• Cardiomyopathy in Pregnancy: Breastfeeding May Be Safe

    Observational study throws into question current recommendations

    Breastfeeding was not associated with worse myocardial recovery in peripartum cardiomyopathy (PPCM), the IPAC study found, throwing into question recommendations against the practice for affected mothers.

    In the 100-woman observational study, the 15 participants who breastfed generally had higher levels of prolactin and cytotoxic CD3+CD8+ T cells at study entry and at 6 months, reported Dennis McNamara, MD, MS, of the University of Pittsburgh Medical Center, and colleagues in the June issue of JACC: Basic to Translational Science.

    However, this was not accompanied by impaired myocardial recovery: the breastfeeding cohort actually trended toward higher left ventricular ejection fraction (LVEF) at study entry (39% vs 34%, P=0.06) and stayed that way over follow-up.

    A European Society of Cardiology (ESC) working group has discouraged nursing and recommend the use of bromocriptine instead to block prolactin in these women, based on a few prior observational studies suggesting harm.

    "Prolactin acts directly on mammary glands to promote generation of milk. However, in some contexts, prolactin can be cleaved by extracellular proteases to yield a 16 kD peptide that is profoundly vasculotoxic. Studies in mice suggest that this action may occur in certain predisposed individuals, leading to loss of cardiac microvasculature, global ischemia, and cardiomyopathy," noted an accompanying editorial.

    The absence of any hazard for breastfeeding in the IPAC study now counters that ESC recommendation and "argues against a significant role for prolactin as a mediator and bromocriptine as a therapy," McNamara's group wrote, although acknowledging their study did not actually measure the 16-kDa prolactin fragment.

    "For women presenting with PPCM who are well compensated, we find no evidence to support a recommendation against BF [breastfeeding]," they concluded.

    Some sicker women may benefit from stopping breastfeeding, they added, but this would require a rigorous large randomized trial to prove.

    And such a trial is unlikely to be conducted, according to an accompanying editorial by Zoltan Arany, MD, PhD, of the University of Pennsylvania, and Arthur Feldman, MD, PhD, of Temple University, both in Philadelphia.

    "In sum, the study does not definitively report that breastfeeding is safe in women with PPCM, but it strongly suggests that it is so," Arany and Feldman wrote. They added that "there are remarkably few published data that directly address the question of breastfeeding in PPCM, in part because most PPCM studies do not report on breastfeeding."

    "With judicious choice of drugs, and appropriate monitoring of the infant, standard PPCM therapy thus seems safe for the infant and should not be a contraindication for breastfeeding," according to the editorialists.

    McNamara and colleagues pointed out that breastfeeding benefits both mother and child in numerous ways. "In developing countries, where PPCM is more common than the United States, BF is of essential importance, not only as food and nutrition but also for neonatal immunity."

     

    The IPAC study enrolled 100 women newly diagnosed during their first 13 weeks postpartum in 2009-2012. The 15 women who were breastfeeding at the time of entry shared similar baseline characteristics as the rest of the cohort.

    All study participants had cardiac function assessed by serial echocardiography and cellular immune activation profiled by flow cytometry at 2 and 6 months postpartum.

     

    McNamara and Arany disclosed no conflicts of interest.

    Feldman reported directorship and equity in Renovacor.

    Source:

    JACC: Basic to Translational Science

    Source Reference: Koczo A, et al "Breastfeeding, cellular immune activation, and myocardial recovery in peripartum cardiomyopathy" JACC Basic Transl Sci 2019; DOI: 10.1016/j.jacbts.2019.01.010.

    JACC: Basic to Translational Science

    Source Reference: Arany Z, Feldman AM "To breastfeed or not to breastfeed with peripartum cardiomyopathy" JACC Basic Transl Sci 2019; DOI: 10.1016/j.jacbts.2019.03.005.

    Read the original article on Medpage Today: Cardiomyopathy in Pregnancy: Breastfeeding May Be Safe

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