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M.mchlibrary.infoA Review of the
to Breastfeeding in
the United States
Lawrence RA. 1997. A Review of the Medical Benefits and Contraindications to Breastfeeding in theUnited States (Maternal and Child Health Technical Information Bulletin). Arlington, VA:National Center for Education in Maternal and Child Health.
A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States (Maternaland Child Health Technical Information Bulletin) is not copyrighted with the exception of tables1–6. Readers are free to duplicate and use all or part of the information contained in this publi-cation except for tables 1–6 as noted above. Please contact the publishers listed in the tables’source lines for permission to reprint. In accordance with accepted publishing standards, theNational Center for Education in Maternal and Child Health (NCEMCH) requests acknowledg-ment, in print, of any information reproduced in another publication.
The mission of the National Center for Education in Maternal and Child Health is to promoteand improve the health, education, and well-being of children and families by leading a nation-al effort to collect, develop, and disseminate information and educational materials on maternaland child health, and by collaborating with public agencies, voluntary and professional organi-zations, research and training programs, policy centers, and others to advance knowledge inprograms, service delivery, and policy development. Established in 1982 at GeorgetownUniversity, NCEMCH is part of the Georgetown Public Policy Institute. NCEMCH is fundedprimarily by the U.S. Department of Health and Human Services through the Health Resourcesand Services Administration’s Maternal and Child Health Bureau.
Published byNational Center for Education in Maternal and Child Health2000 15th Street, North, Suite 701, Arlington, VA 22201-2617(703) 524-7802(703) 524-9335 faxInternet: email@example.comWorld Wide Web: http://www.ncemch.org Single copies of this publication are available at no cost from:National Maternal and Child Health Clearinghouse2070 Chain Bridge Road, Suite 450Vienna, VA 22182-2536(703) 356-1964(703) 821-2098 fax This publication has been produced by the National Center for Education in Maternal and Child Healthunder its cooperative agreement (MCU-119301) with the Maternal and Child Health Bureau, HealthResources and Services Administration, Public Health Service, U.S. Department of Health and HumanServices. publication. Technical reviews and recommen-dations were contributed by many individu- In its report Breastfeeding: WIC’s Efforts to als, including Dr. Cheston M. Berlin, Jr., Promote Breastfeeding Have Increased (1993), the Pennsylvania State University; Dr. Margaret U.S. General Accounting Office (GAO) recom- Prevention; Dr. Armond S. Goldman, Univer- Agriculture (USDA) and the U.S. Department sity of Texas; Dr. Audrey Naylor, Wellstart International; Dr. Mary Francis Picciano, develop written policies defining the condi- Pennsylvania State University; Dr. Walter J.
tions that would contraindicate breastfeeding Rogan, National Institute of Environmental Health Sciences; and Dr. Carol West Suitor, cate this information to all pregnant and Institute of Medicine. Thoughtful comments breastfeeding participants of the Special were received from Ms. Brenda Lisi and Ms.
Supplemental Nutrition Program for Women, Alice Lockett, representing the U.S.
Department of Agriculture. The document also reflects the contributions of NCEMCH com- USDA, developed a plan to respond to GAO’s munications staff—Carol Adams, director of recommendation. In late 1994, MCHB award- ed a contract to Dr. Ruth Lawrence, a nation- Anne Mattison, editorial director; and Oliver ally recognized expert in the area of breast- feeding, to develop a policy document on themedical contraindications of breastfeeding.
The policy document was reviewed by othernational experts in the field of infectious dis- Benefits and Risks
eases, environmental toxins, acute and chron-ic diseases, and metabolic disorders. In July Benefits
1996, the policy document was submitted toGAO to assist states in developing policies. To ensure widespread dissemination, the docu- breastmilk (human milk), it is important first ment has been prepared as a technical infor- to establish breastmilk’s distinct and irre- mation bulletin (TIB) for distribution to placeable value to the human infant.
DHHS and USDA regional offices, state and Breastmilk is more than just good nutrition.
local health departments, WIC state and local Human breastmilk is specific for the needs of agencies, and other interested organizations the human infant just as the milk of thou- and health care providers. USDA is encourag- sands of other mammalian species is specifi- ing WIC state agencies to develop policies cally designed for their offspring. The unique regarding contraindications to breastfeeding composition of breastmilk provides the ideal that take into consideration the information nutrients for human brain growth in the first presented in this document and that are con- year of life. Cholesterol, desoxyhexanoic acid, sistent with the policies of their respective and taurine are particularly important.
Cholesterol is part of the fat globule mem-brane and is present in roughly equal amounts in both cow milk and breastmilk.
National Center for Education in Maternal and Maternal dietary intake of cholesterol has no impact on breastmilk cholesterol content. The Special Supplemental Nutrition Program for cholesterol in cow milk, however, has been Women, Infants and Children (WIC), and Ms.
removed in infant formulas. These elements are readily available from breastmilk, and the essential nutrients in breastmilk are readily providing guidance in the preparation of this transported into the infant’s bloodstream. The A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States bioavailability of essential nutrients (includ- ing the microminerals) means that there is great efficiency in digestion and absorption.
infants who were exclusively formula-fed, Comparison of the biochemical percentages of until the publication of data on the growth breastmilk and infant formula fails to reflect curves of infants who were exclusively breast- the bioavailability and utilization of con- fed.8 The physiologic growth curves of breast- stituents in breastmilk compared to modified fed infants show a pattern similar to that of cow milk (from which only a small fraction of formula-fed infants at the 50th percentile, with significantly few breastfed infants in the90th percentile. This is most evident in the The presence of living leukocytes, specific examination of the z scores, which indicate antibodies, and other antimicrobial factors that formula-fed infants are heavier compared protects the breastfed infant against many common infections. Protection against gas-trointestinal infections is well documented.1 Protection against infections of the upper and tions have been evaluated in case–control lower respiratory system and the urinary tract studies, cohort-based studies, and mortality is less recognized, although those infections studies in both clinic and hospitalized chil- lead to more emergency room visits, hospital- izations, treatments with antibiotics, and world.1–3,10,11 The results all show clearly that health care costs for the infant who is not breastfeeding has a protective effect, especial- ly in the first six months of life. A random-ized controlled trial indicated that withhold- ing cow milk and giving soy milk provided infections in infants has been evaluated in a no such protective effect.7 The incidence of number of studies examining the relationship acute otitis media in formula-fed infants is between respiratory infections and breast- feeding or formula feeding in these infants.4–6 infants,12,13 not only because of the protective These studies confirm that infants who are constituents of human milk but also because breastfed are less likely to be hospitalized for of the process of suckling at the breast, which respiratory infection, and, if hospitalized, are protects the inner ear.14 When an infant bot- less seriously ill. In a study of infant deaths tlefeeds, the eustachian tube does not close, from infectious disease in Brazil, the risk of and formula and secretions are regurgitated death from diarrhea was 14 times more fre- up the tubes. Child care exposure increases quent in the formula-fed infant and the risk of the risk of otitis media, and bottlefeeding death from respiratory illness was 4 times more frequent.6 The association of wheezingand allergy in relation to infant feeding pat- In addition to the protection provided by terns has also shown a significant advantage breastfeeding against the presence of acute to breastfeeding. In a report from a seven-year prospective study in South Wales, the advan- revealed a reduced incidence of childhood tage of breastfeeding persisted to the age of lymphoma,11 childhood-onset insulin-depen- seven years in non-atopics, while in at-risk dent diabetes,15 and Crohn’s disease16 in infants who were breastfed the risk of wheez- infants who have been exclusively breastfed ing was 50 percent lower (after accounting for for at least four months, compared to infants who have been fed infant formula. In addi- overcrowding).7 Breastfeeding is thought to tion, breastfed infants at high risk for develop- confer long-term protection against respirato- asthma by two years of age show a reduced incidence and severity of symptoms in early Maternal and Child Health Technical Information Bulletin life.17 Some studies suggest the protective formula, the performance by the breastfed effect continues through childhood.17–20 In addition to clinically proven medical ben- Nourishment with breastmilk is a combina- efits, breastfeeding empowers a woman to do tion event, in which nutrient-to-nutrient inter- something special for her infant. The relation- action is significant. The process of mixing ship of a mother with her suckling infant is isolated single nutrients in formula does not guarantee the nutrient or non-nutrient bene- bonds. Holding the infant to the mother ’s fits that result from breastfeeding. The com- breast to provide total nutrition and nurturing position of human milk is a delicate balance creates an even more profound and psycholog- of macronutrients and micronutrients, each in ical experience than carrying the fetus in utero.
the proper proportion to enhance absorption.
Ligands bind to some micronutrients to In studies of young women enrolled in the enhance their absorption. Enzymes also con- tribute to the digestion and absorption of all assigned to breastfeed or not to breastfeed nutrients.1 An excellent example of balance is the action of lactoferrin, which binds iron to support person throughout the first year post- make it unavailable for E. coli bacterium (which is dependent upon iron for growth).
