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- 1. Circumstances when Breastfeeding is Contraindicated Robert M. Lawrence, MD INTRODUCTION Universal and exclusive breastfeeding for the first 6 months of every infant’s life remain the recommendation and stated goal for infant feeding by numerous national and international organizations including; World Health Organization (WHO), United Nations International Children’s Emergency Fund, US Department of Health and Human Services, and the American Academy of Pediatrics (AAP). Human milk has Pediatric Infectious Diseases, Department of Pediatrics, Health Science Center, University of Florida, 1600 Southwest Archer Road, ARB1-118, Box 100296, Gainesville, FL 32610-0296, USA E-mail address: lawrerm@peds.ufl.edu KEYWORDS Breastfeeding Breastmilk Human milk Contraindications Infectious diseases Environmental contaminants Chemicals Heavy metals KEY POINTS The infectious diseases in the mother that remain contraindications to breastfeeding, at this time, are HIV-1 and HIV-2 (in industrialized settings) and human T-cell lymphotropic virus I and II. Temporary interruption (either for an initial period of treatment in the mother or for the finite period equal to the duration of illness) of breastfeeding and provision of breast milk is appropriate for a few infections with potential serious consequences. In some infectious situations, preventive interventions are available for the infant (immune serum globulin, vaccination, or prophylactic antimicrobial medication) while continuing to provide breast milk to the infant. Yellow fever vaccine and smallpox vaccine are the only contraindicated vaccines during breastfeeding. Coordinated medical care and lactation assistance are essential for successful breast- feeding in the face of maternal illness. Restrictive diets or malnutrition in the mother are not contraindications to breastfeeding. The substance exposure should be accurately identified and assessed for the individual mother-infant dyad, and temporary cessation as a potential intervention to decrease the infant’s toxic exposure should be discussed. When faced with the question of a possible contraindication to breastfeeding, a balanced assessment of the potential risks versus the probable, known benefits of breastfeeding must be completed and discussed with the mother and family. Pediatr Clin N Am 60 (2013) 295–318 http://dx.doi.org/10.1016/j.pcl.2012.09.012 pediatric.theclinics.com 0031-3955/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
- 2. evolved as a unique nutritional substance that is specific and ideal for the optimal growth and development of human infants.1–3 The numerous, important benefits of exclusive breastfeeding for the mother and infant have been well documented in evidence-based medicine literature4–6 and in this issue. Any circumstance, situation, condition, or illness that interferes with exclusive breastfeeding is a threat to the infant’s growth and development and the health of the mother-infant dyad. The ques- tion of contraindications to breastfeeding, relative or absolute, is a crucial topic for pediatricians in their role as knowledgeable advocates for breastfeeding. There are few absolute contraindications to breastfeeding or the use of human milk for infant nutrition. Among the relative contraindications there are numerous circum- stances or situations that constitute theoretical or potential risks to the infant or mother-infant dyad. A balanced discussion of the potential risks versus the probable, known benefits of breastfeeding must be considered. That discussion should include the scientific, evidence-based data on the potential risks; the specific facts of the situ- ation for the mother-infant dyad; and the cultural and personal conceptions, beliefs, and preferences of the mother and family. In certain situations, it may also be appro- priate to discuss the risks of not breastfeeding for the mother and infant.7 Additionally, a distinction should be made whether the potential risk or contraindication exists in the act of breastfeeding (eg, pulmonary tuberculosis in the mother and the potential for respiratory transmission of tuberculosis during the close contact of breastfeeding) or in the substance of the mother’s breast milk (eg, medication that is potentially toxic to an infant in the mother’s milk). This article summarizes the potential contraindications to breastfeeding with a focus on infectious diseases and exposure to environmental contaminants. Potential contra- indications to breastfeeding due to restrictive diets or malnutrition in the mother by Valentine and colleagues and medication and drug use by the mother are discussed by Hale and colleagues elsewhere in this issue. CIRCUMSTANCES Circumstances that pose potential contraindications are highly varied and include infectious diseases in the mother or infant, other medical conditions in the mother or in the infant (particularly metabolic diseases in the infant that necessitate special changes in the infant’s diet), environmental contaminants in the milk due to maternal exposure, and medications or drugs in the milk due to maternal use (prescribed or not prescribed) of those substances (Box 1). Infectious Diseases Most infectious diseases occurring in the mother are not contraindications for breast- feeding (Tables 1 and 2). In most cases, by the time the diagnosis is made in the mother, the infant has already been exposed through contact with the mother or others in the household. There is extensive evidence that breastfeeding protects infants against many common infections, including upper respiratory or lower respira- tory tract infection, otitis media, respiratory syncytial virus bronchiolitis, and gastroen- teritis.5,6,8–11 To interrupt or stop breastfeeding in this scenario would only deprive the infant of potentially beneficial antibodies (secretory IgA), and antiinflammatory or immunomodulating substances contained in human milk.12–16 In general, other mechanisms of transmission (blood or body fluids, contact, droplet, or airborne) are the more common risk for transmission of infection between a mother and her infant. In rare situations, temporary separation of the mother and infant (related to the risk of transmission via another mechanism) can be considered Lawrence296
