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MS, Medications and Mothers Milk

Very few people these days decide against breastfeeding their baby. In Australia, more than 90% of
babies begin life fed on their mothers milk. While establishing and maintaining breastfeeding can be a
challenge, with the right support most women set out to meet the infant nutrition guidelines of
exclusive breastfeeding until solids are introduced around six months and continued breastfeeding for
one year or more. (The World Health Organisation recommend two years and beyond)
Alongside the nutrition and health outcomes of breastfeeding, the emotional connection between
mother and child is often an unconsidered bonus: whilst acknowledging the role of breastfeeding in
mother/child bonding, often that bond is forgotten by others, who see only a child being fed.
So imagine the impact of being told - perhaps after a time of blood, sweat and tears to establish
breastfeeding - now you must now wean as soon as possible, for your own health?
This is the issue that faces many women with MS.
When a woman with MS conceives a baby or a pregnant or new mother is diagnosed with the disease
the issue of continuing or beginning treatment is paramount in the neurologists mind.1 Breastfeeding
may be supported for a short time, but longer term can be seen as a barrier to the management of the
mothers MS. Yet to the mother, the thought of not being able to begin or continue to breastfeed can be
traumatic. And for the baby, weaning is not just a matter of learning to drink formula from a bottle, but
the loss of a strong connection with his/her mother.
So how are the physical and emotional health of the mother and child to be balanced with the medical
needs of the woman with MS?
Ideally, the mother needs support and understanding of her circumstances and time to look at all her
options. Her health care providers need to be sensitive to the distress that premature weaning can
cause for both mother and baby.
It is also worth keeping in mind the positive aspects of breastfeeding in the health of mother AND child:

Breastfeeding reduces the childs own risk of developing MS later in life.2


Breastfeeding reduces the risk of relapse in the post-partum period.3
Women who breastfeed report significantly more hours of sleep, better physical health, more
energy, and lower rates of depression than mixed- or formula-feeding mothers.

Pregnancy and Multiple Sclerosis, October 1st 2013, http://www.overcomingmultiplesclerosis.org/AboutMS/Pregnancy-and-MS/ [Accessed 9/12/13]
2
Conradi, Malzhan, et al. Breastfeeding is associated with lower risk for multiple sclerosis. Multiple Sclerosis
Journal 19, April 2013 553-558
3
Exclusive Breastfeeding May Protect against MS relapse, http://www.unicef.org.uk/BabyFriendly/News-andResearch/Research/Miscellaneous-illnesses/Exclusive-breastfeeding-may-protect-against-Multiple-Sclerosisrelapse/ [Accessed 9/12/13]

There is a likely connection between cows milk consumption and development of MS: babies
who are not breastfed will generally be fed a cows milk formula.4
Studies have shown the high levels of the hormone prolactin may be associated with the
remission many women with MS experience during pregnancy.5 Prolactin is essential to the
ability to make milk. It begins to be active around the eighth week of pregnancy and increases in
amount for the next seven months, peaking at the baby's birth. The prolactin level decreases to
its normal level after the baby is born. Around a week after birth, prolactin is down to 50
percent of its normal level, and after three or four months, it is the same as it was before
pregnancy. But every time the baby feeds, there is a new surge of prolactin. Breastfeeding itself
may have an ongoing protective role.

Medications are an integral part of having MS, and it is of importance to acknowledge the role they may
take for the breastfeeding mother. It is also important for anyone prescribing medications to women
with MS to be well-informed with current research on the safety of the range of drugs used to treat the
disease in breastfeeding mothers. Some treatments, thought to be contra-indicated in the past, have
since been shown to be suitable during breastfeeding. These drugs might not be the first choice for the
mothers treatment but be acceptable in the short-term until the baby is naturally weaned and other
drugs may be considered. The list provided here is a short summary of the most common drugs
associated with MS which can be discussed with proscribing doctors. Dr Thomas Hale MD (Medications
and Mothers Milk)6, Dr Jack Newman, Rodney Whyte7 or LactMed8 are the world leaders in research into
breastmilk and medications, and much of the information of medications not included in this list can be
found there.

