IBD Motherhood Unplugged: My Personal PIANO Study Results

As an IBD mom of three who stayed on my Humira (adalimumab) injections until late into my third trimester with all my pregnancies, I recognized the importance of contributing to ongoing research about the safety and efficacy of biologics. When I was approached to participate in the PIANO (Pregnancy Inflammatory bowel disease And Neonatal Outcomes) study for my pregnancy this past year I jumped at the opportunity. While I knew staying on my medication until 37 weeks pregnant would pass Humira through to my baby and that it is considered to be safe, I didn’t know much beyond that.

My son Connor is 8 weeks today. The day of my C-section blood samples were taken from him, me, and my umbilical cord. The purpose of the samples was to measure the concentration of the Humira at the time of delivery. The process in the hospital was simple. Detailed instructions were mailed to me at home ahead of time. When I walked into the hospital for my scheduled C-section my husband and I handed over a small box that included three vials, an ice pack, and proper packaging for the transfer from St. Louis to California to the nurse who was prepping me for surgery. Once all the samples were ready to go my husband made a quick stop at FedEx to hand over the package and voila the science of it all was on its way.

The Results

The past few weeks we’ve anxiously awaited the results. This week, we received them. I have an almost 4.5-year-old son, a 2.5-year-old daughter, and a newborn. With each pregnancy—Crohn’s-wise, the experience was flawless. I felt like a “normal” person. Foods that typically trigger me, didn’t cause any issues. If I wanted a cup of coffee, I didn’t pay the price. It felt glorious to have zero abdominal pain for all those months and know that my babies were thriving in utero. I credit my own health and deep remission and my children’s health to the fact that I chose to follow my care team’s recommendations and stay on Humira until the final weeks of my pregnancies.

When the results popped up in my email inbox, I was nursing Connor. I felt a few emotions, more than I had anticipated. I hesitated to open it. Even though I could see Reid and Sophia watching TV and know how healthy they are, it still made me feel a rush of mom guilt to know that I needed a heavy-duty medication to bring all three of my children into this world and that even though studies like PIANO have shown the safety profile, that as IBD moms we still worry and wish we didn’t need to do injections or get infusions while a life is growing inside of us.

I texted my husband Bobby while he was at work and expressed how I was feeling. His response, “It’s all good babe, I’m sure it’s emotional but kids are all healthy and in good shape so just thankful for that. You did good.” Having a supportive partner through your patient journey and especially through parenthood makes all the difference.

Here are my PIANO study findings. I stopped medication at 37 weeks, and my last injection was 16 days prior to C-Section and this blood test.

My blood—7.3 mcg/mL

Connor’s blood—6.8 mcg/mL

Cord blood—5.9 mcg/mL

When I saw the numbers, my eyes filled with tears. Even though just looking at the numbers didn’t mean a whole lot, it just showed me that my baby had medication in his system, and it made me feel sad. I knew this would be the case—but I want to be transparent that it did upset me, even though I know it was for the best and have seen how my other children have thrived despite their exposure.

I waited to share this so the PIANO study’s lead organizer, Dr. Uma Mahadevan could weigh in and provide further explanation for not only myself, but for our community. She told me that in the PIANO study,  the concentration of Humira for baby on average is 9.4 mcg/ml (range 2.5-26) and for moms 25 mcg/ml (range 0-56.4). As stated above, I was at 7.3 mcg/ml and Connor was 6.8 mcg/ml.

“Cord blood is the blood from the baby that is left in the umbilical cord and placenta after birth. It comes from the baby, so those concentrations are similar. Beginning around week 14 of pregnancy the placenta has a receptor called FcRn. This grabs antibody by the “Fc” portion and pulls it actively from mom to baby. This is most efficient in the third trimester when 80% of antibody transfer occurs. Since Humira is an antibody, it gets pulled across the placenta as well.”

Dr. Mahadevan went on to say that baby often has more drug at birth than the mom, but that was not the case for me. The PIANO study has shown several positive outcomes for IBD moms:

  • There is not an association between the amount of drug present in a baby at birth with infections.
  • Even though there was no increased risk of infection seen based on exposure to anti-TNF or on drug level at birth, in theory these babies (like Connor) are considered immunocompromised until no drug is present. For Humira that’s about 3 months, for Remicade (infliximab) that’s about six months.

“My advice to moms is that all the risks to the baby seem to come from disease flare rather than from medication. In a large French study, the risk of infection in baby was in moms who flared in the third trimester, not based on anti-TNF exposure. Risk of pre-term birth is increased with disease activity, not with anti-TNF medication. Risk of miscarriage comes with disease activity, not anti-TNF use. There is a clear and significant risk from having a flare during pregnancy. Compared to babies of IBD moms not exposed to medications, there is no evidence of increased harm to the baby (at least out to 4 years of age) from TNF exposure,” explained Dr. Mahadevan.