- 3. Box 1 Selected conditions for which the question of contraindication to breastfeeding is frequently raised Infectious diseases Human immunodeficiency virus Human T-cell lymphotropic virus I and II Hepatitis: A, B, C, E Measles Cytomegalovirus Herpes simplex virus Varicella-zoster virus Human papilloma virus Syphilis Lyme disease Tuberculosis Brucellosis Candida infection West Nile virus Influenza Localized infection of the breast: mastitis, breast abscess Staphylococcus aureus Streptococcus (Group A or B) Vaccinations in the lactating mother Medical conditions in the infant Galactosemia Phenylketonuria Inborn errors of metabolism Lactose intolerance Milk protein allergy Hyperbilirubinemia (breastfeeding jaundice, breast milk jaundice) Medical conditions in the mother Wilson disease Galactosemia Phenylketonuria Cystic fibrosis Cancer Rheumatologic disorders and/or inflammatory bowel disease Obesity and/or gastric bypass surgery Polycystic ovarian disorder Renal failure and/or dialysis When Breastfeeding is Contraindicated 297
- 4. along with maintaining the milk supply and providing the infant with expressed breast milk (eg, active pulmonary tuberculosis, pertussis). There are a few rare and serious infections in the mother in which breast milk should temporarily not be provided to the infant until the mother is clinically well (eg, Ebola and Marburg hemorrhagic fevers). In other serious invasive infections (bacteremia, meningitis, osteomyelitis, septic arthritis) due to specific organisms (Brucellosis, Group B Streptococcus, Staphylo- coccus aureus, Haemophilus influenza b, Streptococcus pneumonia or Neisseria men- ingitidis), temporary suspension of breastfeeding from an infected mother should occur until an initial period (usually 24–96 hours) of treatment of the mother has occurred and there is evidence of some clinical improvement. Mastitis and breast abscesses are not considered invasive infections (see later discussion). In other rare situations in which specific infections involve the mother’s nipple or breast (eg, herpes simplex virus, tuberculosis), if the milk cannot be expressed and/or collected without contamination it should not be given to the infant until the mother is treated and the lesions resolved.17 The infectious agents are not in the breast milk unless contami- nated at the time of expression. In some situations, prophylactic or empiric therapy for the infant against the identified organism can be considered and, once instituted, breastfeeding can continue (eg, azithromycin for pertussis, varicella immune globulin or acyclovir for varicella, immune serum globulin and vaccine for hepatitis A, rabies immune globulin and rabies vaccine for maternal rabies, isoniazid for pulmonary tuber- culosis).18–22 The only real infectious contraindications to breastfeeding are human T-cell lymphotropic viruses (HTLV) I and II, and HIV-1 and HIV-2, in resource-rich regions.6,23 The WHO continues to recommend exclusive breastfeeding for at least 6 months for HIV-positive mothers in resource-poor regions, and combining comple- mentary feeds and continued breastfeeding through the first 12 months of life, for improved overall survival, child growth and development, and greater HIV-free survival. In situations when the mother is too ill to breastfeed or severely immune sup- pressed, she should be encouraged to consider alternative feeding when that choice of feeding is affordable, feasible, accessible, sustainable and safe (AFASS criteria).23–27 Breastfeeding in resource-poor settings offers a significant mortality and morbidity benefit regardless of whether or not the infant becomes HIV infected Diabetes Hyperlipidemia Restrictive diet or malnutrition in the mother (see discussion elsewhere in this issue on nutrition management by Valentine and colleagues) Caloric restriction Protein deficiency Vitamin A, C, D, or B6 deficiency Nutrients: Calcium, iron, zinc Exposure to environmental contaminants Herbicides Insecticides Heavy metals Radionuclides Medications and drug use (see discussion elsewhere in this issue for a complete list and discussion by Hale and colleagues) Lawrence298
- 5. Table 1 Summary of selected bacterial infections and concern as a contraindication to breastfeeding Problem or Infection Mode of Transmission Breastfeeding Use of Expressed Breast Milk Preventive Interventions Special Conditions Staphylococcus Contact TI 24–48 h of Rx OK after 24–48 h of Rx Prophylactic antibiotics Severe MI, toxin- mediated disease Streptococcus Group B Contact TI 24–48 h of Rx OK after 24–48 h of Rx Prophylactic antibiotics Severe, invasive MI, recurrent infections Brucellosis Milk, contact TI 48–96 h of Rx OK after 48–96 h of Rx None Severe MI Listeria Contact, perinatal OK OK None Severe MI Meningococcus Respiratory droplets TI 24 h of Rx OK Prophylactic antibiotics Severe MI Pertussis Respiratory droplet TI 5 d of Rx OK Prophylactic antibiotics, vaccine — Latent TB infection None OK OK None Maternal Rx with INH, B6 Active Pulmonary TB Respiratory, Airborne TI for 7–14 d, or until infant on INH OK INH for the infant, subsequent testing and f/u Insure adherence to therapy by mother TB Mastitis Contact TI for Rx TI until lesions resolved, Cx negative INH for the infant Insure adherence, f/u Syphilis Sexual, secretions, contact with skin lesions TI for 24 h of Rx OK after 24 h of Rx If a nipple or breast lesion, no BM until healed Empiric or prophylactic Rx for the infant Isolation and Rx for the infant if congenital infection and/or rhagades, f/u Lyme disease, Borrelia burdorferi Tick borne, rarely other modes TI for 24–48 h of initial Rx of mother OK after initial Rx of mother None Informed discussion Abbreviations: B6, vitamin B6; BM, breast milk; Cx, culture; f/u, follow-up, including testing of the infant; INH, isoniazid; MI, maternal illness; Rx, therapy; TB, tuberculosis; TI, temporary interruption. WhenBreastfeedingisContraindicated299
