Getting Pregnant While BreastfeedingAugust 20, 2011. Posted in: After the First Year,Breastfeeding during pregnancy,Older Infant,What is Normal?

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By Hilary Flower, author ofAdventures in Tandem Nursing: Breastfeeding During Pregnancy and Beyond, published by La Leche League International

So you’re 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. Let’s look at seven of the most common questions.

Do I have to wean in order to get pregnant?

Probably not. It is true that breastfeeding can delay the return of fertility, especially while frequency and duration of breastfeeding sessions remain high. But most women can become fully fertile while still breastfeeding.1

Is there a way to bring my fertility back sooner?

Try tinkering with your breastfeeding pattern. Each pair is different. There is no magic or typical threshold of breastfeeding intensity which predicts the return of fertility. Abrupt changes generally bring back fertility more rapidly and at a higher threshold of breastfeeding frequency than gradual changes.1

Of course, you and your child would have to be ready for a radical change. And bear in mind, your body may be trying to space your children more so as to prolong the special status your current nursling is enjoying!

My menstrual cycle has returned; am I fertile yet?

If you are experiencing regular menstrual cycles, and if you were normally fertile before, chances are you have returned to normal fertility. Long, short, or irregular cycles can be a sign that your cycles are not yet fertile. Sometimes it’s just the way your body works; it helps if you have a record of your cycles from before you were breastfeeding.1

How can I tell if I am fertile?

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.

Can I get pregnant before my first period?

Yes! Some lucky and patient moms manage to “catch the first egg.” While you are still amenorrhoeic you can monitor your returning fertility on a family planning chart. Patience is the key, because the amenorrheic period when changes are occurring can involve weeks or months of wet cervical fluid. Weschler’s Taking Charge of Your Fertility has great information on this.

I have had problems with infertility in the past; should I wean before treatments?

If you’re eager to become pregnant first steps may include charting some cycles or reducing breastfeeding to evaluate your fertility status. If you are not ready to try to conceive, though, you may do well to take precautions since fertility reversals do occur.

Although there is no direct research, there is no obvious reason to believe that fertility treatments would harm the breast milk. To find out the latest on how a particular drug affects breastfeeding, turn to Thomas Hale, MD’s Medications and Mothers’ Milk. Clinical observations suggest that Clomid (Clomiphene) is compatible with breastfeeding.2 And there is no reason to expect that breastfeeding would affect your fertility treatment because the drugs will control your cycle.3

Is it safe to continue breastfeeding while pregnant?

Breastfeeding is believed to be compatible with healthy pregnancies. Many moms go on to nurse throughout pregnancy and nurse both newborn and toddler together, an arrangement known as tandem nursing. For the latest in research related to breastfeeding and such concerns as preterm labor, miscarriage, and the nutrition of the unborn child, see my book Adventures in Tandem Nursing: Breastfeeding during Pregnancy and Beyond.

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 world’s leading

researcher on the return of fertility during lactation.

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Breastfeeding through pregnancy and beyondBy Bronwyn Warner, ABA Counsellor

So you're pregnant and still breastfeeding your baby or toddler. You may be wondering if you can continue to breastfeed though your new pregnancy, and even beyond. Perhaps you have been told you must wean. Or maybe you know others who have breastfed through subsequent pregnancies and wondered how it all worked.

Your second and later pregnancies are a special time. You may feel more confident in your role as a mother. Your body has given birth and continued to nourish your baby, completing the natural reproductive role. You could also be apprehensive - how could you love another child as you love your first? Or perhaps you are worried about the physical demands of being pregnant and then having two children to look after. The Australian Breastfeeding Association uses the term 'tandem feeding' to describe concurrent breastfeeding of siblings who are not twins. The children may feed together or at separate times.

As your baby grows into toddlerhood and beyond, your milk is always nutritious and the best food your child could have. If your child's feeds have reduced over time, the immunological benefits are still very valuable. Sometimes a mother, or her child, prefers to wean gradually over the course of the pregnancy, however many are happy to continue, especially if the baby is still quite young or the pregnancy is unexpected. Continuing breastfeeding can also mean an extra rest period or more for you through the day, especially during the first trimester.

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.

What about my unborn child?

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.

How will I feel?

There are various possible side effects to breastfeeding while pregnant. Some mums report their morning sickness being worse during a feed, possibly due to hormonal release in the body, hunger, thirst or tiredness, among other things. You may experience nipple tenderness, as a result of pregnancy hormones, which for some mums can be excruciating. This may last a trimester or longer, or not at all. Paying careful attention to positioning and attachment can relieve the discomfort - lying down to feed may be an option for you. Other mums, despite the pain experienced, continue anyway as the benefits of continuing to breastfeed outweigh any negatives they encounter. Most mums note that this nipple tenderness disappears entirely at birth. Some mothers report that the tenderness is worthwhile, as they have found it helps to reduce problems, such as nipple trauma, after the baby is born.

