Vaccinating Your Baby After Biologic Treatment for IBD

One of the medication classes that is used for the treatment of inflammatory bowel disease (IBD) is biologics. Biologics are medications that are derived from living organisms: either from an animal, or a human, or some combination of both. A biologic medication is a large molecule, as opposed to small-molecule medications that are given by mouth, such as aspirin.

Biologic medications are often given by infusion or injection, usually several weeks apart (anywhere from four weeks to eight weeks). Some are given at home by self-injection and others are given in an infusion center via an IV. These drugs have changed the outlook for people with IBD since the first one of its kind was approved to treat IBD in the late 90s. Prior to that time, there were few effective treatments, and the mainstays, corticosteroids, are now understood to put patients at increased risks of adverse effects over biologics.

Considering Pregnancy With IBD

When considering pregnancy, many women living with Crohn’s disease or ulcerative colitis naturally begin to think about their current treatment and how it may or may not affect a fetus and a newborn. One of the most important factors for a healthy pregnancy, uneventful birth, and healthy baby is keeping the IBD in remission.

Most medications for IBD are considered to be safe for use during pregnancy. Therefore it’s widely recommended that women not discontinue their IBD treatments when they are pregnant, because of the increased risk of a flare-up.

While it might make sense to stop certain types of medications, complementary and alternative therapies, or over-the-counter treatments during pregnancy, most medications for treating IBD don’t need to be stopped during pregnancy.

With biologic medications, pregnant women may have a concern that the medication will cross the placenta and the baby will get a certain amount in their bloodstream. Biologic medications work to treat IBD because they dampen the immune system. When the immune system is not as active, there's less inflammatory activity in the digestive systems and/or other parts of the body. How much the immune system is suppressed depends on the particular class of medication.

It’s true that most biologic medications do cross the placenta and therefore may also suppress the immune system of the baby for a time . For this reason, scientists have studied how much of the biologic drug a baby has in their body when they’re born. It is important to study this information because while continuing to take medication is important to preventing an IBD flare-up, the amount of medication the baby receives through the mother may affect when a baby can receive certain types of vaccinations.

This article will discuss how biologic medications affect the immune system of mothers with IBD and their newborns, how dosing of biologic medications in the third trimester may be altered, and if and when vaccinations in an infant need to be avoided or delayed for a time.

Live, Attenuated vs. Inactivated Vaccines

Part of understanding why there may be a difference in the vaccine schedule for infants born to women who received biologics is in knowing more about the vaccines themselves. Two categories of vaccines recommended for infants include those that contain a living, but weakened, form of the virus and those that contain an inactivated or killed form of the virus.

Live, Attenuated Vaccines

Live, attenuated vaccines contain the virus but it is weakened. The body responds to the vaccine by generating an immune response. The advantage of the live vaccines is that a life-long immunity to the disease can be gained after only 1 or 2 doses.

However, for people who are receiving medication(s) that suppress the immune system, it may not be possible to receive this type of vaccination. It is often recommended that women with IBD receive any live vaccines that are needed before starting on a biologic medication or before becoming pregnant.

Similarly, babies born to women who are receiving certain medication(s) that suppress the immune system may need to receive live vaccines on a different schedule. The medication may need to clear from the baby’s system before a live vaccine can be given. Some attenuated vaccines include the measles, mumps, rubella (MMR); chickenpox (varicella); and rotavirus.

Inactivated Vaccines

Inactivated vaccines also contain the virus, but it is killed in a laboratory. These vaccines usually need more doses than the live vaccines do in order to confer the same immunity from disease. In addition, “booster” doses may also be needed at certain points later in life.

People who have IBD and those who are looking to become pregnant will want to make sure that these vaccinations are also up-to-date, including any booster doses that are needed. Some inactivated vaccines include inactivated influenza, pertussis (whooping cough), and polio. 

Biologic Therapies During Pregnancy

Each biologic therapy has a different clearance rate. This is the time that it takes for a biologic medication that passes through the placenta to clear from the baby’s system after the mother’s last dose during pregnancy. The last dose given during pregnancy is usually scheduled with the clearance rate in mind. In all cases, it’s recommended that the dosing schedule be resumed after delivery, with the first dose being given as soon as 48 hours later.

Cimzia (certolizumab pegol). This medication is different than other biologics in that it is passively transported across the placenta and therefore less is taken up by the baby. In the third trimester, it’s recommended that the regular dosing schedule be kept . 

Entyvio (vedolizumab). Maintenance dosing is every eight weeks with Entyvio. According to published guidelines, it’s recommended that the last dose be given between six and 10 weeks prior to birth. 

Humira (adalimumab). Humira crosses the placenta. Guidelines recommend working towards scheduling the last dose in the third trimester about two to three weeks before birth. Studies have shown no link to short-term issues or birth defects in babies born to women receiving Humira during pregnancy.