domized to breastfeed changed their behav- When the iron is bound, E. coli cannot flour- ish and the normal flora of the newborn gut, lactobacillus bifidus, can thrive. In addition, interacted more maturely with their infants the small amount of iron in human milk is almost totally absorbed whereas only about 10 percent of the iron in formula is absorbed by the infant. Examples of multiple functions of proteins in human milk include preventing infection, preventing inflammation, promotinggrowth, transporting microminerals, catalyz- ing reactions, and synthesizing nutrients.29 noted by Newton23 to be more mature, secure,and assertive, and they progressed further onthe developmental scale than non-breastfed Risk/Benefit Ratio
children. More recently, studies by Lucas24and other investigators25 have found that pre- Breastfeeding may provide the mother with mature infants who received breastmilk pro- several benefits, including reduced risk of developmentally at 18 months and at 7 to 8 cancer.30–32 Women who breastfeed return to years of age than those of comparable gesta- tional age and birthweight who had received formula by tube. Such observations suggest incidence of obesity in later life.29,33 The bene- that breastmilk has a significant impact on the fits of breastfeeding are so strong and com- growth of the central nervous system. This is pelling that very few situations definitively further supported by studies of visual activity contraindicate breastfeeding. The decision to in premature infants who were fed breastmilk breastfeed in the presence of a possible con- compared to those who were fed infant for- traindication should be made on an individ- mula.26 When similar studies were performed ual basis, considering the risk of the complica- in term infants, visual acuity developed more rapidly in the breastfed infants.27 Even when tremendous benefits of breastfeeding. The benefits of being breastfed are greater for the A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States infant born in poverty where crowding, poor mineral loss experienced during pregnancy environment, and higher infection rates pre- and lactation is temporary. Bone mineral densi- vail. For example, in developing countries, ty returns to normal following pregnancy and the death rate from diarrhea and other infec- even following extended lactation when miner- tions in the first year of life is 50 percent for al density may exceed the original base line.40 infants who are not breastfed. Thus, although Serum calcium and phosphorus concentrations some studies suggest that breastfeeding when are greater in lactating than in nonlactating women. Lactation stimulates increases in frac- infant’s risk of HIV, at this time, breastfeeding tional calcium absorption and serum calcitriol under these circumstances is still recommend- most markedly after weaning.41 Postweaning concentrations of parathyroid hormone are sig-nificantly higher than in other stages and uri- There is general agreement that a woman’s increasing number of pregnancies, increasinglength of oral contraceptive use, and increas- Whenever the clinician is confronted by a ing duration of lactation are protective against situation that might suggest a conflict in encouraging breastfeeding, the theoretical between lactation and epithelial ovarian can- risk should be measured against the projected cer was studied from a multinational data- benefits of breastfeeding. The discussion that base, short-term lactation was as effective as follows is relevant only when the risk/benefit long-term lactation in decreasing the inci- ratio is considered for individual cases.
dence of ovarian cancer in developed coun-tries where ovulation suppression may be lessprolonged in relation to lactation.35 In a study Risks Associated with Breastfeeding
of African-American women, who are knownto have a lower incidence of ovarian cancer, There are no nutritional contraindications to breastfeeding for six months or longer as well breastfeeding infants unless they have special as four or more pregnancies and oral contra- health needs. Infants with intestinal lactase ceptive use had an effect in further reducing deficiency, galactosemia, or phenylketonuria (PKU) require special diets that reduce theintake of lactose, galactose, or phenylalanine, When researchers controlled for other vari- respectively. Infants with galactosemia require ables such as age and parity, a reduced risk of total artificial specific lactose-free formula; infants with PKU may be partially breastfed at who have lactated was reported in a study of the discretion of the physician.1,43,44 Because of over 5,000 cases in the United States.37 The the low level of phenylalanine in breastmilk, longer the lactation, the greater the protection.
the breastfed infant may be given a high pro- A population-based case–control study of portion of breastmilk and require very little 1,211 cases failed to show such a relationship phenylalanine-free formula. The formula-fed when duration of breastfeeding was less than infant can tolerate very little regular formula in addition to the phenylalanine-free milk to duration of breastfeeding, the greater the pro- between 5 and 10 milligrams per deciliter. All infants need some phenylalanine in their diet.
The risk of osteoporosis in later life is great- est for women who have never borne infants, Maternal Diet
somewhat less for those who have borneinfants, and measurably less for those who have borne and breastfed infants.39 The bone infants in the United States under ordinary Maternal and Child Health Technical Information Bulletin circumstances, even if the maternal diet is not The need for dietary counseling during lac- Subcommittee on Nutrition During Lactation maternal stores.47–49 Regardless of the moth- was impressed by the strong evidence that er ’s intake, it is recommended that breast- mothers are able “to produce milk of suffi- feeding mothers be screened for nutritional cient quantity and quality to support growth and promote the health of infants.”29 Studies reporting volume of milk produced relate the restrictive eating pattern, she should be coun- variability to the demand or consumption by seled to make the necessary changes. Table 1 the infant and not the dietary intake of the presents suggested measures for improving mother.45 It is known that maternal intake of excess fluids does not increase milk produc- Suggested Measures for Improving the Nutrient Intakes of
Women with Restrictive Eating Patterns
Type of Restrictive Eating Pattern
Excessive restriction of food intake (i.e., ingestion of Encourage increased intake of nutrient-rich foods to <1,800 kcal of energy per day), which ordinarily achieve an energy intake of at least 1,800 kcal/day; leads to unsatisfactory intake of nutrients compared if the mother insists on curbing food intake sharply, with the amounts needed by lactating women promote substitution of foods rich in vitamins, min-erals, and protein for those lower in nutritive value;in individual cases, it may be advisable to recom-mend a balanced multivitamin-mineral supple-ment; discourage use of liquid weight loss diets andappetite suppressants Complete vegetarianism (i.e., avoidance of all ani- Advise intake of a regular source of vitamin B , mal foods, including meat, fish, dairy products, and such as special vitamin B -containing plant food products or a 2.6 µg vitamin B supplement daily Avoidance of milk, cheese, or other calcium-rich Encourage increased intake of other culturally appropriate dietary calcium sources, such as col-lard greens for [African Americans] from the south-eastern United States; provide information on theappropriate use of low-lactose dairy products ifmilk is being avoided because of lactose intoler-ance; if correction by diet cannot be achieved, itmay be advisable to recommend 600 mg of ele-mental calcium per day taken with meals Avoidance of vitamin D-fortified foods, such as for- Recommend 10 µg of supplemental vitamin D per tified milk or cereal combined with limited expo- Source: Reprinted with permission from Nutrition During Lactation.29 Copyright 1991 by the National Academy ofSciences. Courtesy of the National Academy Press, Washington, DC.
A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States 1. Restriction of total intake to less than 1,800 kilocalories energy per day is associated women adhere to nutritionally unsound diets.
If the mother refuses such advice, the infant’s erals. In extreme cases where the mother is amounts of the nutrient in question.29 Poor maternal diet is not a contraindication tobreastfeeding. The urgency of dietary coun- 2. Complete vegetarianism (veganism)—that seling in the lactating woman is to replenish is, avoidance of all animal protein (meat, fish, dairy products, and eggs)—is com-monly associated with diminished mater-nal body stores of B6 and B12. It is impor- tant to recognize that symptoms may occur Infectious Diseases and
in the breastfed infant before they appear Breastfeeding
in the mother. Supplementation of themother ’s diet is the preferred route oftreatment, although in symptomatic cases In general, acute infectious diseases in the the infant may require direct treatment ini- mother are not a contraindication to breast- tially. This is not a contraindication to feeding, if such diseases can be readily con- breastfeeding. A daily vitamin B12 supple- trolled and treated.53 In most cases, the moth- er develops the infection during breastfeed- ing. By the time the diagnosis has been made,the infant has already been exposed and the 3. Avoidance of milk and other dairy prod- best management is to continue breastfeeding so that the infant will receive the mother’s antibodies and other host resistance factors in certain allergic problems in their offspring.
breastmilk. This is true for respiratory infec- Avoidance of these dairy products is asso- tions such as the common cold. Infections of ciated with inadequate intake of calcium, the urinary tract or other specific closed sys- tems such as the reproductive tract or gas- during lactation. Low calcium intake does trointestinal tract do not pose a risk for excret- not affect the composition of the milk, but ing the virus or bacteria in the breastmilk unless there is generalized septicemia. When the offending organism is especially virulent intake of other calcium-rich foods such as or contagious (as with beta-hemolytic strepto- greens, nuts, fish with bones, and tofu.
should be treated, but breastfeeding is not supplements totaling 1,200 milligrams per 4. Inadequate dietary sources or exposure to protect against infection, and their presence is not affected by nutritional status. Protection increasing maternal vitamin D in the diet against infection is important in the United or supplementing the mother’s diet with States, especially among infants exposed to multiple caregivers, child care outside thehome, compromised environments, and less attention to the spread of organisms.3 One of the most important and thoroughly studied maternal diet or giving supplements. It is agents in breastmilk is secretory immunoglob- ulin (specifically, secretory IgA), which is pre- Maternal and Child Health Technical Information Bulletin sent in high concentrations in colostrum and result of the virus in the first year of life if early breastmilk and in lower concentrations they are protected by breastfeeding, whereas throughout lactation when the volume of milk 50 percent of all non-breastfed infants in this is increased.54 Secretory IgA antibodies may population and in the general population die neutralize viruses, bacteria, or their toxins and during their first year for lack of the protec- are capable of activating the alternate comple- tive constituents of breastmilk.53,59–61 ment pathway.55 The normal flora of theintestinal tract of the breastfed infant, as well as the offspring of all other mammalian species studied until weaning, is bifidobacterium or lactobacillus.54 These bacteria further inhibit developing an ethical study with adequate the growth of bacterial pathogens by produc- sample size and controls, a computer model ing organic acids. This is in striking contrast to was developed to assess the impact of breast- the formula-fed infant, who has comparatively feeding practices on the mortality of children little bifidobacterium and many coliforms and under five years of age in developing coun- enterococci. In addition, although the attack tries (using parameter values for a hypotheti- rates of certain infections are similar in breast- cal East African country).62 Cessation of fed and formula-fed infants in the same com- breastfeeding in urban areas was projected to munity, the manifestations of the infections are result in a 108 percent increase in mortality in children under age five whose mothers were breastfed. This appears to be due to anti- HIV negative at the time of the infant’s birth, and a 27 percent additional increase in mor-tality among those whose mothers were HIV A few specific infectious diseases are capa- positive. The numbers projected for rural ble of overwhelming the protective mecha- areas were even higher. These calculations nisms of breastmilk and breastfeeding, as detailed in the discussion that follows.53,57 breastfeeding in the case of maternal HIV.59,62 Present studies in the United States that Human Immunodeficiency Virus and
Acquired Immunodeficiency Syndrome
dothymidine (AZT) during pregnancy andimmediate treatment for their infants at birth Clinically effective treatments for human immunodeficiency virus (HIV) and acquired infants, with a reduced rate of infection.
immunodeficiency syndrome (AIDS) are still Although AZT is not a contraindication for being developed; therefore, any behavior— breastfeeding, both mother and infant would including breastfeeding—that increases the require postpartum treatment. A carefully risk of transmitting the virus from mother to infant should be avoided in the United States.
