TOPIC:

Purpose: Maternal immune thrombocytopenic purpura (ITP) accounts for 5% of all cases of pregnancy associated thrombocytopenia and is a common cause of neonatal thrombo­cytopenia. One of the common mechanism involves transfer of IgG autoantibodies against platelet receptors which are found in the blood samples of affected patients. The neonatal thrombocytopenia usually subsides within 2 months. The autoantibodies are often of the IgG type and therefore can cross the placenta and cause fetal and/or neonatal thrombocytopenia. Recently we observed persistence of neonatal ITP which disappeared following discontinuation of breast feeding. The aim of our current work was to discern whether breast milk of mothers with ITP contains anti-platelet antibodies and whether these antibodies may be the cause for persistent neonatal ITP.

Methods: Breast milk samples were collected from 12 women with ITP. Six of them were thrombocytopenic during pregnancy and their neonates also had thrombocytopenia. The remaining 6 mothers had a history of ITP but not during the current pregnancy, and neither did their neonates. As controls, breast milk from 8 healthy women was also examinied.

The presence of anti-platelet antibodies were evaluated by incubating washed platelets from healthy donors with breast milk or extracted milk – Ig. The type of immune globulin was defined by flow cytometry using fluorescence conjugated anti-human IgA, IgG or total Ig antibodies. To prove that the antibodies were against an antigen that is platelet specific and not against HLA epitopes, we also tested the samples on cultured cells expressing the fibrinogen receptor, αIIbβ3, and compared the results to mock cells (transfected with empty vectors).

Results: In the cases of women with active ITP, 3 were positive for anti-platelet antibodies, 2 were inconclusive and one was negative. In the mothers with a history of ITP, 1 was positive, 1 was inconclusive and 4 were negative. No anti-platelet antibodies were found in breast milk of healthy women. In all 6 cases of active ITP, the cell cultured assay for the fibrinogen receptor αIIbβ3 was positive, indicating that there were anti platelet specific antibodies in their milk. Of the 6 neonates of mothers with active ITP, 4 of them required treatment with oral steroids, and the average time to resolution of thrombocytopenia was 3.5 months.

Conclusion: This study demonstrates that breastmilk of women with active ITP contains anti platelet specific antibodies. The presence of these antibodies demonstrated an association with persistant and prolonged neonatal thrombocytopenia.

ash.confex.com/ash/2014/webprogram/Paper67131.html

Thanks for this sandi!!

I was aware of this study & was anxiously awaiting the results.

It seems to suggest that the antibodies will only affect baby whilst he/she is breastfeeding but won't cause long term itp.

Whilst that is reassuring, they haven't done long term follow up so it's not certain (??).

I breastfed my first & am considering feeding bump when he/she arrives but I am also really worried about the risks that might carry.

The more I think about this study the more uneasy I feel.

Anyone else thinking of breastfeeding?? Or not because of itp??

Aww Kat, it's a shame that you have to feel that way. Maybe you can do both formula and breast feeding? That way, the baby would not get as many antibodies but would still get some of the benefits of breast milk. I don't know if that would help, but it might.

I have spoken to several doctors about this throughout my pregnancy and was told even if an ITP mom transfers the platelet antibodies to her child, the antibodies will not attack the child's platelets. I was told the baby's system is different and the mom's anti-platelet antibodies only attack her own platelets but will not know to do the same in the baby since the baby's system is completely different.

But MDgal, the study said this:

Conclusion: This study demonstrates that breastmilk of women with active ITP contains anti platelet specific antibodies. The presence of these antibodies demonstrated an association with persistant and prolonged neonatal thrombocytopenia.

That doesn't mean the baby's counts will be seriously low, but it could be a concern.

Well I will still breastfeed because I think my baby will get a lot of good stuff.

You can do that if you want to!

I breastfed dd for 6 weeks. I found that "natural" is not the same as "easy"

I do think she got a lot of good things from it - antibodies, immunity etc. I don't feel that it particularly helped us bond though - she latched really well and then would "nip" me several times during each feed! Ouch!! I often cried & dreaded the feeds.

All in all I feel very strongly that breastfeeding is every woman's choice and nobody should be pushed in or out of it. I had thought that I wouldn't be too fussed about breastfeeding a second, but the thought of not being able to because of the fear of passing on a more persistent thrombocytopenia is upsetting. Surprisingly!

Sandi - were there any long term outcomes detailed in the study? Is there a chance of passing on actual itp? Or does it always go when breastfeeding stops? I want to ask my haematologist if he would want his wife to breastfeed if she had itp - but I'm pretty sure he won't give me a straight answer. Would you sandi? In our shoes??

So hard to decide on the best action

Kat:

A baby will not acquire ITP due to being breast fed, but the antibodies could be passed on temporarily which could cause thrombocytopenia. The baby could also be born with low platelets for the same reason. Both are temporary.

You're right about the 'not easy' part. I did not have ITP when I had my babies, but I had a heck of a time with breastfeeding. I tried. The baby would fall asleep too fast and you can't tell how much milk they are getting, so the baby would wake up hungry constantly. I remember falling asleep in the rocking chair night after night from exhaustion. Some women are natural breast-feeders and others are not. If anyone has a hard time with it, I think they should not feel guilty about it and just move on to the bottle. I finally got the hang of it by my third child, but got mastitis and had to quit. I'm telling you this because it could be part of your decision.