Copaxone: data from the manufacturer indicates that Copaxone rapidly degrades to amino acids and
shorter peptides and cannot be detected in the plasma, urine or feces.9 (In simpler terms this means
that is does not pass into breastmilk). Copaxone needs to be injected as it is destroyed by the gut (so
cannot be taken by the MS patient orally), and thus will not be absorbed by infants even if it was present
in milk. This drug is considered safe for breastfeeding.

Malosse D, Perron H, Sasco A, et al. Correlation between milk and dairy product consumption and multiple
sclerosis prevalence: a worldwide study. Neuroepidemiology 1992; 11:304-312.; Malosse D, Perron H. Correlation
analysis between bovine populations, other farm animals, house pets, and multiple sclerosis prevalence.
Neuroepidemiology 1993; 12:15-27.
5
Zhornitsky, Yong, et al. Prolactin in multiple sclerosis. Multiple Sclerosis Journal 19, January 2013 15-23
6
http://www.infantrisk.com/forum/showthread.php?84-Breastfeeding-and-MS
7
Mr Rodney Whyte, Monash Medical Centre, 246 Clayton Road Clayton VIC 3168 Locked Bag 29 Clayton VIC 3168
E: r.whyte@southernhealth.org.au T: (03) 9594 2361 F: (03) 9594 6595
The drug information centre is a service for the general public and health professionals for advice and assistance
on medicines for children, during pregnancy and breastfeeding and for women's health.
8
http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
9
Ziemssen T, Neuhaus O, Hohlfeld R. Risk-benefit assessment of glatiramer acetate in multiple sclerosis. Drug Saf.
2001;24:979-90. PMID: 11735654

Interferon Beta (Avonex, Rebif and Betaferon): Breastmilk tests revealed less than 0.006% of the
maternal dose would pass to the infant.10 Part of the reason for this low transfer is molecule size- the
molecules being too large to pass through to the milk.11 Interferon is poorly absorbed orally (which is
why it is an injection), and would not likely be absorbed by the infant. This drug is considered safe
during breastfeeding, but neurologists may prefer Copaxone.
Fingolimod: Fetal harm has been shown in pregnancy.12 It has a molecular weight which will pass into
breastmilk and it has a high oral bioavailability (meaning it can be digested by the gut). Dr Hale considers
this drug unsafe during breastfeeding.13
Tysrabi: Has a very large protein molecule and weight. This means it is unlikely to pass into the milk in
large quantities. It has poor oral bioavailability, so would be destroyed by the infants gut, except
perhaps in preterm babies.14 Some doctors may be very unwilling to prescribe this drug while
breastfeeding, but available evidence suggests that infants would not be effected by the drug.15
Tecfidera (BG12): No studies have of yet been done on this drug. This drug rapidly metabolizes from
dimethyl fumerate to mono-methyl fumerate, which makes up a fraction (13%) of total circulating.16 The
protein binding is low for MMF and higher for DMF17, and as DMF is unstable in blood, and has a rapid
halflife (33.2 mins). The drug company states MMF does not significantly penetrate into red blood
cells thus very little should pass into breastmilk.18 Absolute bioavailability has not been established.19 It
is rapidly metabolized, so breastfeeding, if undertaken, should be avoided if possible for 2 hours post
doasage. Based on this limited data, Dr Jack Newman and Rodney Whyte state that is would be safe to
nurse an older child (>12 months) who nurses infrequently and has a good intake of other foods, but it
cannot be determined the safety for a younger (<12 month) infant. Dr Whyte suggested childs
lymphocytes should be checked alongside the mothers if concerns still exist. Due to the newness of this
drug, Neurologists may be unwilling to prescribe to the nursing mother and Copaxone or Interferon may
be considered instead.
Methylprednisolone: Used during relapses at high doses via IV. Low doses of this drug are fine for the
breastfeeding infant (such as those taken by mouth), but the higher doses (1gram IV) are riskier.
LactMed states With high maternal doses, especially intravenous doses, avoiding breastfeeding for 3 to
4 hours after a dose should decrease the dose received by the infant. However, this maneuver is
probably not necessary.20 There is some suggestion of growth suppression at high doses.21 It is classed
10