How will my older child feel?

While you may be feeling positive about feeding two children - meeting their nutritional and emotional needs - how could your older child feel? Many older siblings feel a special bond with the baby, as they are both sharing something very special and important. This can help lessen any feelings of jealousy and resentment, as he's not being left out. More importantly, he's still able to have the one thing that may be most important to him - a breastfeed with mummy.

What about my milk supply?

If your baby is under nine months of age, you eat a healthy well balanced diet and offer the breast whenever your baby seems to be interested, you may find your supply is maintained. Breastmilk remains a major part of your baby's diet. If you feel your baby isn't getting enough breastmilk, you may want to speak to your health adviser. Some mothers find their supply diminishes in response to the hormones in pregnancy.3

To wean or not to wean?

If you choose to wean your baby who is under 12 months of age, you will need to speak to your medical adviser about a suitable substitute. An older baby may be able to drink other liquids from a cup, avoiding the need to introduce a bottle. If your child is old enough, you could explain that you are feeling sick or that your nipples are sore. You could delay feeds, or your child could feed for a shorter period. The Australian Breastfeeding Association booklet, Weaning, has information and suggestions on weaning children of all ages. ABA booklets are available from Mothers Direct.

If your baby or child chooses to wean during pregnancy,2 it is normal to feel guilty - 'Did I hasten the process?' or grief at the end of the relationship. It may help to try and focus on the new baby and the relationship you will have together. Some mothers report that their 'weaned' child returns to the breast after the baby is born.

It may be that your baby isn't ready to wean, no matter what you try. Perhaps reassessing your needs at this time may help. You could try weaning more slowly or try to encourage shorter feeds. You may even decide not to wean.

Why tandem feed?

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.

What about the practicalities?

You could feed both your children at the same time, or one after the other, or at completely different times. You may find that your toddler wants to feed all the time, especially once your milk comes in, and you have a plentiful supply. You may be happy to accommodate this, at least at first, while other mums find it important to limit their toddler's feeds. Only you can decide what works for you. You could try sitting up to feed, perhaps with cushions to help prop you, or maybe laying down to feed will work. There are many ways to tandem feed.

Because you are producing more milk than a mother feeding a singleton, you may find your newborn has difficulty coping with your let down reflex. Changing your feeding routine may help. Perhaps you could offer one side to your toddler, then, after he has stimulated your let down reflex, attach your newborn. ABA's booklet Breastfeeding through Pregnancy and Beyond has many more ideas on the logistics of tandem feeding, as well as many other considerations not mentioned in this article.

We suggest you speak to your medical adviser about breastfeeding through pregnancy and afterwards. The Australian Breastfeeding Association has trained counsellors who can offer you information and support in your decision.

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

Is it safe to breastfeed during pregnancy?

Jan Barger lactation consultant

Absolutely! There's no reason to not continue breastfeeding while you're pregnant if you want to do so. Many mothers not only continue nursing during pregnancy but also "tandem nurse" – that is, breastfeed both their newborn and their older child.

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.

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J Psychiatry Neurosci. Jul 2006; 31(4): 226–228. PMCID: PMC1488905

Pregnancy, depression, antidepressants and breast-feedingPierre BlierAuthor information ► Article notes ► Copyright and License information ►This article has been cited by other articles in PMC.

“Pregnancy protects against depression.” This is a common belief, perhaps based in part on some women experiencing a heightened feeling of emotional well-being during pregnancy. However, the evidence indicates otherwise. In particular, pregnancy is a high-risk period for a relapse of depression. A recent prospective study, conducted on 201 patients who had been euthymic for at least 3 months, examined relapse rates over the course of pregnancy.1 Women who discontinued their medication had more frequent relapses when compared with women who maintained their 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.6–9 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.23–25 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 well-controlled 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.27–30 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 1.5–2 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.

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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 Cyberonics, Eli Lilly, Forest Laboratories, Janssen Pharmaceuticals, Lundbeck, Organon Pharmaceuticals and Wyeth Ayerst and has received grant funding from Eli Lilly, Forest

Laboratories, Janssen Pharmaceuticals, Mitsubishi Pharma, Organon and Wyeth Ayerst. He is President of Medical Multimedia Inc.

