Arthritis, Fibromyalgia, and Breastfeeding
From: LEAVEN, Vol. 36 No. 1, February-March 2000, pp. 3-4
We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time
A mother with arthritis may face special challenges. People who are unfamiliar with arthritis may think of it as a disease associated with aging and wonder what it has to do with breastfeeding. While osteoarthritis (OA) is more common in older people, inflammatory arthritis and fibromyalgia are much more likely to affect young women. Indeed, pregnancy and having a baby may actually trigger a flare of symptoms for those with systemic lupus erythematosus (SLE or lupus) or fibromyalgia (see below).
You can assist a mother with arthritis by helping her anticipate adaptations she may need to make when caring for her baby. Some concerns related to arthritis are described in this article.
Types of Arthritis
Osteoarthritis is the most common form. It is known colloquially as "wear and tear " arthritis and is more likely to occur among the elderly, and/or at the site of a previous injury.
Inflammatory arthritis is a category that covers over 120 different diseases. These diseases not only affect the joints, but can affect other organs in the body. These types of arthritis include rheumatoid arthritis, systemic lupus erythematosus (SLE or lupus), and systemic sclerosis, and are most likely to strike women of childbearing age. These types can range from mild to life threatening. Many of these diseases are categorized as "autoimmune." This means that autoantibodies are produced which attack normal cells and cause destruction of tissue.
Fibromyalgia is a chronic pain syndrome characterized by diffuse soft tissue pain (sometimes called "arthritis of the muscles"). It can occur in conjunction with inflammatory arthritis or by itself. One common symptom of fibromyalgia is disturbance, where alpha waves intrude on delta sleep and no REM sleep is achieved. This is thought to cause pain, as the muscles need this deep sleep in order to repair the microtraumas that occur during the day. Not surprisingly, another characteristic symptom is fatigue. While not a fatal disease, it can be disabling.
Pain in the Upper and Lower Extremities
Proper positioning is important for all breastfeeding mothers, but it is even more so for a mother with arthritis or fibromyalgia. This mother needs to position her baby in a way that does not stress the muscles or joints of her upper and lower body. The use of pillows, footstools, and other supports may be necessary so that the mother does not stress her hands, wrists, elbows, shoulders, neck, hips, or knees. Carrying the baby may also stress these joints. A front-pack that causes the mother to lean forward might not be useful for long. A baby sling is helpful until the baby gets too heavy, then she may have to shift to a carrier that takes most of the weight in her hips. A baby car seat with a carrying handle may be very difficult to use. A mother may also need to give special consideration to the paraphernalia that she carries with her when she goes out with her baby. You can help by brainstorming with the mother about adaptations she can make in carrying her baby and bringing fewer baby supplies along on outings (of course, the breastfeeding mother is at an advantage here). If the mother has not already done so, this might be a good time for her to discuss exercises and stretches with her health care providers to counter some of the strain of caring for her baby.
The mother with arthritis can be susceptible to yeast infections. Sometimes, this increased susceptibility is due to medication use. Steroids, in particular, can make a mother vulnerable to yeast infections. If the mother has had serious episodes of her illness in the past, she may have been given IV steroids during or immediately after labor, or the mother may be on low-dose steroids as a general regimen. If this mother develops cracked or bleeding nipples, thrush should certainly be considered.
Raynaud's Phenomenon is another possible co-occurring symptom of fibromyalgia and many forms of arthritis. It can also occur by itself (known as "primary Raynaud's"). Raynaud's phenomenon involves constriction of the veins in the hands and feet so that they blanch or turn blue. They may also become red and hot as the blood rushes back into the area. The most commonly affected areas are the hands and feet, but other extremities can be affected including the nose, ears and mouth. There are even some anecdotal accounts of Raynaud's affecting the nipples. If this happens, it could inhibit let down. Both stress and cold can trigger Raynaud's. If the mother suspects this might be occurring, encourage the mother to consult her health care provider. The mother may appreciate strategies that help her relax and stay warm as she breastfeeds.