- 6. Table 2 Summary of selected viral infections and concern as a contraindication to breastfeeding Problem or Infection Mode of Transmission Breastfeeding Use of Expressed Breast Milk Preventive Interventions Special Conditions Acute hemorrhagic fevers (Ebola virus, Lassa fever) Contact, body fluids, blood No for DI No for DI None Separation and isolation Cytomegalovirus Body fluids OK, caution in premature infants OK, caution in premature infants Freeze-thaw or pasteurize milk None Extremely premature or VLBW infants HAV Fecal-oral, food, water OK after intervention OK after intervention SIG or HAV vaccination — HBV Blood, body fluids, vertical OK after intervention OK after intervention HBIG, and HBV vaccination Standard protocol for HBV surface Ag 1 mothers Hepatitis C Blood, IVDU OK OK None Informed discussion HSV Perinatal, contact OK, except if a lesion involves the nipple or breast No, if a lesion involves the nipple or areola and contamination of expressed BM is unavoidable Systemic and topical Rx for mother, cover any lesions Can consider prophylactic Rx for the infant HHV 6 and 7 Oral secretions OK OK None — Parvovirus Oral secretions vertical OK OK None — Lawrence300
- 7. HTLV I and II Blood, sexual contact, BM No No None Avoid BF when alternate infant feeding is AFASS HIV-1 Blood, sexual, perinatal, vertical, BM Yes in resource-poor settings No in resource- rich settings Yes in resource-poor settings No in resource- rich settings Exclusive BF, antiretroviral Rx or prophylaxis for the mother and/or the infant When avoiding BF alternate infant feeding should be AFASS HIV-2 Blood, sexual, perinatal, vertical, BM Yes in resource-poor settings No in resource- rich settings Yes in resource-poor settings No in resource- rich settings None When avoiding BF alternate infant feeding should be AFASS Smallpox Contact, airborne No No None Avoid contact with lesions Vaccinia virus (smallpox vaccine) Contact, airborne OK if local lesion can be covered No, if a lesion involves the nipple or areola and contamination of expressed BM is unavoidable — Do not vaccinate pregnant women West Nile virus Mosquito, blood Yes Yes — Severe maternal illness can interfere with BF VZV Contact, Airborne No, until lesions are crusting and dried Yes, if no lesions on the breast VariZIG, acyclovir 5 d before delivery up to 2 d aftera Abbreviations: AFASS, acceptable, feasible, affordable, safe, sustainable; Ag 1, antigen positive; BF, breastfeeding; BM, breast milk; DI, duration of illness; HAV, Hepatitis A virus; HBIG, Hepatitis B immune globulin; HBV, Hepatitis B virus; HHV, human herpesvirus; HIV, human immunodeficiency virus; HTLV, human T-cell lymphotrophic virus; HSV, herpes simplex virus; IVDU, intravenous drug use; Rx, therapy; SIG, immune serum globulin; VLBW, very low birth weight; VZV, varicella zoster virus. a American Academy of Pediatrics. Varicella-Zoster Infections. In: Pickering LK, Baker CJ, Kimberlin DW, et al, editors. Red Book: 2012 Report of the Committee on infectious diseases. Elk Grove Village (IL): American Academy of Pediatrics; 2012. p. 774–89. WhenBreastfeedingisContraindicated301
- 8. because of the significant risk in many settings for other infections and malnutrition in the absence of breastfeeding. Exclusive breastfeeding reduces the risk of transmis- sion of HIV from the mother to the infant compared with mixed feeding. Breastfeeding does not adversely affect the HIV-infected mother’s health.23 Now, there are possible situations in which ongoing breastfeeding by an HIV-1–infected mother while the mother, infant, or both receive effective antiretroviral medication regimens throughout the breastfeeding period can improve HIV-free survival of the infant.23,28,29 There are multiple prospective studies demonstrating the proof of this concept. The true efficacy of such an approach and an optimal regimen for prevention in various situations and/ or locations has not been studied in well-controlled prospective trials. The WHO does state that continued breastfeeding with antiretroviral therapy for the mother or prophy- laxis for the mother or infant is a strategy that, in certain situations, can offer the child the greatest chance of HIV-free survival.23 The American Academy of Pediatrics has not changed the recommendations for the United States; breastfeeding by an HIV- infected mother is proscribed.6 In Great Britain, the British HIV Association has com- mented that, in very rare instances, breastfeeding by an HIV-positive mother can be considered with effective antiretroviral treatment of the mother, infant, or both.30 There are limited data concerning the risk of transmission of HIV-2 via breastfeeding. Breast- feeding by mothers with confirmed HIV-2 infection should currently follow the guide- lines for HIV-1 in the mother’s locale. HTLV-1 and HTLV-2, which cause leukemia or lymphoma and chronic neurologic disorders, are associated with significant transmission through breastfeeding because both are present in human milk, associated with a longer duration of breastfeeding, and demonstrate an increased risk of transmission in breastfed infants in comparison with formula-fed infants. There are no immunologic or pharmacologic interventions currently available to prevent HTLV I and II infections; however, a shorter duration of breastfeed- ing, freezing and thawing breast milk, and complete avoidance of breast milk have shown decreased transmission to the infant.31–33 For each of these retroviruses (HIV-1, HIV-2, and HTLV I and II), avoidance of breastfeeding is one form of prevention that still requires that the use of a formula or alternative feeding meets AFASS criteria, whether the circumstances are in a resource-rich or resource-poor country. Transmission of Brucella from human to human is exceedingly rare and there are only a handful of cases that describe breastfeeding or breast milk as a possible source of infection for the infant. Brucella is readily identified in animal milks but has been cultured from human milk in only one reported case. Other, more likely, routes of trans- mission include direct contact with infected animals or their unpasteurized milk or milk products. Other uncommon routes of infection include intrauterine infection, exposure during delivery, blood transfusion, bone marrow transplantation, and sexual contact.34 Documented Brucella infection in a mother is a situation in which temporary suspen- sion of breastfeeding should occur. Breast milk should not be given to the infant until at least 72 to 96 hours of maternal treatment of Brucella with evidence of clinical improvement. Then the use of breast milk can be resumed or breastfeeding continued if the mother is able.35,36 Although invasive Candida infection occurs in premature, low-birth weight or very- low birth weight infants, mild mucocutaneous infection is the most common form of this infection in infants. Several aspects of mammary candidosis or candidiasis remain areas in need of further study including; how to make the clinical diagnosis, the signif- icance of associated pain, and the presence or absence of Candida albicans isolated from human milk of symptomatic and asymptomatic women. Candida does survive to a large extent in frozen-thawed breast milk. The direct contact during breastfeeding of the infant-mother dyad is the probable source of ongoing recolonization and Lawrence302
