with no lovemaking or breast play allowed.
Share
J Psychiatry Neurosci. Jul 2006; 31(4): 226228.
PMCID: PMC1488905
medication, with a hazard ratio of 5.0. Moreover, in the women who discontinued their
antidepressant, the reintroduction of medication decreased the risk of relapse, but to a much
lesser extent than if medication was continued throughout pregnancy. Therefore, transient
interruption of medication may still predispose pregnant women to a negative outcome. In
addition, allowing major depression to occur during pregnancy may result in a negative impact
on fetal conditions. Because the placental barrier is limited in its capacity to protect the fetus
against the systemic perturbations that depression can produce, it appears imperative to prevent
depressive relapses from occurring. The endogenous substances that can be produced in greater
concentrations during depression, and could have a negative impact, include cortisol and
catecholamines. The former can lead to increased corticotropin-releasing factor production,
which can induce premature labour, whereas the latter can alter uterine blood flow and induce
uterine irritability.2,3 Finally, depressed mothers may have a decreased appetite and may be more
at risk of using alcohol or illicit drugs, factors that can have a negative impact on the fetus.4,5
Therefore, it is important to weigh the benefits of not allowing depression to occur during
pregnancy against the risks of using antidepressants during this period. The use of
antidepressants clearly offers a protective influence against such relapse.
Antidepressants increase the risk of congenital malformations and perturb organ development.
Again, the evidence indicates otherwise. Reviews of the literature indicate that antidepressants,
especially selective serotonin reuptake inhibitors (SSRIs), do not increase the risk of major and
minor malformations.69 However, there would appear to be a small, but statistically significant,
increased risk of spontaneous abortions with SSRIs. The role of depression itself cannot be
eliminated as a contributing factor to this increase from 8.7% to 12.4%.10 More troublesome is a
recent study reporting an increase of persistent pulmonary hypertension of the newborn (PPHN)
in babies whose mothers were exposed to SSRIs after the first 20 weeks of gestation.11 This study
reported that 14 infants with PPHN had been exposed to an SSRI (3.7%) versus 6 control infants
(0.7%). Nevertheless, it is important to mention that the crude risk of PPHN at any time in
pregnancy was not increased by SSRI exposure. This seemed to result from an apparent, though
not significant (p = 0.08), protective effect of SSRIs in the first 20 weeks. It is also possible that
the finding resulted from studying a small number of subjects. As an illustration of the latter
possibility, the number needed to treat to obtain 1 PPHN was 200. This study cannot establish
causality, as pointed out by the authors themselves, but it is well known that serotonin has
mitogenic and comitogenic effects on pulmonary smooth-muscle cells that can produce
pulmonary hypertension (PH).12,13 It was thus postulated that elevated circulating levels of
serotonin, presumably resulting from reuptake inhibition by the SSRIs, could be responsible for
the proliferation of smooth-muscle cells seen in PH.11 The problem with this hypothesis is that
SSRIs have been shown to protect against smooth-muscle hyperplasia in the pulmonary bed.14
This is because serotonin reuptake inhibition in the periphery decreases circulating levels of
serotonin, since platelets can no longer store serotonin through reuptake,15 thereby decreasing
any potential release. It should be noted, in support of this mechanism, that serotonin synthesis
inhibition has the same effect as fluoxetine.16 In mice with the serotonin transporter (5-HTT)
gene deleted, pulmonary hemodynamic parameters are normal, and when these mice are exposed
to hypoxia, the number and medial-wall thickness of muscular pulmonary vessels are reduced.17
Finally, in patients with chronic pulmonary obstructive disease, the presence of two l alleles,
which is associated with a higher level of 5-HTT expression in pulmonary artery smooth-muscle
cells than the l/s or s/s genotypes, is associated with higher PH.18 Consequently, the purported
role of SSRI exposure in PPHN after the first 20 weeks of pregnancy appears doubtful.