Clinical Trials Group Protocol 076 (ACTG 076) Even though the value of being breastfed is yielded the most important result in clinical great, failure to breastfeed does not result in a AIDS research to date. The study demonstrat- large increase in mortality among U.S. infants.
ed that HIV transmission could be prevented Not all infants born to U.S. HIV-infected in approximately 67 percent of infants when mothers are infected at birth, but present lab- oratory techniques require several months to mother both intragestationally and during the intrapartum period, and to the infant during known from work in Africa that infants with HIV who are breastfed do better than thosewith HIV who are not breastfed.59 Fifteen per- Much publicity has surrounded the issue of cent of HIV-positive infants in Africa die as a breastfeeding by women who became infect- A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States ed with HIV while lactating.58,60,64,65 It seemed cyte counts, beta -microglobulin levels, or initially that most of these cases occurred clinical case criteria.57 Much is still to be because of a maternal transfusion with conta- minated blood postpartum, so that the path- breastfeeding and transmission of HIV to the way of the infant’s exposure seemed clear.
recipient infant and about the associated indi- One study found a 29 percent risk of vertical cators, since all infants breastfed by HIV-posi- transmission (mother to infant) if the mother Australia, 3 of 11 infants (27 percent) breast-fed for nine months or more by mothers who An estimation of risk of HIV-1 transmission received contaminated transfusions (and by through the breastmilk of infected mothers was determined in a study of 168 breastfed and 793 formula-fed infants of seropositivewomen. Odds ratios were determined by duration. This study found that the longer the third of infants of infected mothers develop AIDS through vertical transmission. Of the period (28 days), the greater the risk of pediatric AIDS cases, 84 percent are due to vertical transmission. There are three pointsperinatally, however, at which the disease In reviewing the role of breastfeeding in could be transmitted: (1) during intrauterine HIV infection, the following major issues con- gestation, (2) during delivery, through blood and secretions, and (3) postnatally, throughmaternal milk and potentially saliva and 1. The risk of vertical transmission of HIV tears. Studies have shown postpartum con- version in women without transfusions, prob- 2. The effect of breastfeeding on HIV-infected ably from sexual activity. Knowing the route of infection in the mother does not establish 3. The effect of breastfeeding on noninfected the route in the infant. In at least four report- ed cases, infected maternal transfusion didnot result in disease in the breastfeeding 4. The effect of lactation on HIV-infected infant.65 The potential transmission of HIV-1 5. The effect of AZT on transmission of HIV quantified. Recommendations are thereforebased on perceived risks and benefits.57 Advances in treatment during the perinatal period may provide the solution in the next Efforts to detect HIV-1 P24 antigen (by the decade. If medication can control viral shed- ding, breastfeeding with all its benefits may means of polymerase chain reaction) in the be available to the infants of HIV-infected HIV-1 DNA in 70 percent of specimens at 0–4days postpartum.67 Samples collected 6–12 While studies and reports about HIV infec- months postpartum yielded a 50 percent cap- tion in the perinatal period continue to accu- ture rate. P24 antigen was detected in 24 per- mulate, its association with breastfeeding is cent of the milk samples of 37 seropositive still unclear. In the United States, the position women at 0–4 days postpartum but not in subsequent specimens. The presence of HIV-1 Prevention (CDC) with regard to HIV-positive DNA or P24 antigen in milk was not signifi- cantly associated with maternal CD4 lympho- Health Organization (WHO) states that, in Maternal and Child Health Technical Information Bulletin developing countries or areas where the risk seronegative but at particularly high risk of of infant mortality from infection is great, seroconversion (e.g., injection drug users and sexual partners of known HIV-positive event of maternal AIDS.10 (This position is undergoing review and investigation, which mendation.) Where the risk of mortality from appropriateness of breastfeeding. In addi- other infections is not great, mothers with tion, during the perinatal period, informa- HIV should be counseled on alternatives to risk of transmitting HIV through humanmilk and about methods to reduce the risk breastfeeding and transmission of HIV in the HIV during the peripartum period andthrough human milk and the potential • Women and their health care providers benefits to her and her infant of knowing need to be aware of the potential risk of and transmitted. The health care provider period, as well as through human milk.
mendation to assist the woman in deciding • Documented, routine HIV education and routine testing with consent of all women • Neonatal intensive care units should devel- seeking prenatal care are strongly recom- op policies that are consistent with these both to prevent the acquisition and trans- require gloves for the routine handling of • At the time of delivery, education about HIV and testing with consent of all women might be frequent or prolonged, such as in assists in counseling on breastfeeding and guidelines developed by the United States screening all donors for HIV infection and decrease the likelihood of acquisition and assessing risk factors that predispose to infection, as well as pasteurization of all • Women who are known to be HIV infected must be counseled not to breastfeed or pro-vide their milk for the nutrition of their Tuberculosis
• In general, women who are known to be women with previously positive skin tests and no evidence of disease.69 In the event of A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States possible tuberculosis in the mother, the urgent ted from mother to fetus via the placenta or problem is to establish the mother ’s and infected amniotic fluid, except in cases of infant’s status, initiate maternal treatment, and if necessary also initiate treatment in the postpartum from active disease would be by droplet formation from intimate contact, not Diagnostic tests include identification of the tubercle bacilli by culture from sputum orgastric washings or other fluid. The skin test The duration of infectivity is usually a few is the only practical tool for identifying infect- weeks after initiation of appropriate antibiotic ed asymptomatic individuals. A positive reac- therapy.53 The success of treatment, however, tion is first detectable from as early as three to depends on the drug susceptibilities of the six weeks to as late as three months after organism, the number of bacilli in infected sputum, and the frequency of the cough.
Compliance with treatment is a key factor.
If all tests are negative, therapy for the The patient is considered noninfectious when infant can be discontinued. An infant born to the sputum is negative on repeated smears a mother with known tuberculosis should be and cultures and the cough disappears.
placed on preventive therapy immediately, Infants with primary tuberculosis are usually consisting minimally of daily isoniazid (INH).
not contagious because their lesions are usu- ally small, few if any bacilli are found in spu- tum, and cough is minimal or absent.
Differentiation between tuberculosis infec- Treatment of active disease consists of at tion and active disease is important. If infec- least six months of therapy. In most cases, tion with Mycobacterium tuberculosis occurs INH, rifampin, and pyrazinamide are given but is contained because of immune respons- es, delayed hypersensitivity to the bacilli can result in a positive skin test, but the chestroentgenogram (x-ray) is normal and no signs If active disease is discovered during preg- or symptoms characteristic of the disease are present. Individuals with the disease, howev- rifampin is given.53 Pyrazinamide usually is er, have clinical signs and symptoms and may not given because of inadequate information have a chest x-ray that is characteristic of the about its potential teratogenic properties.
disease.53 The interval between the initial Ethambutol may be added to the initial regi- infection and the onset of disease may be men if a resistant strain of Mycobacterium weeks to years. Cases of active disease are tuberculosis is suspected. Isoniazid, ethambu- currently most commonly seen in urban, low- tol, and rifampin appear to be relatively safe income areas and in non-white racial and eth- for the fetus, and the benefit of medication for nic subgroups in the United States. Specific active disease outweighs the risk. In pregnant groups with the highest incidence of disease women with a positive skin test but no major are first-generation immigrants from high- risk factors, preventive therapy can be post- risk countries, Hispanics, African Americans, Asians, American Indians, and AlaskanNatives. The homeless and residents of cor- rectional facilities are at greatest risk.
women with previously positive skin tests Transmission of the bacillus is usually by and no evidence of disease.69 An individual inhalation of droplet nuclei produced by an with a recent conversion to a positive skin test adult or adolescent with cavitational lung dis- should be evaluated for active disease with a ease, and the portal of entry is usually the res- medical history, physical examination, and piratory tract. Tuberculosis is rarely transmit- chest x-ray. If there is no sign of disease, Maternal and Child Health Technical Information Bulletin breastfeeding can begin or continue. If the Pyridoxine (B ) is recommended as an adjunct mother has suspicious symptoms, especially a to therapy with INH in adults and adoles- productive cough, direct contact with the cents and in breastfeeding infants of mothers infant to breastfeed or to bottlefeed should be receiving INH. INH has a maternal half-life of discontinued until the diagnosis is made. If about six hours. Food decreases the absorp- the mother wishes to breastfeed, she should tion in the infant, so INH is less well absorbed pump her breasts to establish and maintain from the breastmilk. The AAP rating for INH is 6 (i.e., compatible with breastfeeding).72 The process. An electric pump may be required in infant’s therapeutic dose can be modified to order to successfully establish the milk sup- account for a small amount from the breast- ply. If the mother is disease-free, breastfeed- ing may then proceed, and previouslypumped milk may be provided to the infant.
Rifampin is also secreted into breastmilk in If there is disease, appropriate medications small amounts. It can also be given to infants should be initiated.71 Breastfeeding may be directly and is considered safe for lactating initiated or resumed after two or more weeks women. Serum concentrations peak at about of adequate maternal therapy. During this time, lactation can be maintained by pumping milk/plasma ratio is less than 1; it is protein and saving the milk since the disease is not bound and only .05 percent of the adult dose transmitted via the milk. If it is safe for the reaches the milk. The peak level is estimated mother to be in contact with the infant, she to be 4.9 milligrams per liter of milk.70,71 The AAP rating for the drug is 6 (compatible with where non-breastfed infants have a 50 percent breastfeeding). It is important to note that the mortality rate from other infections, breast- drug may turn the milk orange, as it does other secretions such as tears, sweat, and should be treated from the beginning.
breastmilk. Ethambutol is less orally bioavail- during lactation depends on the safety of the able (77 percent), the serum concentration drug itself for the infant. (Drugs and breast- feeding are discussed fully in the section on ratio of the agent is less than 1. About 1 to 5.7 medications.) As with most antibiotics, some percent of the therapeutic dose is found in the of these compounds cross into the breastmilk.
milk.1 AAP has given ethambutol a rating of 6 It is important to note that the infant of a mother who requires antituberculosis medica-tions should also be treated, regardless of Pyrazinamide also appears in breastmilk in very small amounts and is readily absorbedorally, but little study has been done on it and Use of these medications during lactation the AAP has not rated it. Pyrazinamide is bac- has received some attention.70 INH is secreted tericidal and well tolerated by most infants.