- 9. reinfection. Simultaneous treatment of the dyad should occur when one or both of the pair are symptomatic. Treatment of mucocutaneous candidiasis and mammary candi- diasis can begin with topical agents, including nystatin, clotrimazole, miconazole, eco- nazole, terconazole, ciclopirox, or gentian violet solution. Various other topical preparations (mupirocin, grapefruit seed extract, or mixtures of mupirocin, betametha- sone, and miconazole) have been recommended for the mother’s breast without avail- able clinical trials for efficacy and toxicity. Systemic therapy is sometimes necessary, and oral fluconazole is the most commonly used preparation because of its favorable side-effect profile. Other antifungal agents can be considered if systemic or invasive disease is present in the infant or mother because of other predisposing factors. Risk factors predisposing for candidal infections in the mother or infant should be addressed (eg, eliminating antibiotic use as soon as possible). Breastfeeding can continue without cessation in the full-term infant with the professional assistance of someone knowledgeable in the management of breastfeeding. Local infections of the breast, mastitis or breast abscess, are not contraindications to continued breastfeeding. Antimicrobial therapy should be chosen with consider- ation of the most common organisms (penicillin-resistant Staphylococcus aureus, Streptococcus, Escherichia coli) and agents that are compatible with breastfeeding.37 In most instances the infecting organism has not been identified unless a culture has been done. Possible factors predisposing to mastitis or milk stasis should be addressed and effective milk-removal strategies encouraged along with more frequent breastfeeding. Pumping and discarding the milk for a short period while opti- mizing continued effective milk removal has been recommended for invasive Group B Streptococcus infection in the mother or infant.38 In most scenarios, appropriate empiric therapy has already been initiated for 1 to 2 days before culture results are available and no temporary interruption of breastfeeding or breast milk is indicated. As long as drainage from the abscess does not directly contact the infant’s mouth, continued breastfeeding from the affected breast is appropriate. It is infrequently useful to culture breast milk to guide decision-making about ongoing therapy and breastfeeding. If there is an initial failure of empiric therapy (after 48–96 hours of therapy) for mastitis, frequent recurrences of mastitis despite appar- ently appropriate therapy, or pain out of proportion to the clinical findings, then culturing the breast milk (collected as a “midstream collection” after gently cleaning the nipple and areola) may provide culture and sensitivity information to alter subse- quent antimicrobial therapy. Material obtained from a discrete abscess that has been drained should always be cultured. Culturing breast milk may also be appro- priate in outbreak or epidemiologic investigations. Immunization of the mothers with common live virus vaccines (eg, varicella vaccine; measles, mumps, and rubella vaccine) is not a contraindication to initiating or continuing breastfeeding. Yellow fever vaccine and smallpox vaccine should not be given to breastfeeding mothers, although it is acceptable (if truly necessary) to give Japanese encephalitis vaccine, typhoid live vaccine, and rabies vaccine. The use of the inactivated influenza vaccine should be encouraged for breastfeeding mothers. Refer to the Centers for Disease Control and Prevention Web site for additional information.39 Medical Conditions in the Infant Galactosemia is a rare disorder, identified by neonatal screening in most states, which is caused by deficiency of galactose 1-phosphate uridyltransferase (GALT) enzyme (Table 3). There are several genetic variants of the disease due to mutations in the GALT gene. “Classic” galactosemia is the most severe, necessitating strict When Breastfeeding is Contraindicated 303
- 10. Table 3 Medical conditions in the infant and concerns regarding breastfeeding or human milk Condition BF or BM Supplement with Animal Milk or Special Formula Comments Alpha-1 antitrypsin deficiency OK Not necessary Potential benefit from BM Adrenal hyperplasia OK Not necessary — Amino acid inborn errors of metabolism (methionine, leucine, isoleucine, tyrosine) OK in combination with a special formula or feeding Formula or feeding without the amino acid for needed protein and calories Monitoring of infant is important: calories, nutrients, growth and amino acid levels Cow’s milk protein allergy OK in most instances Uncommonly need a formula without cow’s milk protein Elimination diet for the mother Cystic fibrosis OK Usually not necessary, can use a hydrolyzed formula Can give infant pancreatic enzymes Galactosemia, classic No No lactose-containing foods Close monitoring Galactosemia, variants OK, combined with some lactose-free formula Supplement with lactose-free formula for needed extra calories Close monitoring is crucial, gal-1-p levels, medical specialists involved Hypothyroidism OK Not necessary — Hyperbilirubinemia, BF or BM jaundice OK BF jaundice—optimize BF, BM jaundice—rarely requires temporary interruption of BF See text and references Lactose intolerance OK BF—benefit in temporary lactase deficiency with gastroenteritis in infant Rarely—truly a problem vs changes to lactose-free formula due to worry or fear Ornithine transcarbamylase deficiency OK with supplementation Supplementation with a nonprotein source of calories Close monitoring of ammonia levels and growth Phenylketonuria OK with supplementation Use BM in combination with a phenylalanine-free formula to provide adequate calories and nutrients Close monitoring, measure phenylalanine levels Abbreviations: BF, breastfeeding; BM, breast milk; vs, versus; gal-1-p, galactose-1-phosphate. Lawrence304