Antidepressants during pregnancy may alter neurocognitive development and predispose to
mood and anxiety disorders later in life. This possibility was raised on the basis of impaired
performance of rodents in some models of rat depression and anxiety.19,20 A persistent decrease of
serotonin-dependent neuronal firing activity in adulthood has also been reported following
neonatal exposure of rats to a serotonin reuptake inhibitor, but this is inconsistent with the
findings of an earlier study.21,22 Three studies of children exposed to antidepressants and followed
up to the age of 7 years showed no significant difference in intelligence quotient, language and
behaviour.2325 A fourth study showed subtle changes in motor movement control in children, but
these children were not age-matched and were tested at varying ages.26 The issue of
predisposition to psychopathology thus remains an open question and will require wellcontrolled studies before any conclusion may be reached.
Taking antidepressants while breast-feeding leads to harmful exposure to the baby.
Antidepressants are present in breast milk generally at concentrations present in the plasma.
However, when their levels are examined in the plasma of babies of mothers taking therapeutic
doses, they are often undetectable or near the threshold of the method.2730 This may appear
surprising, but if one does the math, it is really what should be expected. In the case of
paroxetine, for example, the plasma concentration is between 20 ng/mL and 100 ng/mL in
individuals taking the minimal effective dose of 20 mg/d.31 This means that the baby is ingesting
milk containing about this concentration of paroxetine. Assuming a 5-kg baby drinks about 1
litre per day, this would represent 100 000 ng/d or 0.1 mg/d if the mother has a plasma
concentration of 100 ng/mL. This would only correspond to a daily dose of 1.52 mg/d for an
adult of average weight. Nevertheless, it is still possible that such low exposure could lead to
significant occupancy of 5-HTT in the brain. Indeed, an occupancy of about 50% of 5-HTT was
recently reported in rat pups feeding from mothers receiving fluoxetine, despite the pups having
very low or undetectable levels of fluoxetine/norfluoxetine.32 This degree of occupancy is still
lower than that which is necessary to obtain an antidepressant effect (~80%), because there is a
significant reserve of 5-HTT.33 Finally, the low level of SSRI exposure during breast-feeding
does not impair infant weight gain, whereas an exposure to maternal depression lasting 2 months
or more does impair weight gain.34
In summary, it seems clear that the risks of not receiving adequate antidepressant treatment thus
far outweigh the risks of adverse events, not only in infants but in mothers as well. The
population should therefore learn to fear the illness more than the antidepressant.
Go to:
Footnotes
Competing interests: Dr. Blier is a consultant with Biovail, Eli Lilly, Forest Laboratories,
Janssen Pharmaceuticals, Lundbeck, Organon Pharmaceuticals, Roche Pharmaceuticals,
Sepracor, Wyeth Ayerst and Sanofi-Aventis and is a contract employee with Forest Laboratories,
Janssen Pharmaceuticals and Steelbeach Productions. He is in the speaker's bureau for
References
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women who maintain or discontinue antidepressant treatment. JAMA 2006;295:499-507.
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2. Lockwood CJ. Stress-associated preterm delivery: the role of corticotropin-releasing hormone.
Am J Obstet Gynecol 1999;180:S264-6. [PubMed]
3. Teixeira JM, Fisk NM, Glover V. Association between maternal anxiety in pregnancy and
increased uterine artery resistance index: cohort based study. BMJ 1999;318:153-7. [PMC free
article] [PubMed]
4. Lou HC, Hansen D, Nordentoft M, et al. Prenatal stressors of human life affect fetal brain
development. Dev Med Child Neurol 1994;36:826-32. [PubMed]
5. Orr ST, Miller CA. Maternal depressive symptoms and the risk of poor pregnancy outcome.
Review of the literature and preliminary findings. Epidemiol Rev 1995;17:165-71. [PubMed]
6. Gentile S. The safety of newer antidepressants in pregnancy and breastfeeding. Drug Saf
2005;28:137-52. [PubMed]
7. Sivojelezova A, Shuhaiber S, Sarkissian L, et al. Citalopram use in pregnancy: prospective
comparative evaluation of pregnancy and fetal outcome. Am J Obstet Gynecol 2005;193:2004-9.