Correspondence to: Dr. Pierre Blier, University of Ottawa Institute of Mental Health Research, Royal Ottawa Hospital, LG 2043, 1145 Carling Ave., Ottawa ON K1Z 7K4; fax 613 761-3610; ac.no.gchor@nosliwor

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References

1. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006;295:499-507. [PubMed]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-André E, Hébert 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;108:1839-44. [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;6:681-4. [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 mother-infant 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;64:73-80. [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 20–25; 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]

Breastfeeding during Pregnancy

Position Paper of the Italian Society of Perinatal Medicine and the Task Force on Breastfeeding, Ministry of Health, Italy

1. Irene Cetin , MD12. Paola Assandro , MD23. Maddalena Massari , MD14. Antonella Sagone , PsyD, IBCLC35. Raffaella Gennaretti , CNM, IBCLC46. Gianpaolo Donzelli , MD57. Alessandra Knowles , MSc68. Lorenzo Monasta , MSc, DSc79. Riccardo Davanzo , MD, PhD210. on behalf of the Working Group on Breastfeeding, Italian Society of Perinatal Medicine

and Task Force on Breastfeeding, Ministry of Health, Italy

1. 1Obstetrics and Gynecology Unit, Department of Biomedical and Clinical Sciences, Hospital L. Sacco, University of Milan, Milan, Italy

2. 2Division of Neonatology and NICU, Institute for Maternal and Child Health – IRCCS Burlo Garofolo, Trieste, Italy

3. 3RIFAM, Italian Network of Trainers in Breastfeeding, Rome, Italy 4. 4RIFAM, Italian Network of Trainers in Breastfeeding, Milan, Italy 5. 5Neonatal Medicine, A. Meyer Children’s Hospital, University of Florence, Florence,

Italy 6. 6Health 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 dell’Istria 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 pregnancy–breastfeeding 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.

Breastfeeding during Pregnancy1. Sherrill R. Moscone , MA

1. HIV Neurobehavioral Research Center, Department of Psychiatry, University of California, San Diego.

1. Mary Jane Moore , PhD1. Department of Anthropology, San Diego State University, San Diego, CA 92182

USA.

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.

Miscarriage/Preterm Labor Risks

This is a common worry, but it does not appear to have a strong foundation. A recent review of research on the pregnant uterus reveals that there is actually no theoretical basis for the common concern that breastfeeding can lead to miscarriage or preterm labor in healthy pregnancies. Instead the uterus has many safeguards preventing a strong reaction to the oxytocin that breastfeeding releases.

Interestingly, experts on miscarriage and preterm labor are not among those who see a potential link between breastfeeding and these pregnancy complications. Miscarriage expert Lesley Regan, PhD, MD, quoted in Adventures in Tandem Nursing, saw no reason that breastfeeding should impact pregnancy, even if the mother has a history of miscarriage or is experiencing a threatened miscarriage.

Mother’s health

There is no evidence that a well nourished mother who nurses during pregnancy is at risk nutritionally. Breastfeeding does not increase a mother’s risk for osteoporosis, even when the mother nurses during pregnancy. Breastfeeding reduces the mother’s risk of breast cancer.

Nursling’s 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 milk’s health advantages. Indeed, weaning before two years increases the risk of illness for a child, according to the American Academy of Family Physicians.

Is the milk safe for the toddler?

“Ingestion of hormones of pregnancy through human milk should not be harmful to the breastfeeding child, according to Thomas Hale, PhD, author of the authoritative text Medications

and Mothers’ Milk. In lay person’s terms, he says, the steroids, including many estrogens and progestins, pass poorly into milk sue to their steroid structures. Secondly, these hormones are not readily bioavailable in humans.” [Adventures in Tandem Nursing, p. 61]

See also: A New Look at the Safety of Breastfeeding During Pregnancy by Hilary Dervin Flower, MA

Experts who endorse the safety of breastfeeding through a healthy pregnancy:

Hilary Flower, MA, author of Adventures in Tandem Nursing: Breastfeeding During Pregnancy and Beyond.

Ruth Lawrence, MD, Professor of Pediatrics, Obstetrics and Gynecology at the University of Rochester School of Medicine and Dentistry, and author of Breastfeeding: A Guide for the Medical Profession.

Nancy Mohrbacher, IBCLC and Julie Stock, MA, IBCLC, authors of LLLI’s The Breastfeeding Answer Book.

Jack Newman, MD, FRCPC, author of The Ultimate Breastfeeding Book of Answers. William Sears, MD, Associate Clinical Professor of Pediatrics at the University of

California, Irvine, School of Medicine, and author of The Baby Book and numerous other books.

Debbie Shinskie, RN, IBCLC and Judith Lauwers, BA, IBCLC, authors of Counseling the Nursing Mother.

La Leche League International The American Academy of Family Physicians

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:

The Mother’s Health(Maternal Bone Density, Breast Cancer, Maternal Fat Reserves)

The Nursling’s Health Health of the Fetus/Newborn

(Weight Gain Issues, Miscarriage and Preterm Labor, Fetal Well-Being or Distress, Postpartum Milk Production)

Going Forward Pregnancy Complications Trust Yourself

Can I still breastfeed my son while I'm pregnant?

ShareExpert Answer

The BabyCentre editorial team

Our panel of health writers.

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.