- 11. diets without any lactose, whereas other variants (with the Duarte allele, D1, or D2) have milder disease with reduced enzyme activity and can be managed with a less restrictive diet. It may be appropriate in the first 14 days of life to avoid any lactose-containing milk or formula (pumping and saving breast milk for possible later use) until the exact genetic diagnosis can be made. When possible, in situations with only reduced GALT enzyme activity, a modified diet can balance the use of breast milk and a non–lactose containing formula can maintain blood galactose-1- phosphate (gal-1-p) levels less than 3 to 4 mg/100 mL. These infants should be managed by a geneticist and a genetic nutritionist, along with someone knowledge- able in breastfeeding. Phenylketonuria is another genetic error of metabolism necessitating a modified diet with limited amounts of phenylalanine for optimal growth and development of the infant. Human milk contains small amounts of phenylalanine and tyrosine. The use of a phenylalanine-free formula can be combined with breast milk in a regimen to provide adequate nutrients and calories as well as essential manageable amounts of phenylalanine. Detailed approaches to management of breastfeeding in the infant with phenylketonuria have been described by Clark40 and Ernest and colleagues.41 Mothers who have phenylketonuria can breastfeed their infants and provide caloric and nutrient-appropriate milk for the infant. Other inborn errors of metabolism involving amino acids can be managed with breastfeeding and careful monitoring of the blood and urine levels of the specific amino acid accumulating based on the specific enzyme defect (eg, methionine, leucine, isoleucine, and tyrosine). A regimen combining breast milk and another milk or formula without the specific amino acid can be developed in conjunction with a geneticist and/or endocrinologist. Careful monitoring of growth, diet, caloric and nutrient intake, and amino acid levels is essential. Ornithine transcarbamylase defi- ciency, one of several urea cycle disorders, results in severe illness due to the accu- mulation of ammonia. Infants can be breastfed combined with a nonprotein caloric supplement. Alpha1-antitrypsin deficiency has more than 24 genetic variants and chil- dren with this deficiency are at increased risk for progressive liver disease, sometimes presenting in infancy. Breastfeeding a child with alpha1-antitrypsin deficiency can be beneficial and potentially reduce the risk of subsequent liver disease.42 Cystic fibrosis is another condition often identified in infancy for which breastfeeding is appropriate. The addition of pancreatic enzymes or hydrolyzed formula to the infant’s diet may be appropriate for certain infants to optimize growth and development. Neither hypothyroidism nor adrenal hyperplasia is a contraindication to breastfeed- ing. Congenital hypothyroidism can be diagnosed by neonatal screening. Breast milk does contain T4 and T3 and may delay the diagnosis or mask the presentation of hypothyroidism.43,44 Neonatal lupus, another rare condition manifesting in infancy, is not a contraindication to breastfeeding.45,46 Jaundice and hyperbilirubinemia are not contraindications to breastfeeding (see elsewhere in this issue for additional discussion by Chantry and colleagues). The management of hyperbilirubinemia is completely reviewed in the AAP guidelines.47,48 Specific guidelines for the management of jaundice in the breastfeeding infant are detailed in the Academy of Breastfeeding Medicine Clinical Protocol #22 on hyperbi- lirubinemia in infants equal to or greater than 35 weeks gestational age.49 Optimization of breastfeeding technique, maintenance of the maternal milk supply and support are recommended during the management of hyperbilirubinemia in any infant. Uncommonly, supplementation with a hydrolyzed protein formula may be initiated to decrease intestinal absorption of bilirubin and, rarely, temporary interruption of When Breastfeeding is Contraindicated 305
- 12. breastfeeding for 24 to 48 hours is appropriate as treatment options in cases with very high bilirubin levels.49 Cow’s milk protein allergy can occur when a breastfeeding infant is transitioned from breast milk to formula or whole cow’s milk or other animal milk-based products. Human milk contains some foreign proteins in small amounts, so some children may react while exclusively breastfeeding and cow’s milk protein allergy should be consid- ered when the infant has symptoms suggestive of cow’s milk protein allergy. Reinsti- tution or continuation of breastfeeding in the former situation is appropriate and, in the latter situation, the strict elimination of cow’s milk protein from the diet of the mother can be attempted with expected disappearance of symptoms in the infant. If the infant’s symptoms do resolve, cow’s milk protein can be slowly replaced in the mother’s diet, to a degree still tolerated by the breastfeeding infant. It has also been recommended, in severe cases of allergic proctocolitis, that the mother be given pancreatic enzymes that, theoretically, break down potential protein allergens in the mother’s intestine.50 Occasionally, supplementation with a formula that contains no cow’s milk protein is necessary. Calcium intake or supplements are essential for the mother on any cow’s milk protein elimination diet.51,52 Lactose intolerance is not a contraindication to breastfeeding. Lactose intolerance is a clinical syndrome characterized by abdominal pain, diar- rhea, nausea, flatulence, and/or bloating after ingestion of lactose containing foods.53 It is very rare in infants except as a transient, secondary lactase deficiency due to intestinal mucosal injury as might