into breastmilk, providing from 6 to 25 per- The agent rarely causes hepatotoxicity in cent of the therapeutic dose for an infant. The agent has been found in the suckling infant’surine but not in measurable amounts in the Streptomycin in short courses is given a rat- blood. Since INH is given to neonates, it is not ing of 6 (compatible with breastfeeding) by considered a contraindication to breastfeed- the AAP. Even though only small amounts of ing. While hepatotoxicity has been reported in the antibiotic reach the milk, extended treat- some infants on full therapeutic doses, it has not been reported in breastfeeding infants.69 because of the potential for ototoxicity.72 A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States Mandatory prenatal testing for HBV exists mastitis or a breast abscess. Local infections, in most states, so the mother’s status with therefore, are not a major factor in the deci- respect to the disease is known at delivery. All sion to terminate breastfeeding. If it is safe for infants born to mothers with active disease or the mother to be in contact with the infant, it persistent hepatitis B surface antigen (HBsAg) should receive hepatitis B specificimmunoglobulin (HBIG) immediately at birthor as soon thereafter as possible. In addition, Hepatitis
these infants should be started on the immu-nization program, receiving their first dose of All types of hepatitis are not the same; each hepatitis vaccine within 24 hours after birth or type carries different risks of contagion, path- ways of exposure, and possible treatments should receive the second dose at 3 to 4 weeks and preventive measures. The major types— of age, and the third dose between 6 and 18 A, B, and C—will be discussed separately.
months of age.53 As soon as HBIG is given,breastfeeding may begin. When a mother is Hepatitis A is an acute illness associated unregistered and no prenatal testing has been with fever, jaundice, anorexia, nausea, and malaise. It is rarely fulminant and does not receive HBIG immediately, followed by vacci- become chronic. It is usually transmitted from nation with hepatitis B vaccine in the new- person to person through fecal contamination born nursery. If there are facilities to quickly and through an oral-fecal route. Food-borne test the unscreened mother, the infant can be given the vaccine immediately or within 12 case spread in child care facilities is well doc- hours after birth and then given HBIG as soon as the results are known to be positive, but no index case or a food handler with the disease, later than one week after birth. Universal vac- gamma globulin (GG) 0.02 milliliters/kilo- cination of all infants, including those born to gram should be given as soon as possible, but mothers who are HBsAg-negative, is recom- no later than two weeks after exposure.53 A newborn infant is rarely infected by vertical In developing countries, where hepatitis is transmission from an infected mother during common and HBIG and vaccine are not avail- delivery. Universal precautions are the appro- able, breastfeeding is recommended because of priate management for the newborn infant.
its tremendous benefits to the infant.53 In this Breastfeeding is permitted and gamma globulin country, HBIG and vaccination are necessary is given to the infant if the mother developed to remove the remote chance of infection when the disease within two weeks of delivery. Severe the mother is HBsAg-positive.53 Breastfeeding disease in newborns has not been reported, with is permitted after the infant receives HBIG.
or without gamma globulin.53 When a mother The first dose of hepatitis B vaccine is given with hepatitis A has received gamma globulin, before discharge. Table 2 presents the recom- mended schedule of HBIG and hepatitis B vac-cine to prevent perinatal transmission of HBV.
Breastfeeding should not be discouraged in seroconversion to fulminant fatal hepatitis or hepatitis C (HCV) carrier mothers without co- chronic liver disease in the carrier state.
infection.73 Hepatitis C, parenterally transmit- Recent developments in prevention and man- ted, was originally identified as non-A non-B hepatitis. It is characterized by the insidious onset of jaundice and malaise, with few or no symptoms associated with positive serologic Maternal and Child Health Technical Information Bulletin Recommended Schedule of Hepatitis B Immunoprophylaxis to
Prevent Perinatal Transmission
Infant born to mother known to be HBsAG-positive
Infant born to mother not screened for HBsAg
If mother is found to be HBsAg positive, give0.5 mL as soon as possible, not later than1 wk after birth †HBIG (0.5 mL) given intramuscularly at a site different from that used for vaccine.
‡ First dose is same as that for infant of HBsAG-positive mother. Subsequent doses and schedules are determined by §Infants of HBsAG-positive mothers should be vaccinated at 1 mo of age.
llInfants of HBsAG-positive mothers should be vaccinated at 6 mo.
Source: Adapted with permission from the American Academy of Pediatrics,53 table 3.19. Copyright American Academyof Pediatrics.
tests on routine screening for insurance, blood are rare but false positives are common.74 The donation, or employment.53 About 50 percent presence of the HCV RNA genome or related of serologically confirmed individuals devel- antigen in the circulation during infection is a op chronic liver disease including cirrhosis; in reliable marker for viremia but the analytical rare cases, individuals develop hepatocellular methods are not refined or practical. There is no specific treatment, although alpha interfer- administration of blood or blood products on may be beneficial in a small proportion of including some early batches of RhoGAM.
cases. Gamma globulin has not been success- Person-to-person spread, including sexual ful for prophylaxis of this infection. HCV contact, is suspected but not confirmed.53,74 At causes a slowly evolving disease with major risk are parenteral drug users, persons receiv- potential for morbidity and mortality associ- ing blood transfusions or blood products, health care workers with frequent bloodexposure, and household and sexual contact It has been established that HCV is vertical- ly transmitted from mother to infant, and therisks of transmission are correlated with the level of HCV RNA antibodies in the mother anti-HCV antibodies. False negative results and in the cord blood.73,75,77–79 Ohto et al.75 A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States conducted a series of three independent stud- ies on transmission of hepatitis C virus from also contained antibodies and HCV RNA. The mothers to infants. In the first prospective infant was not breastfed and at four months study of 53 antibody-positive mothers and was antibody- and RNA-negative. Unfortun- their infants (54 infants, including one set of ately, the breastmilk was not analyzed.
twins), three of the infants (5.6 percent)became positive within six months. The moth- ers of these infants were HCV RNA-positive mother-to-infant transmission of hepatitis C at the time of delivery. None of the infants virus, none of the 94 babies of mothers with anti-HCV alone (without HIV) became infect- became infected. In the second prospective ed, and by age one year their titers were nega- study, one of six infants born to women with tive.79 Furthermore, 71 (76 percent) of these known disease became infected. In the third infants, 23 of whom were born to HCV RNA- study, three infected infants were followed retrospectively, and their mothers were all although they were breastfed. In this study, co-infection with HIV was associated with in mothers of infected infants were all signifi- HCV infection in the infants. These authors did not feel that breastfeeding was a signifi- infants. Other studies have reported 0 to 13 percent of infants born to anti-HCV-positive women to be HCV infected.80 No womanwhose HCV RNA titer was negative or less than 106 per milliliter transmitted disease to were HCV-positive, 22 of the mothers were also infected with HIV. Of the infants whosemothers were HCV-positive but not HIV-posi- In response to queries, Ohto et al. reported tive, none acquired HIV infection. Of the 22 that of a group of 63 infants studied, 6 of the 7 infants whose mothers were co-infected with infected infants were breastfed; however, 33 HCV and HIV, 8 of the infants (36 percent) of the 56 noninfected infants were also breast- fed; 6 of the 7 mothers of the noninfected HIV. These data support the concept that HIV infants who were breastfed had HCV RNA in enhances the risk of neonatal infection.79 their serum at a titer > 106 per milliliter (i.e.,comparable to the titers of mothers with infected infants). The duration of breastfeed- tion, Lin et al.73 reported that both HCV anti- ing differed between the two groups.
Although the findings were not statistically colostrum of all 15 mothers. Although the significant, the infected infants nursed 6.6 ± mothers’ titers varied from 1:80 to 1:40,000 and the RNA concentrations varied from 104 nursed 2.0 ± 2.9 months. When the entire to 2.5 x 108 copies/milliliter, the colostral lev- group of 63 infants (for all three studies in the els were lower. The 11 breastfed infants had series) was considered, the duration of breast- feeding for the 6 infected breastfed infants one year. Breastfeeding duration had ranged was 6.6 ± 3.6 months, compared to 3.3 ± 3.1 mean of two months. Lin et al. concluded that breastfeeding should not be discouraged inHCV carrier mothers without co-infections and proposed the following explanations:73,74 woman who received an infected blood trans-fusion at seven months’ gestation and deliv- 1. HCV levels are too low in colostrum to ered an infant who had anti-HCV antibodies Maternal and Child Health Technical Information Bulletin 2. A small amount of HCV may be inactivat- immunosuppressive therapy for transplant.
ed in the infant’s gastrointestinal tract.
Infections acquired transplacentally, during 3. The integrity of the mucosa of the infant the intrapartum period, or in early infancy may preclude infection by the oral route.
may be a problem. Congenital infections usu-ally are asymptomatic but can result in later hearing loss or learning disability. About 5 percent of infected infants have profoundinvolvement with growth retardation, jaun- Venereal Warts
dice, microcephaly, intracerebral calcifica-tions, and chorioretinitis.81 Infections acquired Venereal warts are epithelial tumors of the at birth from maternal cervical secretions or skin and mucous membranes of the anogeni- breastmilk usually are not associated with (HPV).53 They vary from asymptomatic infec- acquired infections usually do better if they tion to condylomata acuminata, skin-colored are breastfed, because of the continuing sup- growths with a cauliflower-like surface. In ply of maternal antibodies provided in their females, the usual sites are cervix, introitus, mother’s breastmilk. Infants, usually prema- labia, perineum, vagina, and perianal areas.
ture infants infected through CMV seroposi- Typically, they are asymptomatic, but they tive blood, have developed lower respiratory may cause itching, burning, localized pain, or tract infections.82 Blood products for neonates bleeding. Transmission to the infant could are now specifically screened for CMV and occur during passage through the birth canal.
On rare occasions, the warts have been associ-ated with laryngeal papillomas. Lesions have not been reported on the breast. The viruses ubiquitous. For infants, the birth process and that cause warts elsewhere are distinct from child care exposure are the common sites.
those causing genital warts.53 Venereal warts Effects on the infant are greatest when the in the genital area are not a contraindication mother develops a primary infection during pregnancy. CMV is usually acquired duringlate adolescence. Young mothers are at greaterrisk for developing the disease during preg- Herpes Viruses
nancy. In a random study of postpartumwomen, 39 percent had CMV in their milk, In the human, there are four known herpes vaginal secretions, urine, and saliva.81 Of the viruses: cytomegalovirus (CMV), herpes sim- infants who were breastfed, 69 percent devel- plex virus (HSV), herpes varicella-zoster virus oped infections while the antibodies were pre- (VZV), and Epstein-Barr virus (EBV). CMV, sent in the milk. The infants shed the virus, VZV, and EBV are believed to be antigenically but did not develop disease. Transmission of observed in immunofluorescent assays.