[PubMed]
8. Rahimi R, Nikfar S, Abdollahi M. Pregnancy outcomes following exposure to serotonin
reuptake inhibitors: a meta-analysis of clinical trials. Reprod Toxicol 2006 May 21 [Epub ahead
of print]. [PubMed]
9. Einarson TR, Einarson A. Newer antidepressants in pregnancy and rates of major
malformations: a meta-analysis of prospective comparative studies. Pharmacoepidemiol Drug
Saf 2005;14:823-7. [PubMed]
10. Hemels ME, Einarson A, Koren G, et al. Antidepressant use during pregnancy and the rates
of spontaneous abortions: a meta-analysis. Ann Pharmacother 2005;39:803-9. [PubMed]
11. Chambers CD, Hernandez-Diaz S, Van Marter LJ, et al. Selective serotonin-reuptake
inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med
2006;354:579-87. [PubMed]
12. Runo JR, Loyd JE. Primary pulmonary hypertension. Lancet 2003;361:1533-44. [PubMed]
13. Eddahibi S, Raffestin B, Hamon M, et al. Is the serotonin transporter involved in the
pathogenesis of pulmonary hypertension? J Lab Clin Med 2002;139:194-201. [PubMed]
14. Marcos E, Adnot S, Pham MH, et al. Serotonin transporter inhibitors protect against hypoxic
pulmonary hypertension. Am J Respir Crit Care Med 2003;168:487-93. [PubMed]
15. Blier P, Saint-Andr E, Hbert C, et al. Effects of different doses of venlafaxine on serotonin
and norepinephrine reuptake in healthy volunteers. Int J Neuropsychopharmacol 2006 May
[Epub ahead of print]. [PubMed]
16. Eddahibi S, Guignabert C, Barlier-Mur AM, et al. Cross talk between endothelial and smooth
muscle cells in pulmonary hypertension: critical role for serotonin-induced smooth muscle
hyperplasia. Circulation 2006;113:1857-64. [PubMed]
17. Eddahibi S, Hanoun N, Lanfumey L, et al. Attenuated hypoxic pulmonary hypertension in
mice lacking the 5-hydroxytryptamine transporter gene. J Clin Invest 2000;105:1555-62. [PMC
free article] [PubMed]
18. Eddahibi S, Chaouat A, Morrell N, et al. Polymorphism of the serotonin transporter gene and
pulmonary hypertension in chronic obstructive pulmonary disease. Circulation 2003;108:183944. [PubMed]
19. Ansorge MS, Zhou M, Lira A, et al. Early-life blockade of the 5-HT transporter alters
emotional behavior in adult mice. Science 2004;306:879-81. [PubMed]
20. Maciag D, Simpson KL, Coppinger D, et al. Neonatal antidepressant exposure has lasting
effects on behavior and serotonin circuitry. Neuropsychopharmacology 2006;31:47-57. [PMC
free article] [PubMed]
21. Maudhuit C, Hamon M, Adrien J. Electrophysiological activity of raphe dorsalis
serotoninergic neurones in a possible model of endogenous depression. Neuroreport 1995;6:6814. [PubMed]
22. Vogel G, Hagler M, Hennessey A, et al. Dose-dependent decrements in adult male rat sexual
behavior after neonatal clorimipramine treatment. Pharmacol Biochem Behav 1996;54:605-9.
[PubMed]
23. Nulman I, Rovet J, Stewart DE, et al. Neurodevelopment of children exposed in utero to
antidepressant drugs. N Engl J Med 1997;336:258-62. [PubMed]
24. Nulman I, Rovet J, Stewart DE, et al. Child development following exposure to tricyclic
antidepressants or fluoxetine throughout fetal life: a prospective, controlled study. Am J
Psychiatry 2002;159:1889-95. [PubMed]
25. Misri S, Reebye P, Kendrick K, et al. Internalizing behaviors in 4-year-old children exposed
in utero to psychotropic medications. Am J Psychiatry 2006;163:1026-32. [PubMed]
26. Casper RC, Fleisher BE, Lee-Ancajas JC, et al. Follow-up of children of depressed mothers
exposed or not exposed to antidepressant drugs during pregnancy. J Pediatr 2003;142:402-8.