Hearing this was music to my ears and was extremely comforting. Point being—there’s a much greater likelihood of pregnancy complications if your IBD is not managed and if you flare than if you stay on your medication and keep your IBD controlled.

“We have completed our breastfeeding study which showed very minimal transfer (a fraction of what transfers by placental blood) and no evidence of harm to baby for breastfeeding when a mother is on anti-TNF.”

Knowing this about breastfeeding gives me great peace of mind as I continue the journey with my son, while still managing my Crohn’s by taking my Humira.

I also want to add that Dr. Mahadevan and her research team have been a huge support to me throughout the entire study. When she read a draft of this article and saw how I felt when I received the email with the blood results, she asked for recommendations about how to better deliver the findings to women. This meant a lot—I suggested sharing the range in blood concentration similar to how lab results are delivered on a patient portal and following up with an email or phone call to explain what the numbers mean further. Those touchpoints of support can make a big difference. I also shared my results over the patient portal with my GI and she called me to discuss them as well, which was helpful.

Interested in participating in the PIANO study? There’s always a need for more women to enroll! So far, 1,700 women have done so. There’s especially a need for women on newer drugs like Stelara, Entyvio, and Xeljanz. Click here to get involved.

Breastfeeding with Crohn’s: What I wish I would have known

Breastfeeding. Before I became a mom, I had no idea what a loaded word it was. So many emotions, so much controversy, so much judgement. As an IBD mom of two little ones, my journeys with my kids differed greatly. Ironically, World Breastfeeding Week wrapped up (August 1-7) and so did my breastfeeding journey with my daughter. IMG-5717 Whether you’re a chronic illness mom or not, one of the first questions you often get asked is “are you breastfeeding?” It’s such a personal choice and decision, that really isn’t anybody’s business. Yet, men and women alike act as though it’s just casual conversation.

For many of us in the IBD community, breastfeeding is complicated. We have a lot more to consider than our milk supply coming in and a proper latch. We have to weigh the pros and cons of how our biologic drug passes through the milk, whether or not to pop a pain pill or struggle through the day so we’re able to feed our babies, along with the stress and exhaustion that comes along with the postpartum period, while navigating motherhood with chronic illness. We have to worry about what’s going to happen if we’re hospitalized and unable to feed our baby, our minds race with the what-ifs, even when we’re in “remission”.

My son, Reid, will be 2.5 in September. IMG-5411Before I ever became pregnant with him and up until the moment he was born, I was adamant on feeding him formula. I personally felt there were too many gray areas with the medication I am on and didn’t want to find out down the road that I put him at risk for dangerous long-term side effects. I ended up nursing the first three days in the hospital so that he could get the colostrum. Even though I was confident in my decision at that time, I sobbed when he got his first formula bottle in the hospital, because once again my Crohn’s prevented me from feeling like a “normal” person. Each time someone questioned my decision to formula feed or assumed I was breastfeeding, it pulled at my heartstrings and made me feel a bit embarrassed and less than.

My daughter, Sophia, will be seven months this week. During her pregnancy, it was like a light switch went off. I did my research and I was determined to give breastfeeding a go. IMG-7340I learned about how breast milk would benefit her microbiome, lower her chance of one day developing IBD, improve her immune system, and that Humira was considered safe for nursing, among other remarkable benefits. Many friends and family members offered invaluable advice and support to prepare me for what was to come once she entered the world. No matter how much I thought I was ready, it was still overwhelming and emotional.

Looking back—here’s what I wish I knew as a breastfeeding mama who has Crohn’s.

Just because it’s natural, doesn’t mean it’s easy

To go from making a formula bottle with my son to pumping and syringe feeding a newborn was a bit of a shock to our family. As you can imagine—it was all new and foreign to us. The first night home was an absolute nightmare. Sophia was cluster feeding the entire night. Didn’t sleep a wink. Her latch was off. I was bleeding. She’d only nurse on the right side. Tears were falling and I didn’t know how I was ever going to breastfeed. I felt like I was letting myself and my daughter down. The IBD piece of it all made me feel the pressure to push through. IMG-0998I wanted to do all I could to protect her and felt guilt for not doing the same for my son. I remember lying in bed with her on my chest that first night, my husband sleeping, and texting a bunch of fellow breastfeeding moms for advice in the middle of the night. They all responded in minutes and comforted me. Initially, I had been told not to use my breast pump the first few weeks. I ended up using my pump the first week and it was the best decision I made. If I hadn’t done that, chances are I would have never made it through that initial week without changing my mind and formula feeding. If nursing is painful or difficult, don’t hesitate to break out the pump and relieve your engorged chest. Whether a baby is nursing or receiving breast milk in a bottle, it’s all the same at the end of the day.