occur with acute gastroenteritis or persistent diar- rhea. Congenital lactase deficiency is the extremely rare condition of complete lactase deficiency. Developmental lactase deficiency is the relative lactase deficiency that occurs in premature infants, usually less than 34-weeks gestation. As children get older, often at 3 to 5 years of age, they can develop intolerance of lactose. Symptoms that are consistent with lactose intolerance do need evaluation in infants, especially if the infant is failing to thrive. This does not require an immediate switch from breast milk to a lactose free formula. Medical Conditions in the Mother There are no medical conditions (the condition itself) in the mother that are absolute contraindications to breastfeeding (Table 4). The most common issues related to a mother’s medical condition that can be relative contraindications, or simply interfer- ences, to breastfeeding include: (1) the severity of maternal illness, (2) exposure to radionuclides for diagnostic purposes (eg, fibrinogen leg scan using iodine-125 for detecting deep vein thrombosis requires discarding the mother’s milk for approxi- mately 2 weeks until the radioactive material is out of the milk), or (3) medications used to treat the condition that are not compatible with breastfeeding (eg, tamoxifen as an antiestrogen, anticancer medication) or not amenable to continued breastfeed- ing with intermittent discarding of breast milk containing the proscribed agent (eg, antineoplastic agent such as vincristine that would require discarding mother’s milk for 35 days). Some maternal conditions or illness may make the mother too sick to breastfeed (eg, adult respiratory distress syndrome requiring intubation, renal failure with or without dialysis, systemic lupus erythematosus with central nervous system vasculitis, or encephalitis). Mothers on dialysis produce caloric and nutrient appro- priate milk for the infant without an accumulation of urea nitrogen or creatinine in their breast milk. Other conditions may hinder or interfere with the initiation (eg, cesarean section delivery or toxemia) or maintenance of adequate milk production (eg, poly- cystic ovary syndrome) for the nutritional needs of the growing infant. A review and meta-analysis of breastfeeding after cesarean section reported that early Lawrence306
- 13. Table 4 Selected medical conditions in the mother that can affect breastfeeding but are not contraindications Condition Additional Benefit of BF for the Mother or Infant Can Interfere with BF Diagnostic Testing a Concern Medications a Concern Comments Cesarean Delivery Yes—oxytocin and uterine involution Yes No Yes — Toxemia Yes, oxytocin, prolactin Yes—severe maternal illness No Yes—sedation, anti- hypertensives — Retention of placenta, lactation failure Yes Yes No No BF improves after surgical removal Venous thrombosis, pulmonary embolus — Yes—severe maternal illness No, angiography, MRI are OK No, heparin, low- molecular weight heparin, warfarin Important to diagnose and treat Mastitis, abscess Yes, effective removal of milk Temporarily No No, alternatives are commonly available Treat engorgement, pain and infection Sheehan syndrome and hypopituitarism — Yes No Yes, bromocriptine Nasal oxytocin spray plus lactation supplement Diabetes mellitus Yes, weight loss, decreased insulin requirement Yes, prematurity, respiratory distress, hypoglycemia, poor feeding, hyperbilirubinemia in the infant No No Adjust diet, monitor insulin and glucose, early education plus support Thyroid disease — Yes Careful test selection Careful choices of medications Coordinated care for successful BF Polycystic Ovarian Syndrome — Yes, insufficient milk supply No No Coordinated care for successful BF CF Yes Yes, if severely underweight or sick No No Plan with CF physicians during pregnancy (continued on next page) WhenBreastfeedingisContraindicated307
- 14. Table 4 (continued) Condition Additional Benefit of BF for the Mother or Infant Can Interfere with BF Diagnostic Testing a Concern Medications a Concern Comments Celiac disease Yes No No No Mother needs additional vitamins and nutrients for herself Galactosemia Yes No No No Calcium and Vitamin D for the mother Phenylketonuria Yes No No No Infant may need a source of phenylalanine Connective tissue disorders — Yes, Sjo¨ gren syndrome, Raynaud phenomenon of the nipple No Yes—dose, timing, drug interactions Coordinated care for successful BF Cardiovascular disease — Severe MI No Yes—choice of medications — Solid organ transplant — Severe MI No Yes Coordinated care for successful BF Glomerular disease and hypertension — Severe MI No Yes Coordinated care for successful BF Osteoporosis — No Bone density scan OK No Maternal therapy appropriate, Vitamins D for infant (400 IU) Inflammatory bowel disease — No No No Maternal nutrition is important Epilepsy — Plus uncontrolled seizures No Sometimes Monitor medication levels in mother Breast Cancer — Yes, surgery, radiation No Yes Depending on stage of treatment, BF can be done Lawrence308
- 15. Fibrocystic breast disease — Yes No No — Gigantomastia — Yes, medication or surgery No Yes, bromocriptine Surgery—reduction mammoplasty Augmentation Mammoplasty — Yes, if minimal functional breast tissue No No — Reduction mammoplasty — Yes—if interruption of nerves or ductal structures No No Options of different procedures, consider BF preoperatively Multiple sclerosis Yes, decreased risk of postpartum relapses Yes, severity of illness No No — Postpartum Depression — Yes, early termination of BF No Yes, medication choices Early diagnosis crucial, combined therapy Abbreviations: BF, breastfeeding; CF, cystic fibrosis; MI, maternal illness; MRI, magnetic resonance imaging. WhenBreastfeedingisContraindicated309