[PubMed]
27. Suri R, Stowe ZN, Hendrick V, et al. Estimates of nursing infant daily dose of fluoxetine
through breast milk. Biol Psychiatry 2002;52:446-51. [PubMed]
28. Baab SW, Peindl KS, Piontek CM, et al. Serum bupropion levels in 2 breastfeeding motherinfant pairs. J Clin Psychiatry 2002;63:910-1. [PubMed]
29. Stowe ZN, Hostetter AL, Owens MJ, et al. The pharmacokinetics of sertraline excretion into
human breast milk: determinants of infant serum concentrations. J Clin Psychiatry 2003;64:7380. [PubMed]
30. Berle JO, Steen VM, Aamo TO, et al. Breastfeeding during maternal antidepressant treatment
with serotonin reuptake inhibitors: infant exposure, clinical symptoms, and cytochrome p450
genotypes. J Clin Psychiatry 2004;65:1228-34. [PubMed]
31. Gilmor ML, Owens MJ, Nemeroff CB. Inhibition of norepinephrine uptake in patients with
major depression treated with paroxetine. Am J Psychiatry 2002;159:1702-10. [PubMed]
32. Jones CFC, Stowe ZN, Owens MJ. Serotonin transporter occupancy in rats exposed to
fluoxetine in utero or via breast milk [abstract]. American Psychiatric Association meeting; 2006
May 2025; Toronto. New Research Abstracts (NR521):217.
33. Meyer JH, Wilson AA, Sagrati S, et al. Serotonin transporter occupancy of five selective
serotonin reuptake inhibitors at different doses: an [11C]DASB positron emission tomography
study. Am J Psychiatry 2004;161:826-35. [PubMed]
34. Hendrick V, Smith LM, Hwang S, et al. Weight gain in breastfed infants of mothers taking
antidepressant medications. J Clin Psychiatry 2003;64:410-2. [PubMed]
6.
Health Services Research and International Health Unit, Institute for Maternal and
Child Health IRCCS Burlo Garofolo, Trieste, Italy
7. 7Epidemiology and Biostatistics Unit, Institute for Maternal and Child Health IRCCS
Burlo Garofolo, Trieste, Italy
1. Lorenzo Monasta, MSc, DSc, Epidemiology and Biostatistics Unit, Institute for Maternal
and Child Health IRCCS Burlo Garofolo, Via dellIstria 65/1, IT-34137 (TS), Italy.
Email: lorenzo.monasta@burlo.trieste.it
Abstract
As more women breastfeed for longer, it is increasingly likely that women may be still
breastfeeding when they become pregnant again. The Italian Society of Perinatal Medicine
(SIMP) Working Group on Breastfeeding has reviewed the literature to determine the medical
compatibility of pregnancy and breastfeeding. We found no evidence indicating that healthy
women are at higher risk of miscarriage or preterm delivery if they breastfeed while pregnant.
No evidence indicates that the pregnancybreastfeeding overlap might cause intrauterine growth
restriction, particularly in women from developed countries. Little information is available on the
composition of human milk of pregnant women, and we found no data on the growth of infants
nursed by a pregnant woman. However, both the composition of postpartum breast milk and the
growth of the subsequent newborn appear to be partly affected, at least in developing countries.
SIMP supports breastfeeding during pregnancy in the first 2 trimesters, and we believe it to be
sustainable in the third trimester. Based on the hypothetical risk, caution may be warranted for
women at risk of premature delivery, although no evidence exists that breastfeeding could trigger
labor inducing uterine contractions. In conclusion, currently available data do not support routine
discouragement of breastfeeding during pregnancy. Further studies are certainly needed to
explore the consequences of breastfeeding during pregnancy on maternal health, on the breastfed
infant, on the embryo/fetus, and, subsequently, on the growth of the newborn.
