Saturday, 5 September 2015

ClinicSpeak & ResearchSpeak: breastfeeding reduces the risk of relapse

Can we now view breastfeeding as a DMT? #ClinicSpeak #ResearchSpeak #MSBlog #MSResearch

"The prospective study from the German MS and pregnancy register confirms that breastfeeding exclusively for a period of 2 months lowers your risk of having a relapse. Woman MSers who did not breastfeed after delivery were 1.8X more likely to have a relapse compared to those who chose to breastfeed. These results mirror the meta-analysis Julia Pakpoor in our group did 3 years ago (see below)."


"These results are very reassuring and will help women make a decision about breast feeding. What about starting your DMTs, whilst breastfeeding? All DMTs are relatively contraindicated whilst breast feeding. This simply relates to a blanket position the regulators take when licensing DMTs. We take a more pragmatic approach and advise on restarting DMTs depending on how active the MS was before pregnancy. In patients who had highly-active or rapidly evolving severe MS, before falling pregnant, we tend to restart the DMT as soon as possible after delivery. In women with less active MS we tend to wait until after a period of breastfeeding. Some DMTs, particularly peptides (GA), proteins (IFNbeta, monoclonal antibodies) or metabolites (DMF), are safe as they cross over into the breast milk in such small amounts they are unlikely to have an effect on  the baby. In addition, the baby's digestive system will breakdown and process these classes of molecules. It is however, different, for small molecule, e.g. fingolimod and teriflunomide, and we don't recommend breastfeeding on these DMTs."



Hellwig et al. Exclusive Breastfeeding and the Effect on Postpartum Multiple Sclerosis Relapses. JAMA Neurol. 2015 Aug 31. doi: 10.1001/jamaneurol.2015.1806. 

IMPORTANCE: Women with multiple sclerosis (MS) experience an elevated risk of relapse after giving birth. The effect of exclusive breastfeeding on postpartum risk of MS relapse is unclear.

OBJECTIVES: To determine the effect of exclusive breastfeeding on postpartum risk of MS relapse and to investigate the effect of introducing supplemental feedings on that risk.

DESIGN, SETTING, AND PARTICIPANTS: Data on 201 pregnant women with relapsing-remitting MS were collected prospectively from January 1, 2008, to June 30, 2012, with 1 year follow-up post partum in the nationwide German MS and pregnancy registry. The effect of the intention to breastfeed exclusively (no regular replacement of breastfeeding meals with supplemental feedings) for at least 2 months compared with nonexclusive breastfeeding (partial or no breastfeeding) on the first postpartum MS relapse, using Cox proportional hazards regression model adjusted for age and disease activity, before and during pregnancy was analyzed. Data analysis was performed from August 30, 2013, to May 25, 2015.

EXPOSURE: Exclusive breastfeeding defined as at least 2 months of breastfeeding without regular replacement of any meal by supplemental feeding.

MAIN OUTCOME AND MEASURE: First postpartum MS relapse.

RESULTS: Of 201 women, 120 (59.7%) intended to breastfeed exclusively for at least 2 months and 81 (40.3%) breastfed and included supplemental feeding (42 [20.9%]) or did not breastfeed (39 [19.4%]). Thirty-one women (38.3%) who did not breastfeed exclusively had a relapse within the first 6 months postpartum compared with 29 women (24.2%) who intended to breastfeed exclusively for at least 2 months (unadjusted hazard ratio, 1.80; 95% CI, 1.09-2.99; P = .02; adjusted hazard ratio, 1.70; 95% CI, 1.02-2.85; P = .04). The time to first postpartum relapse after the introduction of supplemental feedings did not differ significantly between women who previously breastfed exclusively and those who did not (P = .60).

CONCLUSIONS AND RELEVANCE: The findings of this study suggest that exclusive breastfeeding is a modestly effective MS treatment with a natural end date. Our study provides further evidence that women with MS who breastfeed exclusively should be supported to do so since it does not increase the risk of postpartum relapse.

META-ANALYSIS

Pakpoor et al. Breastfeeding and multiple sclerosis relapses: a meta-analysis. J Neurol. 2012 Oct;259(10):2246-8.



CoI: Prof G is a co-author on the 2012 meta-analysis

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