I think if it were me and I really wanted to breastfeed, I would first base the decision on the initial platelet count of the baby at birth. I would imagine that the count would be checked if a mother has ITP. If the baby's counts are low, maybe breastfeeding would not be a good idea. Most babies are born with a normal platelet count, but some are not. A few need to be treated and if that were the case, I wouldn't push my luck with breastfeeding. If the baby's counts were normal at birth, I might try breastfeeding, but would ask for a platelet count to be checked after a few days or weeks. Seems like a simple solution to me, although it leaves you with the problem of not knowing which direction you are going. It does seem like the safest option for the baby though.

Thanks sandi - it's so nice to get a straight answer instead of a "professional" one. Sometimes the two are not the same thing!! & thanks for the clarification on the study!

The shame about me & dd with the feeding is that I think I was good at it (made loads of milk lol! Supply was not an issue!! She gained weight like a pro!) and she was good at it (fed every three hours like clockwork, from birth, for just 20 minutes unless she was in a growth spurt) but we weren't compatible. She nipped to stem the flow that was too fast. Nothing to be done & I felt no guilt moving to bottles. It was right for us. We weren't bonding. I know people who've had awful guilt about bottle feeding & it just seems such a waste of energy to me. As long as baby is thriving... who cares!!

And in writing that - it seems I have my answer. If it's ok for baby then I'll do it. If it's too risky then I won't. It has to be best for both of us. Phew - I feel happy with that for now.

Still going to try & ask my haemo the wife question though. Lol!!

Good luck, Kat! Let me know what the doctor says.

I breast fed with ITP. Because I was a very nervous mom, my son had CBCs periodically. He has enough platelets for both of us and had since birth. If you want to nurse, you could have your baby monitored so that you can stop if there is any problem.

A bit late in the day but this thread has just popped up on a search. My baby is 13 weeks and Breast fed. I had itp for 1 yr prior to pregnancy and was closely monitored throughout. At delivery my platelets increased to 135 so no concern and had natural birth. My platelets have now dropped to 78- I requested an earlier check because I noticed bruising. My concern is that if my platelets have dropped, could my baby's even though her's were normal at delivery (&5 days after) and am I causing her harm breastfeeding as I didn't realise this could?
Sorry lots of questions but this is all very new!

Yes, it is possible to pass the anti-platelet antibodies to your baby through breast milk. It would only cause a temporary problem though; it wouldn't last for long if you stopped breast-feeding. There is also a good chance that the baby will not be affected at all. The only way to know is to have the baby's counts tested once in a while. It isn't anything that you have to really stress about; chances are the baby is just fine.

This is very interesting. I nursed all 3 of my kids, with active ITP, for over a year. Doctors never told me that there were any health risks to my kids, and encouraged me to nurse. My platelets were around 30 to 60 thousand around delivery and while nursing. I was never put on any meds. My kids are now from the ages of 17 to 23, and they are all healthy and fine, while I still continue to struggle with ITP. After I stopped nursing my 3rd child, my platelets dropped to 20K, and I was hospitaized, put on solu-med-erol, and prednisone. I just checked my daughters medical records, and her platelet counts as of last year are 315K. Out of courisity this is something I will discuss with my hematologist at my next appointment.
Thanks for the info Sandi.

The risk to the baby is a small one and as I said, it's temporary. I'd be willing to bet that many Hemo's are not aware of the antibodies being passed through breast milk. This would not follow the baby into adulthood unless that child developed ITP too. If that happened, it would be a genetic thing and not caused by the fact that you breast fed.

mmune thrombocytopenia (ITP) in pregnant women can cause neonatal thrombocytopenia by transport of anti platelet autoantibodies across the placenta. Usually, infant's platelet count normalizes within two months. We observed neonatal thrombocytopenia that persisted more than four months and disappeared following discontinuation of breastfeeding. The aim of our study was to discern whether breast milk of ITP mothers contained anti platelet antibodies causing persistent thrombocytopenia. We collected milk samples from 3 groups of women: ITP - 7 women who had ITP during the pregnancy, R-ITP - 6 women who recovered from ITP before pregnancy and 9 healthy controls. We found increased levels of anti-platelet antibodies of the immunoglobulin A type in the milk of ITP patients compared to the other 2 groups. Similar increase was demonstrated for antibodies binding to αIIbβ3 expressed in cultured cells. Thus, transfer of anti-platelet antibodies from ITP mothers by breastfeeding can be associated with persistent neonatal thrombocytopenia.

www.ncbi.nlm.nih.gov/pubmed/26077397

Immune thrombocytopenia (ITP) in pregnant women can cause neonatal thrombocytopenia by transport of antiplatelet autoantibodies across the placenta. Usually, an infant’s platelet count normalizes within 2 months. We observed neonatal thrombocytopenia that persisted more than 4 months and disappeared following discontinuation of breastfeeding. The aim of our study was to discern whether breast milk of ITP mothers contained antiplatelet antibodies causing persistent thrombocytopenia. We collected milk samples from 3 groups of women: ITP group, 7 women who had ITP during pregnancy; R-ITP group, 6 women who recovered from ITP before pregnancy; and 9 healthy controls. We found increased levels of antiplatelet antibodies of the immunoglobulin A type in the milk of ITP patients compared with the other 2 groups. Similar increase was demonstrated for antibodies binding to αIIbβ3 expressed in cultured cells. Thus, transfer of antiplatelet antibodies from ITP mothers by breastfeeding can be associated with persistent neonatal thrombocytopenia.

Submitted November 28, 2014.
Accepted June 9, 2015.

© 2015 by The American Society of Hematology

www.bloodjournal.org/content/126/5/661.abstract?sso-checked=true