CMV from breastmilk is related to the dura-tion of breastfeeding. Reactivation of CMV in Cytomegalovirus causes systemic infections the breastmilk peaks between 2 and 12 weeks, a time when transplacental antibody is wan- ing. Infants who continue to receive antibody asymptomatic.53 Although infections acquired or associated protective factors via the milk postnatally can be similar to those found in rarely manifest any symptoms. Non-breastfed infectious mononucleosis, infection is rarely infants can be infected via other secretions, including saliva; they do not receive protec- individuals who are being treated for malig- tive antibodies or other host resistance factors present in breastmilk82 and may have signifi- A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States cant residuals of the disease (e.g., micro- from breastfeeding until they are completely mother is shedding virus in her milk because covered and the mother should be instructed of the passively transferred maternal antibod- to wash her hands carefully before handling ies. Premature infants with low concentra- the infant. A mother with herpes labialis (cold tions of transplacentally acquired maternal sore) or stomatitis should wear a disposable antibodies can develop disease from fresh surgical mask and wash her hands carefully breastmilk containing the virus.53 Freezing when touching her newborn until the lesions destroys the virus, and breastmilk can be have crusted and dried. Whether breastfeed- frozen at -20 degrees centigrade for seven ing or formula feeding the mother should not days before feeding it to the infant for the first kiss or nuzzle her newborn until the lesions few weeks, until the titer of antibody received via the milk increases. (Some experts considerstorage for three days at -20 degrees centi- Herpes varicella-zoster virus (which causes chicken pox) is one of the most contagious ofdiseases.85 The incidence is reported at 5/10,000 pregnancies. As the vaccine becomes neonatal period is often severely debilitating more widely used and natural disease less or fatal. It can be manifested as a generalized likely, new guidelines may be necessary.
systemic infection, as localized central ner- Presently, risk of infection to the neonate vous system (CNS) disease, or as localized depends upon when the disease occurs dur- infection of skin, eyes, and mouth. Typical ing the mother ’s pregnancy or postpartum vesicular lesions are helpful diagnostic signs.
period. Congenital chicken pox, by definition, The infection is most frequently transmitted occurs in neonates younger than 10 days of to the infant during passage through the birth age and is associated with significant mortali- canal when the mother has an infected lower ty. Varicella virus DNA has been detected in genital tract. In 33 to 50 percent of cases, there breastmilk, but the spread of disease from is risk of neonatal disease from a primary mother to infant after delivery is by direct lesion in the mother. The risk to the infant contact, not by feeding. Infants born to moth- born to a mother with recurrent HSV is, at ers who have varicella can develop the infec- most, 3 to 5 percent. Disseminated neonatal tion between 1 and 16 days of life. The usual time interval from onset of rash in the mother to onset in the neonate is 9 to 15 days.
The cases reported in the literature associat- ing neonatal herpes with breastfeeding have involved lesions on the breast itself.83,84 HSV delivery and no lesions are present in the cultures are easily obtained and the virus usu- neonate, mother and infant should be isolated ally grows in a few days; smears of secretions from each other. Only half of the neonates will are readily done and serum antibody titers develop the disease, but all of them should can be obtained. A definitive diagnosis of a suspicious lesion on the breast can be made (ZIG) immediately at birth. When the mother quickly and breastfeeding withheld temporar- becomes noninfectious, she can be with her ily until herpes is ruled out. This is especially important in the first few months of life whenthe neonate is very prone to serious infection Epstein-Barr virus is the principal cause of infectious mononucleosis, which is usually a with herpetic lesions on their breasts refrain disease of adolescence and young adult life Maternal and Child Health Technical Information Bulletin and is rarely recognized in infants and young Toxoplasma gondii (T. gondii) have been iso- children. An association between pregnancy lated from breastmilk, menstrual fluid, pla- and EBV has not been established, and breast- centa, lochia, amniotic fluid, embryo, and feeding is not restricted during Epstein-Barr fetal brain in 33 percent of the subjects in one Toxoplasmosis
humans has not been demonstrated. It is pos-sible that unpasteurized cow milk could be a vehicle of transmission. The human mother, infections of humans throughout the world.
however, would provide appropriate antibod- The protozoan organism is ubiquitous, caus- ies via her milk. From this information, it ing a variety of illnesses previously thought to be due to other agents or unknown causes.1 depriving the neonate of breastmilk when the The normal host is the cat. The pregnant or mother is known to be infected with T.
lactating woman should not handle kitty lit- ter. Kitty litter should, however, be disposedof daily, as the oocysts are not infective for thefirst 48 hours after passage. In humans, preva- Mastitis
lence of positive serologic test titers increaseswith age, indicating past exposure, and there Mastitis is rarely a cause for discontinuing is equal distribution in males and females in breastfeeding. It usually does not occur until the United States.86 The risk to the fetus is 10 days postpartum (or later) except in rare related to the time when maternal infection occurs. In the last months of pregnancy, the her breasts or nipples before delivery.73 protozoa are most frequently transmitted tothe fetus, but the infection is subclinical in the Mastitis is an infectious process in the breast newborn. Early in pregnancy, transmission to producing localized tenderness, redness, and the fetus occurs less often but does result in heat, together with systemic reactions of fever, severe disease. Once the placenta has been malaise, and sometimes nausea and vomiting infected, it remains so throughout pregnancy.
(i.e., flu-like symptoms). Mastitis is usually Characteristics of Engorgement, Plugged Ducts, and Mastitis
Source: Reprinted with permission from Lawrence,1 table 8-5.
A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States due to an acute bacterial infection of a duct or 2. Ensure bed rest, with the mother’s only lobule of the breast, precipitated by trauma or responsibility being to feed the infant.
transient obstruction of the duct due to pres- 3. Select the antibiotic that is effective and safe for the infant. A minimum of 10 to 14 drainage. It must be distinguished from a days’ treatment will reduce the incidence plugged duct or engorgement. The key differ- ential points are compared in table 3. Beforethe development of antibiotics, when women 4. Apply local treatment of cold packs or mastitis was epidemic in hospitals. Today, however, mastitis may be acquired in the hos-pital and then develop during the first four weeks postpartum at home if the mother or infant is colonized with a virulent bacteria.
quickly. If surgical drainage is necessary, Because treatment is given at home, hospital- breastfeeding should continue; the surgeon ization for mastitis is rare and large series are may leave a drain in place. Applying firm pressure over the incision will minimize thedrainage of milk through the incision during feeding. Between feedings, the surgical drain lococcus aureus and, less commonly, E. coli.
When the infection is bilateral and the motheris especially toxic, the bacteria is usually beta Selection of the best antibiotic for mastitis depends upon safety and efficacy. In general, and infant should be treated aggressively. A antibiotics pass into the milk. If the antibiotic mother should always be instructed to contact can be given to the infant directly, it is consid- her physician if unusual symptoms occur, so ered safe for use during lactation.89 Thus, only a very small number of antibiotics should be promptly. Inappropriately or inadequately treated cases of mastitis predispose to recur- tetracycline, streptomycin, and ciprofloxacin.
rent or chronic mastitis. Most reports indicate In most cases, there are sufficient alternatives that the cases of acute mastitis that result in so that breastfeeding need not be discontin- poor outcomes, including abscess and recur- ued.1,72 Generally, breastfeeding should con- rent disease, had significant delay between tinue during acute mastitis. In rare circum- the onset of symptoms and the start of antibi- stances when the abscess drains into the duct otic therapy.87,88 Recurrent mastitis can also be system, breastfeeding is contraindicated on traced to inadequate treatment when antibi- that breast. Infected lesions on the breast, otics are discontinued before a full 10 to 14 such as superficial boils, impetigo, and herpes simplex are contraindications to breastfeedinguntil the lesions clear.
involve early evaluation by the physician,mid-stream cultures of the milk from the Lyme Disease
affected breast, and antibiotics. The followingkey points outline the recommended manage- Lyme disease has attracted increasing atten- tion since it was identified in the UnitedStates in 1975.53 The greatest concentration of 1. Continue to breastfeed on both breasts, cases is in the Northeast. Lyme borreliosis is a usually starting with the unaffected side tick-borne infectious disease caused by the and taking care to totally empty the affect- spirochete, Borrelia burgdorferi. The spiro- chete has been found in the fetus during preg- Maternal and Child Health Technical Information Bulletin nancy and results in fetal death if untreated. If Medication/Prescription Drugs
the mother is adequately treated during preg- and Street Drugs
nancy, the outcome is good.90 The mother andinfant need not be isolated from each other or Medications
If the disease is diagnosed postpartum, the expressed regarding the question of medica- mother should be treated immediately. The tions taken by lactating women and the risk spirochete has been found in breastmilk,91 so to the suckling infant. In reality, very few the infant should also receive treatment, espe- drugs are contraindicated during breastfeed- cially if any symptoms (e.g., rash, fever) devel- ing.72 Each situation should be evaluated on a op. Indirect fluorescent antibody and ELISA tests are available. Once maternal treatment important factors include the pharmacokinet- has begun, lactation can continue. The treatment ics of the drug in the maternal system and prescribed is doxycycline or amoxicillin or the also the absorption, metabolism, distribution, cephalosporins for at least 14 days. If the infant storage, and excretion in the recipient infant.
is healthy and the mother has initiated treatment Variables that should be considered in the for Lyme disease, the infant can be breastfed.