Ewaschuk JB, Unger S, O'Connor DL et al. Effect of pasteurization on selected immune components of donated
human breast milk. J Perinatol. 2011;31:593-8. PMID: 21330996
11
http://www.ncbi.nlm.nih.gov/pubmed/11153157?dopt=Abstract
12
http://www.drugs.com/pregnancy/fingolimod.html
13
http://www.infantrisk.com/forum/showthread.php?110-Gilenya-an-oral-pill-for-MS
14
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~Zl9Qnz:1
15
http://www.infantrisk.com/forum/showthread.php?690-Breastfeeding-on-Tysabri
16
Center for Drug Evaluation and Research Application 204063Orig1s000 page 2,3, 42
17
Ibid page 87
18
Ibid 88
19
Ibid, page 19
20
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~EoBHSv:1

by the AAP (American Academy of Pediatricians) as an L2, which means that risk of side effects is
remote.22 Dr Hale recommends pumping and dumping for up to 24 hours past dosage for a younger
child (<2 years) or 8 hours for the older child (>2 years) to clear most of the drug from the mothers
system.23
Gadolinium (MRI Contrast): Although early investigators recommended withholding breastfeeding, a
more recent and much larger study indicated that the amounts of gadolinium excreted into breastmilk
are less than 1% of the amount allowed to be given to infants. In addition, it is poorly absorbed orally, so
not likely to reach the bloodstream of the infant or cause any adverse effects in breastfed infants.
Guidelines developed by several professional organizations state that breastfeeding need not be
disrupted after a nursing mother receives a gadolinium-containing contrast medium.24

Jennie Jeppesen
PhD Candidate, University of Melbourne
MS Diagnosed 2007

21

Yvette ODowd
Breastfeeding Counsellor
Australian Breastfeeding Association
MS Peer Support Volunteer
MS diagnosed 2000

http://www.drugs.com/pregnancy/methylprednisolone.html
http://kellymom.com/bf/can-i-breastfeed/meds/aap-approved-meds/#Steroids
23
http://www.infantrisk.com/forum/showthread.php?76-IV-of-1-gram-solu-medrol-while-Breastfeeding,
http://www.infantrisk.com/forum/showthread.php?293-Iv-steroids-with-older-nursling
24
American College of Radiology Committee on Drugs and Contrast Media. Administration of contrast media to
breast-feeding mothers. In, ACR manual on contrast media. 2012;Version 8:79-80. Webb JA, Thomsen HS, Morcos
SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). The use of
iodinated and gadolinium contrast media during pregnancy and lactation. Eur Radiol. 2005;15:1234-40. PMID:
15609057 Chen MM, Coakley FV, Kaimal A, Laros RK Jr. Guidelines for computed tomography and magnetic
resonance imaging use during pregnancy and lactation. Obstet Gynecol. 2008;112:333-40. PMID: 18669732
Schmiedl U, Maravilla KR, Gerlach R, Dowling CA. Excretion of gadopentetate dimeglumine in human breast milk.
AJR. 1990;154:1305-6. PMID: 2110745 Rofsky NM, Weinreb JC, Litt AW. Quantitative analysis of gadopentetate
dimeglumine excreted in breast milk. J Magn Reson Imaging. 1993;3:131-2. PMID: 8428080 Kubik-Huch RA,
Gottstein NM, Frenzel T et al. Gadopentetate dimeglumine excretion into human breast milk during lactation.
Radiology. 2000;216:555-8. PMID: 10924585
22