Safety Considerations: Breastfeeding after Transplant

Abstract

Organ transplant is an effective treatment for end-stage organ failure. For women, restoration of organ function can restore fertility and the ability to successfully carry a pregnancy. Posttransplant pregnancies have been reported among recipients of all types of solid organ transplants via case and center reports plus registry data. Stable graft function is dependent on prevention of rejection, currently accomplished by using maintenance immunosuppressant medications, to which the fetus is exposed in utero. Common among neonatal outcomes in transplant recipients are preterm and low-birth-weight infants. Emotional, nutritional, and immunologic benefits of breastfeeding have been well-documented and could be valuable for these newborns. Concern must be directed at the effects of the child's exposure to immunosuppressive agents excreted into the breast milk. Breastfeeding could be considered in transplant recipients if it can be shown that the level of exposure does not result in risks to the newborn, immediately and throughout childhood. Despite concerns of health care professionals, some recipients have chosen to breastfeed. Breastfeeding after transplant must be approached with consideration of many issues, and the potential risks require further study. This review focuses on benefits of breastfeeding, common immunosuppressive agents used in organ transplant recipients, a summary of the reports of women who have breastfed their infants while on immunosuppressive therapy and the published studies on breastfeeding and immunosuppressive agents. Recommendations are provided to guide health care professionals to help mothers receiving immunosuppressive agents to make informed choices about breastfeeding their infants.

Pregnancies in liver and kidney transplant recipients: a review of the current literature and recommendation

“…The American Association of Pediatrics has made recommendations supporting breastfeeding by mothers taking prednisone and warns against breastfeeding by mothers taking cyclosporine, but there are still no recommendations for mothers taking tacrolimus, azathioprine or a mammalian target of rapamycin (mTor) inhibitor such as sirolimus or everolimus [25,26].…”

AISF position paper on liver transplantation and pregnancy

“…Small amounts of glucocorticoids can be present in the breast milk of women on steroid therapy; however, no adverse effects have been reported, and the American Academy of Paediatrics has declared prednisone and prednisolone safe and compatible with breast-feeding [107]. Special attention should be devoted to diagnosing and treating postpartum depression, which may be exaggerated by chronic steroid use [129,130].…”

Complex chimerism

“…74 In preliminary data, no adverse neonatal outcomes (n = 98 infants) were found by the NTPR in breastfeeding women on a variety of immunosuppressants, but postpartum graft rejection in this population has not been fully evaluated. 75 HLA sensitization can occur following (or during) pregnancy and has been described in two cardiac transplant recipients who developed new cross-reactive HLA class II paternal and donorspecific antibodies. In one case, the antibodies developed following a normal pregnancy and stable immunosuppressant regimen 17 years after transplantation.…”