decision include gestational age, chronologi-cal age, body weight, breastfeeding pattern,and other dietary practices. Ultimately, the Human T-Cell Leukemia Virus Type 1
decision is made by assessing the risk/benefitratio (i.e., the risk of a small amount of the drug compared to the tremendous benefit of virus type 1 (HTLV-1) is increasing in parts of the world such as the West Indies, Africa, andsouthwestern Japan.92 There is virtually no transmission from the mother to the fetus, Committee on Drugs has prepared a rating of infected cells. On the other hand, infected might be prescribed for women while lactat- lymphocytes have been found in the milk of ing.72 Following are the numerical ratings: infected mothers. Mathematically, it can becalculated that if 10 percent of cells in human colostrum are T-lymphocytes, and if 1 percent of them are infected, then 1 milliliter of milk 2. Drugs of abuse: contraindicated during will contain 1,000 infected T-cells. In a study in Japan,93 the incidence of mother-to-childtransmission of HTLV-1 was 30 percent 3. Radioactive compounds that require tem- among breastfed infants, 10 percent among 4. Drugs whose effect on nursing infants is formula-fed infants. Though it has not been confirmed whether the presence of infectedcells in the milk actually causes disease, 5. Drugs that have been associated with sig- future studies may demonstrate that breast- milk and its antibodies are actually protective.
and should be given to nursing motherswith caution 6. Maternal medication usually compatible United States, trends may change. At the pre- sent time, it is recommended that, in theUnited States, the mother with HTLV-1 dis- 7. Food and environmental agents: effect on A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States Table 4 presents the list of drugs contraindi- “pumped” into the milk and has a milk/plas- cated for breastfeeding. It is important to note ma ratio greater than 1. Radioactive iodine that bromocriptine suppresses the production appears in high concentrations in milk. Some of one of the main lactogenic hormones, pro- radioactive iodine compounds take more time lactin.72 However, if a woman has been able to to clear the body than others; for example, iodine 131 (131I) takes two weeks to clear the infant while on bromocriptine for pituitary body, while gallium 67 (67GA) takes only two adenoma, the drug is not a contraindication to days.1 Table 5 lists the radioactive compounds breastfeeding her infant. It will be particularly and the time they take to clear from the milk.
important, however, to monitor her milk pro- duction. Thus, bromocriptine should not be instructed to pump her milk to maintain her rated 1 but rather 5 or 6, and its use in indi- vidual cases should be decided by the moth-er’s physician.
multiple doses for therapeutic purposes, it Radioactive compounds, if given for diag- may take weeks or months to clear radioactiv- nostic purposes in a single dose, require tem- ity from the milk and breastfeeding usually porary cessation of breastfeeding.1 Once the radioactive compound has cleared the moth- pounds are used therapeutically (e.g.,131I used er’s plasma, breastfeeding may be resumed.
for thyroid malignancy), the primary disease The time, however, varies from compound to is usually serious, presenting an additional Drugs That Are Contraindicated During Breastfeeding
Reason for Concern, Reported Sign or Symptom in Infant, or
Effect on Lactation
Suppresses lactation; may be hazardous to the mother Possible immune suppression; unknown effect on growth or association with car- Possible immune suppression; unknown effect on growth or association with car- Possible immune suppression; unknown effect on growth or association with car- Vomiting, diarrhea, convulsions (doses used in migraine medications) One-third to one-half therapeutic blood concentration in infants Possible immune suppression; unknown effect on growth or association with car- Anticoagulant: increased prothrombin and partial thromboplastin time in one *Drug is concentrated in human milk.
Source: Adapted with permission from the American Academy of Pediatrics Committee on Drugs,72 table 1. CopyrightAmerican Academy of Pediatrics.
Maternal and Child Health Technical Information Bulletin Radioactive Compounds That Require Temporary Cessation of Breastfeeding*
Recommended Time for Cessation of Breastfeeding
Radioactivity in milk present 2–14 d, depending on study Radioactivity in milk present 15 h to 3 d *Consult nuclear medicine physician before performing diagnostic study so that radionuclide that has shortest excre-tion time in breastmilk can be used. Before study, the mother should pump her breast and store enough milk in freezerfor feeding the infant; after study, the mother should pump her breast to maintain milk production but discard all milkpumped for the required time that radioactivity is present in milk. Milk samples can be screened by radiology depart-ments for radioactivity before resumption of nursing.
Source: Adapted with permission from the American Academy of Pediatrics Committee on Drugs,72 table 3. CopyrightAmerican Academy of Pediatrics.
breastfeeding for the infant. The pharmacolog- ic properties of the drug that will affect pas- Drugs72 require individual consideration.
sage into the milk are often known, even in the absence of extensive studies measuring the with breastfeeding. Drugs of abuse (rated 2) actual amount of drug that reaches the breast- and environmental agents (rated 7) will be milk. If compounds are quickly metabolized discussed separately. The AAP list is not by the mother, little trace of the agents may exhaustive, and other resources may need to remain in the plasma at feeding time. Thus, such medications are not a problem for the available in other references; see Briggs89 and suckling infant. Compounds taken only occa- sionally by the dose (such as aspirin for Lactation Study Center ( 275-0088) pro- headache) are rarely a problem. They clear the vides additional information to professionals maternal plasma in a short period of time and through an extensive computer database that do not accumulate in the infant. If the peak is updated continually. Often, more than one maternal plasma time for the drug is known, drug is available for a given therapeutic need this will help in planning dosing times in rela- and it may be possible to change the medica- tionship to feedings. Some medications are so tion to one that is less likely to cross into the poorly absorbed orally that they are given to milk or that is not well absorbed from the the mother by injection or nasal spray. Such drugs have low oral bioavailability and wouldnot be absorbed from the infant’s stomach.
Therefore, before breastfeeding is summari- ly discontinued, adequate information should be sought and the clinician should consider infant play an important role in the way com- the risk of the drug versus the benefit of pounds are metabolized by the infant; gesta- A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States tional age has an effect in the first few months expressed as (milliliter kilogram-1 minute-1).
of life because of the immaturity of liver This concept takes a pharmacokinetic parame- metabolism and renal excretion. Thus, a drug ter (drug clearance) and a physiochemical that might be of concern for an infant at one parameter (the milk/plasma ratio) to deter- week of age might be of little concern at four mine infant exposure.98 Thus, high clearance drugs (those requiring large doses to achieveclinical effect) have lower levels in the milk.
Clearance rates, however, are not readily avail- attempted to simplify the concept of deter- able for most drugs. While these calculations have theoretical significance, they have little infant.94–96 The three-compartment pharmaco- practical application in the clinical setting.
logic model of Wilson et al.95 assumes thatbreastmilk is the third compartment and only In general, only small amounts of medica- tions that are acidic, water soluble, highly removing milk. This model suggests that the protein bound, and with low oral bioavail- amount of the drug in breastmilk can be cal- ability pass into milk. Drugs of large molecu- culated if the level of the drug is known in lar size (e.g., insulin, heparin) do not cross the one of the other compartments (e.g., the plas- ma). When breastmilk is not being removed,the breastmilk compartment equilibrates with Because of the wide selection of therapeutic compartment two, the interstitial compart- medications available today, the clinician can ment.95 Application of this model is depen- select an alternative medication for the moth- dent upon knowing the rate constant for each er if one drug is known to develop high levels drug—a factor not readily available.
in the milk. Antibiotics usually cross intobreastmilk to some degree. In general, if the Another model involves the volume of dis- antibiotic is considered safe enough that it tribution of the parent compound.97 The vol- could be given directly to the infant, it is con- ume of distribution is determined by the total amount of drug in the body divided by the concentration of the drug in the plasma. This assumes the most elementary kinetic model in when the nursing infant is under six months which the body is a single compartment and of age. Some antibiotics are not absorbed oral- the drug is assumed to distribute evenly.
ly and must be given parenterally (aminogly- Actually, if the volume of distribution of a cosides); thus, little is absorbed from the gas- drug is known, then the amount available to trointestinal track and no threat is posed to the infant via the milk can be calculated if the the infant receiving a small amount in the weight of the mother and the dose of the drug are known.97 In general, drugs with a smallvolume of distribution (≤ 1) have milk/plas- ma ratios of 1 or higher (that is, some gets directly to infants—especially premature into the milk). Drugs with a large volume of infants—to stimulate them to breathe, but distribution and a small dosage have very low concentrations that appear in the milk.
because they do not clear it quickly. Thus, The volume of distribution of many common than three to four times a day will accumulatein the infant after a few days and may cause exposure index, which has been described as afunction of a coefficient (10 milliliter kilogram-1 Information about a wide group of antihy- minute-1). The drug clearance in the infant is pertensive drugs indicates that a few of them Maternal and Child Health Technical Information Bulletin cross into the milk in high levels (e.g., about molecule size, pH, protein-binding, and nadolol, atenolol), while others appear at very other properties. Local poison control centers low levels (captopril and metoprolol).100,101 can also provide additional information, as AAP gives atenolol, nadolol, captopril, and can other sources (see Briggs89 and Lawrence1).
metoprolol a rating of 6 (compatible withbreastfeeding).
Street Drugs and Drugs of Abuse
In assessing a specific woman’s risk/benefit of breastfeeding her infant, it can be stated Generally, drugs of abuse are contraindicat- that, generally, most medications taken by the ed during breastfeeding. The AAP presents a mother are considered safe. Those that are list of such items in table 6. Although the con- contraindicated are listed in tables 4 and 5.
traindication of illicit drugs such as ampheta- Otherwise, the mother should be encouraged mines, cocaine, heroin, marijuana, and phen- to breastfeed, and the health care professional cyclidine is undisputed, universal agreement has not been reached concerning all of the drug that the mother needs. Usually, the ques- tion about a medication comes after lactationis established. Time can be taken to evaluate the best medication to accomplish the thera-peutic goal without compromising the infant.
recommended, these can be viewed as a mat- ter of risk/benefit ratio: the risk of some nico- drug, the mother can pump and discard her tine exposure versus the tremendous benefit milk during treatment. The infant will need to of being breastfed. Formula-fed infants of receive formula by cup or bottle during that mothers who smoke also excrete nicotine and time. Metronidazole (Flagyl) used for tri- cotinine in their urine. Infants who live in chomonas vaginalis and amoebiasis is consid- households where adults smoke have a high- ered a problem when the infant is under three er incidence of pulmonary problems, especial- months of age, because the drug passes into ly infections and asthma.105 Breastfeeding milk.102 Instead of a 10-day course of therapy, provides some protection from both infection and asthma; breastfed infants of smokers do given in a 1- to 2-gram dose and that the milk better than those who are formula fed.
be pumped and discarded for 12 to 24 hours.