Fatigue and Sleep Deprivation
Fatigue and sleep deprivation can be considered "occupational hazards" of being a new mother. But for a mother with arthritis who may lose sleep due to pain, or for the mother with fibromyalgia who may have an associated sleep disorder, it is of special concern. Lack of sleep can cause a mother's symptoms to flare and she may experience a substantial increase in pain. Depending on the severity of a mother's symptoms, nighttime feedings may be difficult. It may be helpful for this mother to learn to nurse lying down and also to rest or sleep while her baby is sleeping; that way she will get as much rest as possible. Unless she is on medication for a sleep disorder, it can be helpful to suggest a co-sleeping arrangement where baby's need for breastfeeding can be met at the same time she continues to rest. If the mother is on medication for a sleep disorder, an alternative nighttime feeding arrangement may be needed. It is also important that she have help during the day, particularly in the early weeks. Doing too much during the day may also lead to a flare of symptoms.
There are many physical illnesses that may have depression as a symptom including several types of arthritis (e.g., fibromyalgia, rheumatoid arthritis and lupus). A mother with arthritis may be at increased risk for postpartum depression. She may be more vulnerable to the depressive effects of lack of sleep. Her pregnancy may have been considered "high risk," and may have had more interventions than she would have liked. Some of the autoimmune conditions can cause pregnancy loss, so a mother may have had a history of miscarriage prior to the birth of this baby. The birth of this baby may trigger a grief reaction for the other babies that she has lost.
A mother with arthritis or fibromyalgia is likely to be on one or more medications. She may need information on medication use while breastfeeding. You can help the mother and her health care provider work together constructively by providing current information. [See "Questions About Medications"] Below I have listed five basic types of medications that may be prescribed to a mother with arthritis or fibromyalgia.
Questions About Medications
When a Leader is asked questions about medications, whether over-the-counter medications or prescription drugs, there are well-established guidelines about the kinds of information that can be shared. (See Leaders Handbook, 1998 edition, pp. 210-13.) A Leader can read information verbatim from references, but she never states that a particular drug is or is not safe. Leaders never give a mother any suggestions or names of other possible medications, nor do they tell a mother whether or not she should take a particular drug.
Those decisions, as well as the one to wean or not in order to take a medication, are solely the mother's in consultation with her health care provider. Resources with drug information are available and Area Professional Liaison Leaders can be contacted to help Leaders with medically related or medication questions.
Judy Minami, USW PLEA
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)These include such over-the-counter medications such as ibuprofen and others that are available by prescription only. They are used to help control inflammation and pain.
For reasons no one completely understands, anti-malarial drugs can help control symptoms of rheumatoid arthritis and lupus. Some have been approved by the American Academy of Pediatrics for use in breastfeeding mothers.
Steroids are used to control inflammation, and suppress an overactive immune system. The most common of these is prednisone. Large doses may be prescribed during life-threatening episodes. Steroids may be prescribed for short-term use while breastfeeding, but if a mother is on large doses, she may be too ill to care for the baby.
These medications were originally developed to use in cancer chemotherapy but have been found to help in some of the more severe or advanced cases of these illnesses. Most are contraindicated for breastfeeding mothers. The mother needs to discuss any possible use of these medications with her health care provider.
Interestingly, antidepressants are also often used not only for depression, but to control pain and help regulate sleep. For example, low doses of a certain tricyclic antidepressant may be prescribed for fibromyalgia because of its sedating quality. Some antidepressants are better than others with regard to breastfeeding. Encourage the mother to discuss with her doctor or health care provider the wide variety of antidepressants available in order to find one compatible with breastfeeding.
In conclusion, mothers with arthritis who want to breastfeed may need accurate information and support for their decision. You can help a mother who calls with these conditions by providing information on medications and breastfeeding, and by helping the mother anticipate and solve some of the issues to help make her breastfeeding experience a satisfying one.
Hale, T. Medications and Mothers' Milk. 8th Edition. Amarillo, TX: Pharmasoft Medical Publishing, 1999.
Koopman, W.J. Arthritis and Allied Conditions: A Textbook of Rheumatology. 13th Edition, Vol. 2. Baltimore: Williams and Wilkins, 1997.
Starlanyl, D., & Copeland, M.E. Fibromyalgia and chronic myofascial pain syndrome. Oakland, CA: New Harbinger, 1996.
Wallace, D.J. Dubois' Lupus Erythematosus. 5th Edition. Baltimore: Williams and Wilkins, 1997.