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1.6 Contraindications to breastfeeding

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?
Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.
What information would you give?
Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.
Why do breastfeeding alternatives have different effects?
Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.
What are mothers' common and valid concerns about breastfeeding?
Topic 1.4: Common breastfeeding concerns
Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.
Would you examine her breasts at this visit?
Topic 1.5: Breast examination
Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.
What are the contraindications to breastfeeding?
Topic 1.6: Contraindications to breastfeeding
There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.
What are the contraindications to breastfeeding?

Contraindications

There are very few conditions when women should be discouraged from breastfeeding

Active tuberculosis

Infants of mothers with active tuberculosis are at increased risk of infection whether they are breastfed or not. When a mother is initially diagnosed with active TB and is thought to be infectious, it is recommended that she be separated from her infant (for as short a time as possible) until she is having adequate anti-tuberculous treatment and the infant is receiving prophylaxis. The mother can continue to provide breastmilk for her infant during the period of separation as long as she does not have tuberculous mastitis.1,2,

HIV

Because of the risk of transmission of HIV from mother to infant via breastmilk, WHO recommends that mothers known to be HIV-infected should be provided with lifelong anti-retroviral interventions to reduce transmission.

3

Human T-cell Leukaemia Virus Type 1

This retrovirus is endemic in the Caribbean, South America, sub-Saharan Africa and parts of Japan. It is associated with the development of adult T cell leukaemia/lymphoma and a progressive neuropathy. As well as being transmitted via sexual contact and with blood and blood products, it is also transmitted via breastmilk - the longer the exposure to breastmilk the greater the risk of transmission4,

Medications

There are very few situations where the need for medications results in an absolute contraindication for breastfeeding. In most instances there are alternative medications that are compatible with breastfeeding. Drugs that are absolutely contraindicated (until not detectable in breastmilk) are antimetabolites and radiopharmaceuticals used in therapeutic doses.

Illicit drug use

Illicit use of drugs such as cocaine and PCP (angel dust) by a mother are known to have a detrimental effect on her breastfed infant and are absolutely contraindicated during lactation. There is limited or no data on the effect of other illicit drugs on breastfed infants. Considering the frequent concomitant use of illicit drugs, the uncertainty of dose and purity of the drugs and impairment of the mother, there must be concern about women who continue to use illicit drugs while breastfeeding. 5
6

Classic galactosaemia and some inborn errors of metabolism in the infant

These are very rare and require specialist assessment and treatment.7,8

Conditions that are NOT a contraindication to breastfeeding.

Hepatitis B

The rate of vertical transmission of Hepatitis B via breast milk is low, even though viral DNA has been recovered from breastmilk. With passive and active immunization of the infant soon after birth the transmission rate is similar regardless of the infant feeding method. Infection with hepatitis B is not a contraindication for breastfeeding.9,10,11

Hepatitis C

Studies have not demonstrated an increase in vertical transmission of Hepatitis C to infants who have been breastfed, and therefore there is no contraindication for women who are HCV antibody positive to breastfeed. 11 12 Because of the theoretical risk of transmission through blood, it is recommended that mothers with cracked or bleeding nipples express and discard milk from the affected breast until the nipples have healed.9,12,11

Pregnancy

There is no reason for a mother to wean her child if she becomes pregnant again. There is no evidence that continued breastfeeding has adverse effects on a normal pregnancy, the growing fetus or older child. 13 Many women experience nipple tenderness during the first trimester and a gradual reduction in milk supply encourages many children to wean during this time. 14

Notes

  1. # Mathad JS et al. (2012) Tuberculosis in pregnant and postpartum women: epidemiology, management, and research gaps.
  2. # Nhan-Chang CL et al. (2010) Tuberculosis in pregnancy.
  3. # World Health Organisation and UNICEF (2010) HIV and infant feeding
  4. # Gonçalves DU et al. (2010) Epidemiology, treatment, and prevention of human T-cell leukemia virus type 1-associated diseases.
  5. # McAfee G ( 2007) Drugs of abuse and breastfeeding.
  6. # Section on Breastfeeding (2012) Breastfeeding and the use of human milk.
  7. # Ahring K et al. (2009) Dietary management practices in phenylketonuria across European centres.
  8. # Huner G et al. (2005) Breastfeeding experience in inborn errors of metabolism other than phenylketonuria.
  9. # Buescher ES (2007) Human milk and infectious disease
  10. # Lawrence RA et al. (2011) Transmission of infectious disease through breastmilk and breastfeeding. In: Breastfeeding: A Guide for the Medical Profession.
  11. # Center for Disease Control and Prevention (2009) Hepatitis B and C Infections
  12. # MacDonald M et al. (2003) Preventing transmission of hepatitis C
  13. # Onwudiegwu U (2000) Is breastfeeding during pregnancy harmful?
  14. # Marquis GS et al. (2002) Postpartum consequences of an overlap of breastfeeding and pregnancy: reduced breast milk intake and growth during early infancy.