- 16. breastfeeding (initiation or breastfeeding at discharge) was significantly lower after cesarean section compared with vaginal delivery. In a separate analysis of mothers who initiated breastfeeding, cesarean delivery had no significant effect on breastfeed- ing at 6 months of age.54 Restrictive Diets in the Mother Exclusive human milk is the preferred food source for human infants for the first 6 months of age. Breastfeeding is recommended in usual circumstances, even when the maternal diet may be poor or restricted. In 1991, the Subcommittee on Nutrition During Lactation of the Committee on Nutritional Status During Pregnancy and Lacta- tion of the Food and Nutrition Board of the Institute of Medicine at the National Academy of Science noted in their report that there is a large body of evidence demon- strating that women are able to “produce milk of sufficient quantity and quality to support the growth and promote the health of infants—even when the mother’s supply of nutrients is limited.”55 A poor or restrictive maternal diet is not a contraindication to breastfeeding. Nevertheless, women on such diets should be counseled concerning possible nutritional deficiencies caused by such diets and the potential effect on their milk.56 Nutritional needs during lactation and restrictive diets are discussed in more detail elsewhere in this issue by Valentine and colleagues. Exposure to Environmental Contaminants The possibility of environmental contamination of human milk by chemicals exists; however, most individuals are not at significantly increased risk of exposure (Table 5). Specific exposures, in the workplace (to chemicals or heavy metals), in the food chain in a geographic area (eg, polybrominated biphenyls in bovine milk and meat products in Michigan in the 1970s or high levels of mercury in the fish food supply in Japan),57 or during a specific period of time (eg, the herbicide Agent Orange exposure during the Vietnam War) are rare events. When the mother is exposed, the greatest risk to the infant is during pregnancy as a fetus, compared with the relatively smaller exposure during breastfeeding. Pesticide and herbicide use in the United States has decreased dramatically since the 1970s, but the most common ongoing source of exposure is through working with or eating fish caught in sport fishing in contaminated waters. Pesticide and herbicide exposure continues to be a significant problem in many other parts of the world. Nevertheless, the WHO has stated that, despite the possible contamination of breast milk with dioxins and other herbicides and pesticides, the benefits of breastfeeding outweigh the potential risk to the infant and has recommended breastfeeding except in specific situations of high-level acute exposures.58 This recommendation is sup- ported by the recommendations of a technical workshop on Human Milk Surveillance and Biomonitoring for Environmental Chemicals in the United States and recommen- dations from experts.59,60 Many herbicides and pesticides are deposited in the fat stores in the body. The concern with breast milk is that they will enter the fat component of the milk. Chlori- nated hydrocarbons (polychlorinated biphenyls, including DDT and its metabolites, dieldrin and aldrin) are the most familiar to the public. Although these and related prod- ucts have been identified in breast milk, in most cases these levels are lower than what is found in cow’s milk.61,62 See Table 5 for consideration of selected compounds. Specific heavy metals that have been identified in human milk include lead, arsenic, mercury, and cadmium. Whenever a significant maternal exposure occurs, leading to a documented, elevated level of the compound in the mother, the breastfed infant and/ or the human milk should be tested. In the case of lead, a level of 40 mg/dL or less Lawrence310
- 17. Table 5 Environmental contaminants and breast milk Class Agent Sources BF and BM are OK Comments Herbicides Dioxin Contaminated water, food supply Yes WHO statement says OK — Furans Contaminated water Yes — Pesticides DDT, DDE Contaminated water, animals, food supply Yes Lower levels in human milk than in cow’s milk — PCBs, PBBs Contaminated water, animals, food supply, waste disposal, “spills” Yes Very low levels in milk — Cyclodiene pesticides — Yes Rare exposures Heavy Metals Arsenic Water, water supply Yes Little arsenic in breast milk — Cadmium Contaminated shellfish, industrial exposures, smokers Yes — — Lead Lead-based paints, lead pipes, water supply, industrial pollutants Yes, when mother’s blood level is 40 mg/dL (little or no lead in BM) Pregnancy is the greater risk, check family members, increase calcium and iron in diet — Mercury Seafood, “spills,” herbs and tonics Yes See text Abbreviations: BM, breast milk; DDE, dichlorodiphenyldichloroethane; DDT, dichlorodiphenyltrichloroethane; PBBs, polybrominated biphenyls; PCBs, polychlori- nated biphenyls. WhenBreastfeedingisContraindicated311
- 18. measured in the mother’s blood is reported to be less than the level of transfer into the breast milk; therefore, testing of the breast milk is unnecessary.63 Lead remains a significant concern throughout the world. Common sources are old paint, contam- inated ground water, gasoline, lead batteries, and even herbs and herbal teas (exported from China). In addition to testing for lead, once found, identifying the source and performing adequate lead abatement is the next step. Mothers and infants should receive extra iron and calcium in their diets to diminish absorption from the intestine and mobilization from bone. Arsenic is commonly found contaminating bodies of water and water supplies from industrial sources. In several arsenic- contaminated areas, high levels of arsenic were detected in some of the women but low levels were detected in the breastfeeding babies, suggesting little arsenic is excreted in breast milk and that breastfeeding is appropriate.64 Mercury is being detected in food around the world, especially in fish, herbs, and tonics. In the Faroe and Seychelles Islands, there are two studies reporting on the good growth and health of breastfed infants chronically exposed to high levels of methylmercury in breast milk.65,66 Breastfeeding is acceptable in the face of methylmercury exposure, although acute industrial or environmental exposures should be investigated carefully and decision-making should be analyzed relative to the individual’s and the mother- infant dyad’s health situation. Cadmium exposure usually occurs from industrial waste or eating large amounts of contaminated shellfish and is often worse in smokers (who seem to accumulate cadmium). The greatest risk of exposure is to the fetus during pregnancy. Breastfeeding is not