Absorption of nicotine is greater from the res- Metronidazole is occasionally used in new- piratory tract than from breastmilk. The nico- tine absorbed from milk is less than 5 percentof the average daily dose of the adult.106 The While lists can be helpful in identifying the nicotine levels in maternal serum reflect few compounds that are contraindicated, lack smoking technique and tend to increase with increased depth of inhalation and the number be used as a reason to avoid breastfeeding.
of puffs per cigarette.106 The risk of sudden The health care professional who cares for the infant death syndrome (SIDS) is significantly infant can determine the safety of the com- higher in infants who are not breastfed and pound by reviewing the available data. The whose mothers smoke; in other words, breast- Physician’s Desk Reference (PDR)104 is not a reli- able source because the manufacturers are required to say that a specific drug or com-pound is not recommended during lactation Smoking is not a contraindication to breast- unless they have carried out extensive studies feeding. Smoking may adversely affect milk wean sooner. No reports have been published A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States Drugs of Abuse: Contraindicated During Breastfeeding*
Reported Effect or Reasons for Concern
Tremors, restlessness, vomiting, poor feeding Only one report in literature; no effect mentioned Shock, vomiting, diarrhea, rapid heart rate, restlessness, decreased milk production *The Committee on Drugs strongly believes that nursing mothers should not ingest any compounds listed here. Not onlyare they hazardous to the nursing infant, but they are also detrimental to the physical and emotional health of the moth-er. This list is obviously not complete; no drug of abuse should be ingested by nursing mothers even though adversereports may not be in the literature.
†Drug is concentrated in human milk.
Source: Adapted with permission from the American Academy of Pediatrics Committee on Drugs ,72 table 2. CopyrightAmerican Academy of Pediatrics.
associating nicotine from breastmilk with utes post maternal ingestion. The infants were observed to suckle more frequently but con- sumed less milk in the presence of alcohol.
Nutrition During Lactation.29 Mothers who The mothers had been unaware of any differ- smoke should be urged not to smoke in the same room as the infant at any time and not alcohol or drink with the speed established in these experiments.109 Alcohol appears in milk if there is alcohol in the serum while nursing.
Acetaldehyde, which is the major metabolite Alcohol
of ethanol and believed to be the major sourceof alcohol toxicity, does not appear in breast- Alcohol (ethanol) presents another series of questions. In countries where, for centuries,alcoholic beverages such as wine and beer have been consumed with daily meals, breast- considerable attention in the lay press in 1989, feeding is universal, and no apparent prob- lems have been reported. More recently in the United States, studies have been reported obtained with the Bayley Scales of Infant regarding the effect on suckling infants when alcohol is present in the breastmilk. These for exposure to alcohol through breastfeed- studies involved the rapid consumption of 40 ing.111 The scores of infants of breastfeeding to 90 milliliters of absolute alcohol by lactat- mothers who drank alcohol occasionally (e.g., one to two drinks per week) did not differ controls.108 Blood levels were drawn every 30 from those of infants breastfed by mothers minutes for four hours, and levels in the milk paralleled the maternal blood levels. The milk drank heavily (a six-pack of beer per day) was noted to smell of alcohol at peak levels, showed slight gross motor delay at one year.
paralleling the concentration of alcohol in the No follow-up has been reported. It is impor- milk, which peaked between 30 and 60 min- tant to note that these infants may well have Maternal and Child Health Technical Information Bulletin them to breathe, but they are dosed only once have been expressing effects of fetal alcohol a day at first because they do not clear the caf- syndrome. The study did not report details of confounding socioeconomic factors or deficitsin maternal interactions, which also affect Herbal and food products
With the blend of cultures and traditions, Committee on Drugs lists alcohol as usually widely used. Much of the traditional and cur- compatible with breastfeeding.72 The Institute rent use of these herbs surrounds pregnancy, During Lactation has concluded that no pub- herbal teas contain innocuous flavors, others lished scientific evidence demonstrates that contain pharmacologically active components that form the basis for folk medicine treat- beneficial impact on lactation performance.29 ments. A number of natural herbs contain bel- ladonna (atropine) and are recommended to that if alcohol is used, intake should be limit- create euphoria and ease pain. Other herbs ed to “no more than 0.5 grams of alcohol per kilogram of maternal body weight per day. . . .
which, when taken to excess, can cause bruis- grams of alcohol per kilogram of body weight been a favorite of traditional midwifery but corresponds to approximately 2 to 2.5 ounces have been banned in Canada and other coun- of liquor, 8 ounces of table wine, or 2 cans of tries because of the association with veno- Caffeine
Licorice, garlic, and ginseng are other herbs with potent pharmacologic properties that Caffeine consumption is of national inter- enjoy great popularity among certain cul- est, and many caffeine-free beverages are tures, but that have been reported to have available. Beverages that are naturally caf- caused serious problems. Licorice in large feine-free may differ from those that are amounts alters potassium levels.115 Garlic has decaffeinated. A study done in rats in Costa caused serious burns when worn against the Rica suggests that other components of coffee skin. Ginseng has been responsible for syn- itself—exclusive of caffeine—affect iron con- centrations when volumes equivalent to threecups of coffee per day are consumed.112 The The clinician should inquire about all foods chief concern with caffeine is related to the and beverages when taking a medical history.
fact that infants in the first few weeks of life If an herbal product is being taken in exces- do not excrete caffeine rapidly.1 Only small sive amounts, the contents should be checked.
amounts of caffeine appear in breastmilk, but Such “self-medication” has posed many prob- if the mother consumes considerable caffeine lems and should be evaluated in the breast- day after day, the caffeine accumulates in the feeding mother. The regional poison control infant. The infant becomes symptomatic (i.e., center may be able to assist in identifying the irritable, wakeful, jittery). Symptoms prompt- active properties of most herbs. The medicinal ly abate with a decrease in caffeine consump- use of herbs per se is not a contraindication to tion. Maternal consumption of one to two caf- feine-containing beverages per day is notassociated with problems.99 As noted earlier,caffeine is sometimes given directly to infants(especially premature infants) to stimulate A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States Environmental Contaminants
only industrial workers exposed to dioxinsare believed to be at risk for any absorption.123 Environmental contamination of breastmilk Very few workers are exposed to TCDD now.
has been investigated in many sites around Because testing is still extremely costly, a the world. In general, chemicals that are woman with an inordinate exposure in indus- lipophilic (dissolve in fat) are found in the try should not breastfeed, but the magnitude lipid fraction of breastmilk. The risk of envi- of the exposure should first be verified.124 Exposure to TCDD is not a general concern based on a woman’s exposure to chemicals.
The greater her exposure, the greater the lev-els in her milk. Women in Vietnam, Turkey,Japan, and Taiwan with high levels of chemi- Pesticides
foodstuffs.117 Women currently at risk in this The levels of DDT and other insecticides in country may have had major exposure in an breastmilk vary with exposure.125 Since DDT industrial accident. However, a spill of poly- was banned in the United States in 1972, the chlorinated biphenyl in North Carolina did threat to the average citizen has become mini- not result in increased levels in mothers’ mal. In developing countries, the risk contin- ues in rural areas among agricultural work- exposure, polybrominated biphenyls (PBBs) ers. In India, China, Guatemala, and Mexico, were unintentionally put in cattle feed, thus rural women have high levels of exposure.
entering the food chain.119 More than 90 per- cent of the residents in this area, including lished pesticide residues limits and recom- pregnant and lactating women, had measur- able amounts in their body fat and breastmilk.
(ADI) of DDT and its metabolites of less than In the face of this information, however, few From a practical standpoint in the United Herbicides
States, the average woman is not consideredat risk for excessive levels of DDT in her breastmilk.124,126 If there is a possibility of cides: 2, 4-D and 2, 4, 5-T. The compound 2, 4, these compounds, the situation should be dis- with 2, 3, 7, 8 TCDD, the best-known diox- cussed with the physician, and, when appro- in.120 Agent Orange was widely used as an priate, testing can be arranged through a herbicide in Vietnam.121 Pooled milk samples state-approved laboratory before recommend- ing whether the mother should breastfeed.
Vietnam contained the dioxin. Although the Breastmilk is not considered a major source of original data from Vietnam were believed to DDT by the World Health Organization.
be flawed technically, nursing infants areknown to retain almost all of the 2, 3, 7, 8 sub- Dichlorodiphenyldichloroethylene (DDE) is stituted dioxins that they ingest from breast- the most stable derivative of the pesticide milk. On a body weight basis, nursing infants have a dietary intake of TCDD and its equiva- ened duration of lactation in the general pop- lents that is 100 times greater than that of ulation in North Carolina.118 A follow-up adults.122 Exposure of the fetus is also signifi- study was conducted in Mexico, where rela- cant; however, transfer of dioxin-like com- tively high DDE levels exist.127 The authors pounds across the placenta is incomplete.
concluded that DDE may affect women’s abil- Exposure of the general public is low, and ity to lactate and postulated that this exposure Maternal and Child Health Technical Information Bulletin may contribute to lactation failure in parts of exposure limits for daily intake, set by the the world where DDT and DDE are prevalent.
World Health Organization.131 Breastmilk lev-els are used epidemiologically as markers of human exposure within a community’s expo- furans in pregnant Japanese and Taiwanese sure because of the close correlation between women who were heavily exposed to contam- breastmilk levels and levels in the fat stores.
ination produced small-for-gestational-age infants with transient darkening of the skin Lakes region were tested by the state of New (“cola babies”). Polybrominated biphenyls York in 1978, and no chemical (PCB, PBB) was (PBBs) are similar compounds and have been associated with a one-time heavy exposure to pling of residents. Thus, unless the circum- stances are unusual, breastfeeding should not be abandoned on the basis of insecticide cont- 1975.119 Women in the United States with the greatest risk of high exposure to PCBs or PBBshave worked with or eaten excessive amounts The cyclodiene pesticides and their metabo- of fish from sport fishing in contaminated lites detected in breastmilk include aldrin, dieldrin, endrin, heptachlor and its epoxide,chlordane, oxychlordane, and trans- Studies have refuted earlier observations of concern. No information is available in the United States concerning the levels of poly- tachlor epoxide.120 Their levels in breastmilk, chlorinated dibenzodioxins (PCDDs) or poly- however, are very much lower than those of chlorinated dibenzofurans (PCDFs) in anglers DDT, and only a fraction of women have lev- who consume a great deal of fish.128 Others els above the detection limit.120 According to considered by some to be at high risk live heptachlor in breastmilk samples are contrary involved in environmental spills. Except in to the fact that these chemicals are trans- cases of unusually heavy exposure, however, formed to epoxide derivatives (e.g., aldrin to there is no contraindication to breastfeeding.
dieldrin) in living organisms and ecosys- When there is a question about environmental exposure and safety of breastfeeding, the state organo chlorine insecticides of higher toxicity health department can be consulted for spe- than DDT and have been banned in industri- cific advice or to measure plasma and breast- alized countries for over a decade. The only milk levels. The epidemiologists usually are source that might remain is from foodstuffs aware of the risks in a given geographic area imported from Third World countries.124 In and know whether it is necessary to measure the United States, levels in breastmilk have breastmilk levels once lactation is fully estab- dropped and are reported undetectable.120 lished. If this sampling is planned far in Heptachlor and its epoxide, which have been advance during the pregnancy, little time limited to use in some southern states for ter- need be lost. Unless the exposure is unique mite eradication, have decreased in impor- and excessive, the infant can be breastfed tance and have not been reported in breast- until levels are returned from the laboratory.1 milk in this country within the last decade.