Abstract
Questionnaire data were gathered on the experiences of 57 women who were concurrently
pregnant and breastfeeding. Respondents provided information on nursing and weaning patterns,
informational and emotional support, and pregnancy history. The main reasons given for
continued breastfeeding after conception were the emotional needs of the child or child-led
weaning. Forty-three percent of the children continued to breastfeed throughout the pregnancy
and tandem nurse after the birth. Mothers who initiated weaning cited breast and/or nipple pain
as the principal reason. Most weanings initiated by the children occurred during the second
trimester, corresponding with the diminution of breastmilk. The infants born to these mothers
were healthy and appropriate for gestational age.
Yes, in most cases. At this time no medical study has been done on the safety of breastfeeding
during pregnancy so it is impossible to list any definitive contraindications. If you are having a
complicated pregnancy, such as lost weight, bleeding, or signs of preterm labor, you should
problem-solve your individual situation with your caregiver. Depending on your individual
situation and feelings you may decide that continued breastfeeding, reduced breastfeeding, or
weaning is for the best.
Breastfeeding Contractions
Although uterine contractions are experienced during breastfeeding, they are a normal part of
pregnancy. Similar contractions often occur during sexual intercourse, which many couples
continue throughout pregnancy.
Mothers health
There is no evidence that a well nourished mother who nurses during pregnancy is at risk
nutritionally. Breastfeeding does not increase a mothers risk for osteoporosis, even when the
mother nurses during pregnancy. Breastfeeding reduces the mothers risk of breast cancer.
Nurslings health
Your child will benefit from breastfeeding into the second year and beyond. The milk is just as
safe during pregnancy, but pregnancy can cause milk to dwindle and can also motivate mother
and child to wean. Thus if pregnancy does cause a child to receive less milk, the child will
receive proportionally fewer of milks health advantages. Indeed, weaning before two years
increases the risk of illness for a child, according to the American Academy of Family
Physicians.
Nancy Mohrbacher, IBCLC and Julie Stock, MA, IBCLC, authors of LLLIs The
Breastfeeding Answer Book.
Jack Newman, MD, FRCPC, author of The Ultimate Breastfeeding Book of Answers.
Debbie Shinskie, RN, IBCLC and Judith Lauwers, BA, IBCLC, authors of
Counseling the Nursing Mother.
For extensive research-based information on the safety of breastfeeding during pregnancy, see
Adventures in Tandem Nursing: Breastfeeding During Pregnancy and Beyond by Hilary Flower.
The chapter on health concerns includes a list of 85 references.
Health topics covered include:
Going Forward
Pregnancy Complications
Trust Yourself
Yes, your body will carry on making milk while you're pregnant, so you will be able
to breastfeed. And after the birth you can breastfeed both your babies (tandem
feeding), if you'd like to.
Breastfeeding during pregnancy is fine if your pregnancy is going well, and you are
healthy. Make sure you're eating a healthy, balanced diet, so you and your baby are
getting all the nutrients you need. If you are suffering from pregnancy sickness, just
eat whatever you can cope with, though.
In early pregnancy you may have sensitive nipples because of hormonal changes.
This may mean your nipples are sore when you breastfeed. Your body releases a
hormone called oxytocin when you're breastfeeding to let your milk down. Oxytocin
is also important in labour, but your uterus (womb) won't react to oxytocin until the
end of your pregnancy, after 37 weeks.
If your son is less than a year old and you are breastfeeding him while you're
pregnant, make sure that he is still putting on weight after your milk changes.
Whether or not you want to carry on feeding your son once your new baby arrives is
a personal decision. If you do, the good news is that mums who tandem feed are
less likely to get mastitis than mums who feed one baby.
If you decide that tandem feeding isn't for you, aim to wean your son while you're
pregnant. If you leave it until after his new sibling arrives, he may feel left out at a
time when he'll already have lots of adjustments to make.