Introduce the bottle early on

When you live with IBD, you rely heavily on others being able to help you when you’re stuck in the bathroom or fatigued beyond belief. Some days other people are going to need to feed your baby, whether it’s a spouse or your mom. If you wait too long to introduce a bottle, you increase the likelihood of your baby refusing a bottle, which puts added pressure on you. IMG-3793 We gave Sophia a bottle the first week home, since I needed to pump. For the past seven months she’s gone back and forth from breast to bottle beautifully. It eased up the pressure on me and helped make it easier on both of us! We still got to bond and be close, but others are able to feed her as well.

Before you take a pain pill, talk with your GI

Like many IBD moms, the fear of a postpartum flare and flaring in general weighs heavily on my heart and on my mind. I noticed symptoms start to creep up when Sophia was about two months old. I took a pain pill and reached out to my GI, only to find out I couldn’t breastfeed for the next 14 hours. At another point, I had to be put on Entocort for a week to help combat a small flare. Rather than try and be a superhero, I reached out to my GI immediately. While on the Entocort I had to pump and dump in the morning. It pained me to pour the “liquid gold” down the drain, but it’s what I needed to do to prevent a hospital visit. My kids needed mama present more than my baby needed a bottle of breast milk.

Supplementing is not failing

Whether you’re pregnant now, aspire to one day breastfeed, or if you’re in the thick of your journey, don’t make yourself feel like it’s all or nothing. For the first three months, Sophia was exclusively breastfed. Once I started introducing formula here and there, it took some of the stress off my shoulders. Was my diet providing her with the proper nutrients? Was she getting enough milk? I have my hands full with a toddler, so sitting next to a breast pump by myself with him running around isn’t all that conducive to my lifestyle. By making Sophia a flexible eater, it made breastfeeding seem like less of a struggle for me and a lot more doable for our family life.

Put your mental and emotional health first

59421BB3-A402-4678-819F-2A1751174DF6As a mom, it’s easy to beat ourselves up about how we choose to feed our babies. There is SO much background noise. Everyone has an opinion. As a mom who has formula fed and breastfed, I’ve had the opportunity to witness both sides. I’ve witnessed a shift within myself. Saying I breastfed felt and still feels like a bit of a badge of honor. Now that I’ve done it, I’m proud, because it was such a labor of love for me. Breastfeeding was blood, sweat and tears and so much effort. While traveling to San Diego I had no choice but to pump in a public bathroom at the airport, right at the sink, while a line of women stood staring at me. I had no choice. I think back to how drained and emotional I was on Sophia’s first night home and can’t believe we made it this far on our journey.

When we took our kids to the zoo last week and I mixed a formula bottle in the food court, I felt a sense of worry—that other parents would look at me and judge my decision to feed my baby this way. Even though in my heart, I know fed is best. There are so many mind games associated with it all!

In the end, if you’re struggling mentally and emotionally, it’s going to take away from the type of mom you are. Don’t allow yourself to get so caught up in the pressure that it’s detrimental to you or your family life.

Lean on fellow IBD moms

While I was pregnant and breastfeeding I found it incredibly helpful to touch base with fellow moms, specifically IBD moms who related to my journey. Do your “homework” and don’t be shy about sending private message or sending an email to ask questions to fellow parents who are patients that you see online. We are all a resource for one another. IMG-7814

In my case, breastfeeding ended up being something I’m so grateful I was able to do for nearly seven months. Unfortunately, once my period started after Sophia was six months, my supply plummeted greatly. I went from making 30-35 ounces a day, to five. Prior to that happening, we had gotten into such a comfortable, easy groove, I was planning on breastfeeding her until her first birthday. My body had different plans, and I’m fine with that. Flexible feeding brought me to this mindset. Pregnancy gave me a renewed love for my body, despite my illness, and now I can say breastfeeding did the very same.

BONUS TIP! Be proactive and set yourself up for success prior to your baby’s arrival. Order your breast pump ahead of time. Have nursing tanks and bras, hands-free bras for pumping and to sleep in, pads for your bra, nipple cream, a Haakaa for catching let down milk, and storage bags. If you’re dealing with extreme nipple pain or discomfort, alert your OB and see about getting a prescription for All-Purpose Nipple Ointment (APNO). This is mixed by a pharmacist and contains an antibiotic, an anti-inflammatory, and an anti-fungal. I used this and it worked wonders!