Technical chlordane, a mixture of 26 com- lished concerning the dilemma of pollutants pounds, is common in termite control in the in breastmilk.118,126,129,130 It has been suggested that the body burden at birth can be added to trans-nonachlor have been detected in breast- by exposing the infant to small levels in the milk in some regions, including the southeast- milk, which may indeed exceed the allowable ern United States (0.08 parts per million), A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States the breastmilk than across the placenta.136 Infants who have been exposed in utero can seven donors). The most recent measurements be expected to lose lead if their daily intake were reported in 1985.120,125,132 In the 1990s, via breastmilk is less than 5 micrograms per the general public in the United States is day.137 If a woman has an elevated lead level, not at risk for exposure to the cyclodiene it is wise to measure the infant’s serum and the milk, even if the maternal level is less than40 micrograms/deciliter. Milk levels are one-tenth to one-fifth of maternal levels. County Heavy Metals
or state health department laboratories usual-ly have lead screening programs. The home environment should be evaluated if the moth- cury, arsenic, and cadmium can be related to er’s level is above 10 micrograms/deciliter, water supplies, cow milk, and even infant for- and a program to reduce the mother’s level of mulas.133 Typically, breastfed infants are lead should be initiated. In studies comparing exposed to lower amounts than formula-fed feeding methods, formula-fed infants have infants because formula is mixed with water higher lead levels than breastfed infants.100 that may contain the heavy metal. Lead is a Breastfeeding is not contraindicated unless heavy metal that still exists in the environ- the maternal level of lead exceeds 40 micro- ment in older housing, lead pipes, certain industries, and auto exhaust pollutants.
Iraqi wheat exposure, and also in some parts National Health and Nutrition Examination of the Great Lakes from industrial exposure in Survey (NHANES III) in 1988–94, compared the 1970s.138,139 Exposure of the general public is limited to industrial exposure of specific (1976–80), reveal a drop across all ages.134 It is presumed that eliminating leaded gasoline exposure to organic mercury (usually methyl and removing lead solder from food and soft drink cans have been responsible for this tal fillings is a small exposure for many in the when a metallic mercury spill from a large American children living in major cities have thermometer was cleaned up with the family the highest lead levels (≥ 10 micrograms/ vacuum cleaner. The mercury remained in the dust bag and was gradually vaporized andinhaled by the family each time the vacuum screening program for children has identified individuals before they are symptomatic andhas also identified women in their childbear- ing years because they live in the same envi- Seychellois children following in utero expo- ronment as children with elevated levels of sure to methyl mercury from a maternal fish lead.135 More women are asking the question: diet showed no association between maternal Is it safe for me to breastfeed? Generally, the hair mercury level during pregnancy and an answer has been: If the blood lead level is less adverse neurodevelopmental outcome of the than 40, it is safe to breastfeed because the infant at six months.140 At 19 and 29 months levels of lead in the milk will be low or unde- after the subjects’ births, the results showed tectable. Considerably less lead passes into possible association between high levels of Maternal and Child Health Technical Information Bulletin Summary of Medical Contraindications to Breastfeeding in the United States
OK to Breastfeed
Acute infectious disease . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . Respiratory, reproductive, gastroitestinal infectionsHIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No . . . . . . . . . . . . . . . . . HIV positiveActive tuberculosis . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . After mother has received 2 or more weeks of Hepatitis A . . . . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . As soon as mother receives gamma globulinHepatitis B . . . . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . After infant receives HBIG, first dose of hepatitis B vaccine should be given before hospital discharge Hepatitis C . . . . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . If no co-infections (e.g., HIV) Venereal warts. . . . . . . . . . . . . . . . . . . . . . YesHerpes viruses Cytomegalovirus . . . . . . . . . . . . . . . . . YesHerpes simplex . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . Except if lesion on breastVaricella-zoster (chicken pox). . . . . . . . Yes . . . . . . . . . . . . . . . . . As soon as mother becomes noninfectiousEpstein-Barr . . . . . . . . . . . . . . . . . . . . . Yes Toxoplasmosis . . . . . . . . . . . . . . . . . . . . . . YesMastitis . . . . . . . . . . . . . . . . . . . . . . . . . . . YesLyme disease . . . . . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . As soon as mother initiates treatment HTLV-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . No MEDICATION/PRESCRIPTION DRUGS AND STREET DRUGS
Antimetabolites (see table 4) . . . . . . . . . . . NoRadiopharmaceuticals (see table 5) Diagnostic dose . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . After radioactive compound has cleared mother’s Therapeutic dose . . . . . . . . . . . . . . . . . No Drugs of abuse (see table 6) . . . . . . . . . . . . No . . . . . . . . . . . . . . . . . Exceptions: cigarettes, alcoholOther medications . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . Drug-by-drug assessment ENVIRONMENTAL CONTAMINANTS
Herbicides . . . . . . . . . . . . . . . . . . . . . . . . . Usually . . . . . . . . . . . . . . Exposure unlikely (except workers heavily DDT, DDE . . . . . . . . . . . . . . . . . . . . . . Usually . . . . . . . . . . . . . . Exposure unlikelyPCBs, PBBs . . . . . . . . . . . . . . . . . . . . . . Usually . . . . . . . . . . . . . . Levels in milk very lowCyclodiene pesticides . . . . . . . . . . . . . . Usually . . . . . . . . . . . . . . Exposure unlikely Lead . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . Unless maternal level ≥40 mg/dLMercury . . . . . . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . Unless mother symptomatic and levels Cadmium . . . . . . . . . . . . . . . . . . . . . . . Usually . . . . . . . . . . . . . . Exposure unlikely Radionuclides . . . . . . . . . . . . . . . . . . . . . . Yes . . . . . . . . . . . . . . . . . Risk greater to bottlefed infants Note: This table provides a brief summary. Each situation must be decided individually. Contraindications are rare inthe United States.
A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States exposure and activity levels in males, with Conclusion
other parameters being unrelated to mercurylevels. This study involved a population in As stated in the introduction, breastmilk which 90 percent were breastfed in the first provides more than just good nutrition—its week of life and 50 percent were still being unique composition provides the ideal nutri- breastfed at 6 months. The breastfeeding cor- ents for human brain growth and protects the infant against infection. Breastfeeding has dis- time.140 However, there were no adverse out- tinct, species-specific, irreplaceable value that is ideal for the infant’s growth, development,and emotional well-being. It is important, however, for health care professionals to beaware of those rare situations when the moth- er should be counseled not to breastfeed.
Japan, where cadmium intake is higher, pre- Table 7 summarizes the information present- traindications to breastfeeding in the United rice. No clear-cut cases of cadmium exposure States. Breastmilk should not be withheld through breastmilk have been reported.122 from any infant unless absolutely necessary.
Itai-Itai disease is believed to be due to cadmi-um, but it may have other etiologies.
Cadmium exposure has not been an issue inthe United States; the major concern related tocadmium intake is cigarette smoke. Heavy References
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Hanson LA, Adlerberth I, Carlsson B, Castrignano Radionuclides
SB, Dahlgren U, Jalil F, Khan SR, Mellander L, EdenCS, Svennerholm AM, et al. 1989. Host defense ofthe neonate and the intestinal flora. Acta Paediatrica Radionuclides have been followed environ- Scandinavica 351(Suppl.):122–125.
mentally since the nuclear age began. The Pisacane A, Graziano L, Zona G, Dolezalova H, Cafiero M, Coppola A, Scarpellino B, Ummarino M, teeth of infants in St. Louis was much greater Mazzarella G. 1994. Breast feeding and acute lower respiratory infection. Acta Paediatrica 83:714–718.
Beudry M, Dufour R, Marcoux S. 1995. Relation Chernobyl nuclear explosion, breastmilk was between infant feeding and infections during the found to be lower in strontium 90 and iodine first six months of life. Journal of Pediatrics126:191–197.
131 than cow milk and other parts of the foodchain and the water supply.142 Victora CG, Smith PG, Vaughan JP, Nobre LC,Lombardi C, Teixeira AM, Fuchs SM, Moreira LB,Gigante LP, Barros FC. 1987. Evidence for protec- tion by breastfeeding against infant deaths from under unusual circumstances of environmen- infectious diseases in Brazil. Lancet 2(8554):319–322.
tal exposure in individual cases, breastfeeding is not contraindicated because of environmen- Eldridge BA, Layzell JC, Merrett TG. 1993. Infant tal hazards and may be safer than formula feeding, wheezing, and allergy: A prospective study. Archives of Disease in Childhood 68:724–728.
Maternal and Child Health Technical Information Bulletin Dewey KG, Heinig MJ, Nommsen LA, Peerson JM, 21. Bryant CA. 1986. Overcoming Breastfeeding Barriers.
PERMETHRIN SPOT-ON TOXICOSES IN CATS Jill A. Richardson, DVM ASPCA Animal Poison Control Center Urbana, IL SUMMARY Spot-on insecticides are becoming popular type of flea control for pets. Spot-on products available include those containing fipronil, imidicloprid, methoprene, and permethrin. Currently, over 15 brands of permethrin spot-on products are labeled for "use i