contraindicated; however, significant or unusual exposures should be investigated and assessed.67 Volatile chemicals are most commonly found in paint shops, repair shops, garages, and industrial chemical workplaces. Protective gear, as recommended by the Occu- pational Safety and Health Administration and the Environmental Protection Agency, is crucial to minimizing the exposure to mothers and their infants. “Protective reas- signment” of pregnant or breastfeeding employees is another appropriate option. Of the thousands of chemicals that humans can be exposed to, Fisher and colleagues68 reported on 19 chemicals that they analyzed via a physiologically based pharmacoki- netic model. The three chemicals they reported as the highest risk exposure for infants were bromochloromethane, perchloroethylene and 1,4-dioxane. There is a low relative risk to breastfed infants for 153 of 5736 substances (2.2%), which show evidence of transfer into human milk, as listed in the Toxicological Index of Quebec.69 Selected databases that can be useful in assessing a specific chemical exposure in the mother include: Toxicological Index maintained by the Division of Occupational Health and Safety of the Nova Scotia Department of Labor and Workforce Development, found at www.gov.ns.ca/lwd/healthandsafety and LactMed in TOXNET, the Toxicology Data Network of the National institutes of Health, and Health and Human Services found at http://toxnet.nlm.nih.gov. Overall, there are inadequate data concerning exposure to volatile chemicals through breast milk.68,70 The benefits of long-term breastfeeding probably outweigh the risks related to an acute short-term exposure; especially if the mother temporarily suspends breastfeeding immediately after the exposure and expresses and discards the milk (or saves it for subsequent testing of the milk for the identified chemicals). The period of temporary cessation of the use of human milk depends on the chemical involved and the type and period of exposure. Temporary cessation of breastfeeding and discarding the milk in situations of longer term exposures to lipophilic chemicals based on the concept that the concentration of the chemical in the milk will decrease over time has been called into question.71 Each individual exposure situation should be assessed with the assistance of experts in chemistry, toxicology, maternal and infant health, and breastfeeding. Lawrence312
- 19. Phthalates, or “plasticizers,” to soften plastic products are ubiquitous in our envi- ronment. They are commonly found in polyvinyl chloride, various other polymers, wiring insulation, automotive parts, personal care products, toys, and pharmaceuti- cals. Phthalate intake for formula-fed and exclusively breastfed infants, estimated from median values measured in breast milk and formula, are approximately equal and correlate with approximately 2% to 7% of the recommended tolerable daily intake. Potential exposure to phthalates and their metabolites through breast milk is not a contraindication to breastfeeding.72 Radionuclides are another class of potentially toxic substances that are most commonly encountered through contact with the health care system as part of a diag- nostic evaluation or therapeutic intervention. These are described elsewhere in this issue by Valentine and colleagues. The American College of Radiology summarizes their review of the use of contrast media in breastfeeding mothers by stating that less than 1% of an administered maternal dose of contrast agent is excreted into the breast milk and less than 1% of the contrast media in breast milk ingested is absorbed from the gastrointestinal tract of the infant. They also note that, if the mother remains concerned about the potential exposure to the infant, temporary abstention from breastfeeding, actively expressing and discarding breast milk from both breasts for 24 hours after the procedure, and feeding the infant saved breast milk expressed before the radiologic study is appropriate.73 Radionuclides associated with nuclear accidents, specifically strontium 90, are measured at lower levels in breast milk than in cow’s milk, formula (produced in the area of the exposure), the water supply, and other portions of the food supply.74 Breastfeeding is not contraindicated after exposure from nuclear accidents. Medication and Drug Use These are discussed elsewhere in this issue by Hale and colleagues and are not considered here. SUMMARY Concerns and questions about various health-related conditions or exposures and the potential risks to the breastfed infant will continue to be discussed and reevaluated. The infectious diseases in the mother that remain contraindications to breastfeeding at this time, are HIV-1, HIV-2 (in industrialized settings), and HTLV I and II. Temporary interruption (either for an initial period of treatment in the mother or for the finite period equal to the duration of illness) of breastfeeding and provision of breast milk is appro- priate for a few infections with potential serious consequences. In some infectious situations, preventive interventions are available for the infant (immune serum globulin, vaccination, or prophylactic antimicrobial medication) while continuing to provide breast milk to the infant. Yellow fever vaccine and smallpox vaccine are the only con- traindicated vaccines during breastfeeding. Classic galactosemia is the only medical condition in an infant that is a true contraindication to breastfeeding. For others condi- tions, breastfeeding remains an important component of infant nutrition. There are no medical conditions in the mother that, by themselves, are contraindications to breast- feeding; however, diagnostic procedures, treatment, or severe medical illness in the mother can interfere with breastfeeding. Coordinated medical care and lactation assistance are essential for successful breastfeeding in the face of maternal illness. Restrictive diets or malnutrition in the mother are not contraindications to breastfeed- ing. They are important opportunities to provide understandable nutritional counseling and guidelines to breastfeeding mothers. In the uncommon instance of a significant When Breastfeeding is Contraindicated 313
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