Remicade (infliximab). The dosing schedule is usually every eight weeks but some patients receive an infusion as soon as every four weeks. There have been no reports of short-term issues or birth defects reported in babies born to women with IBD who receive Remicade during pregnancy. Remicade transfers across the placenta during the third trimester. Therefore some patients and physicians choose to work towards scheduling the last dose of Remicade before birth about six to 10 weeks before the due date. 

Simponi (golimumab). The maintenance dose of this drug is given every four weeks. This drug does cross the placenta and it’s recommended that the last dose be given in the third trimester approximately four to six weeks before birth.

Stelara (ustekinumab). The dosing schedule is typically every eight weeks but in some cases might be reduced to as often as every four weeks. Guidelines recommend giving the last dose between six and 10 weeks before birth and resuming the usual dosing schedule after birth. For dosing that’s been moved up to every four to five weeks, it’s recommended that the last dose be given in the third trimester about four to five weeks before birth.

Tysabri (natalizumab). The dosing schedule for this medication is every 28 days. It’s recommended that the last dose in the third trimester be given four to six weeks before birth. 

Guidelines for Vaccinations 

For babies born to women with IBD who have not received any biologic medications in the third trimester, the recommendation is to follow the vaccination schedule from the Centers for Disease Control and Prevention.

For women who receive a biologic (with the lone exception being Cimzia) in the third trimester (which is after 27 weeks), the vaccination schedule changes. In general, it’s recommended that live vaccines not be given to newborns and babies whose mothers received a biologic medication until they reach the age of 6 months.

The only live vaccination that is given to babies under the age of 6 months in the United States is that for rotavirus. Rotavirus is a common virus that causes diarrhea, low-grade fever, vomiting, and nausea. It usually lasts about three days. The development of the rotavirus vaccine has meant that this illness is far less common in small children than it once was.

The rotavirus vaccine is normally given at 2 months and again at 4 months, so it falls within that 6 month period during which it’s recommended that live vaccines not be given. This vaccine is most effective when given before 15 weeks of age and not given after the age of 6 months due to a risk of a rare complication, so it can’t be given later. All other vaccines given prior to 6 months, besides rotavirus, are not live and should, therefore, be given on schedule. 

New moms with IBD who received biologics may also be concerned about how their newborn may respond to vaccinations overall. It’s important for a newborn’s immune system to have the appropriate response after a vaccine is given. Scientists have studied how newborns of moms who received biologics responded by measuring the antibody response to a vaccine in the baby’s blood. They then compared these blood test results to infants of mothers who did not receive any biologics. There weren’t any differences found and the authors conclude that the babies will have the same immunity as other infants who weren’t exposed to biologics.

Special Considerations

There are a few situations that pregnant women and physicians may want to take into consideration with particular medications.

Cimzia

Cimzia does not pass through the placenta in the same way that other biologic medications do. For this reason, the recommendation to withhold live vaccines is not the same. Guidelines don’t recommend waiting six months to give a live vaccine to a baby that was born to a mother receiving Cimzia. However, it is still important to discuss the vaccination schedule with all physicians involved in the care of the mom and the baby.

MMR Vaccine

The measles, mumps, rubella vaccine is live but the first dose is given at 1 year of age. Therefore, guidelines recommend that it is given on schedule, because it falls beyond that six-month window.

The exception is Xeljanz (tofacitinib), when a mother is breastfeeding a baby at 1 year, because guidelines about the use of this medication are still being developed. It’s currently not known if Xeljanz affects the immune system of a 1 year old and should therefore be stopped for a time by a breastfeeding mother when the baby receives the MMR vaccine.

The decision to stop Xeljanz in a breastfeeding mom at the time of the MMR vaccine should be made after discussing all the options with the specialists involved in the care of mom and baby, including the gastroenterologist and pediatrician. 

A Word From Verywell

Receiving a biologic during pregnancy to treat IBD may cause a fair amount of worry for women. However, it’s well known that the most important factor in a pregnancy for women living with IBD is that the disease is in remission at the time of conception. Women who discontinue their treatment plan during the pregnancy run the risk of developing a flare-up of the disease, which can threaten not only the health of the mother but also the baby.

It’s important to discuss the timing of receiving the last dose of a biologic therapy before birth with the care team, including the gastroenterologist, obstetrician, and, if needed, a maternal-fetal medicine specialist.

Babies born to moms who received biologics may need to avoid the rotavirus vaccine because it is live, but in the United States, other vaccines are usually given on schedule. Every biologic is treated slightly differently in the guidelines and because every person with IBD is different, there could be other considerations. Pregnant women who have any questions about the treatment of their IBD during pregnancy or which vaccines a baby should receive should consult their care team for more information.