Breastfeeding and Maternal Illness Part 2
Some infectious diseases
A full discussion of all infectious diseases and breastfeeding could result in a book the size of War and Peace, so I will try to deal, briefly, only with those that seem to cause the most problems for doctors and, as a result, for the breastfeeding mothers. It should be assumed that if an infectious disease is not included here, that it is safe for mothers to breastfeed.
Hepatitis is an infection of the liver and of most concern with regard to breastfeeding are hepatitis A, B and C. There are other viruses, maybe named up to hepatitis z by now, but they are uncommon causes of liver infection.
This virus is typical of viruses as already mentioned in Breastfeeding and Maternal Illness Part 1 in the sense that by the time the mother is aware she is unwell, the viremic phase has already passed for many days or even weeks (the viremic phase is when the virus is found in the blood). Though infection of others is very possible from virus in the bowel movements, infection from bowel movements is no longer likely either. Once the mother has symptoms, the virus is no longer in the intestinal tract. In other words, by the time the mother is obviously sick, she can no longer pass the infection to the baby, not by being with the baby or by breastfeeding. And in any case, switching to formula does not help prevent illness in the baby and just might make his illness worse without the protection of breastfeeding.
If, at some earlier moment, the baby did pick up the virus, breastfeeding will help decrease the risk of his becoming infected. If he does get infected while the mother still has no symptoms but is infectious, continued breastfeeding will likely diminish the severity of the infection.
It is true that hepatitis A or B, if it is severe (it can be mild or even asymptomatic), can cause the mother to be extremely tired, with abdominal pain and not being able to eat as well as feeling weak and this may make it difficult for her to care for the baby. It is best if the mother go to bed with the baby and nurses him in bed. It would also be best if she not be responsible for other chores.
Hepatitis B is similar to hepatitis A in that the symptoms are very similar; jaundice, fatigue, abdominal pain. As with hepatitis A, not everyone who is infected develops the illness. However, unlike hepatitis A, about 10 to 15% of all people who are infected with hepatitis B become chronic carriers of the virus and this is possible even if they did not develop hepatitis B. This means their bodily fluids may be infectious even though they have no symptoms of the disease. However, like hepatitis A, by the time the mother develops symptoms, it is possible the virus already passed on to the baby. There is no evidence though, that the virus will enter the milk. Breastfeeding can still protect the baby.
When the pregnant woman is a chronic carrier of hepatitis B, breastfeed is still recommended
It is now recommended in most jurisdictions that the newborn baby of a mother with hepatitis B should be immunized with the hepatitis B vaccine at birth as well as given hepatitis immune globulin within 12 hours of birth.
The clinical picture of hepatitis C is similar to hepatitis A and hepatitis B, though it is frequently milder and very often asymptomatic. Like with hepatitis B, however, a chronic carrier state is not rare with hepatitis C. It is now possible to cure the carrier state of hepatitis C with medication. The various regimes for treatment of the chronic carrier state of hepatitis C are not contraindications to breastfeeding, since the usual drugs used are too large to get into the milk as well as highly protein bound.
There is no evidence that breastfeeding can transmit the infection to the baby.
Drug treatment of the carrier state of hepatitis C is now available. Many of the drugs used to treat the carrier state are very large molecules, too big to get into the milk and so are not contraindicated during breastfeeding.
Human Immunodeficiency Virus (HIV)
This is a special virus in the sense that it attacks and destroys the immune system. It can also be transferred to the baby in breastmilk. Thus, until recently, breastfeeding was considered contraindicated where formula feeding was considered safe and feasible.
Now, however, with effective medication that will treat the mother and also the baby, there has been a sea change in the recommendations for breastfeeding. When drug treatment of an HIV positive pregnant woman is begun during the pregnancy and the baby is started on treatment immediately after birth, breastfeeding has become possible and again preferable for both the mother and baby. The World Health Organization has published this statement, that where the mother and baby are treated, breastfeeding should be encouraged.
At present, there are 9 different herpes viruses known to cause disease in humans. It is likely that in the future more will be discovered. In addition to sores on skin, lips, mouth, genitals, and conjunctiva of the eyes, herpes viruses can also cause chicken pox, infectious mononucleosis, and herpes zoster (shingles). It should be noted that the vast majority of infections with herpes viruses do not cause symptoms. The person is infected but does not develop disease and this is true of many types of infections.
Herpes virus 1 and 2
These two viruses can cause infectious lesions of the lips and mouth (herpes 1) and genitals (herpes 2, occasionally herpes 1).
The most common situation I run across occurs when a breastfeeding toddler, usually, develops herpes stomatitis, ulcers in the mouth, that are painful enough sometimes to prevent the child from breastfeeding or eating or drinking anything at all. Usually, though the child may refuse food and liquids, he usually will continue to breastfeed and should be encouraged to do so. However, refusal of all liquids and food including breastfeeding, occasionally requires the child to be admitted to hospital for intravenous fluids to maintain hydration. I believe that if the child continues with breastfeeding, hospitalization is rarely needed. But if the child is admitted to the hospital, he should continue to breastfeed.
Sometimes, the breastfeeding mother develops sores on her nipples which can be very painful. As with the other infections discussed previously, the incubation period of herpes virus before the toddler develops the sores is about a week, so the mother will have been infected by the breastfeeding child several days before the child had sores. The following photo shows herpes virus infection of the nipples.
It is best if the mother continues to breastfeed if she can. Hand expressing her milk and feeding it to the baby is better than pumping because proper hand expression does not including squeezing the nipples. The milk can be fed to the baby by cup or spoon, or mixed with solids, if he will take anything by mouth. A pump can cause pain of the nipple and frequently does.
It is important to note that the medications such as acyclovir and valacyclovir used to treat the mother for herpes virus 1 and 2, do not require the mother to interrupt breastfeeding.
Lyme disease is caused by a bacterium which is transmitted from the bite of a tick (actually, there are several different species of bacteria that can cause Lyme disease in different parts of North America and the rest of the world) . It is a disease which can affect several systems in the body, including the skin, the joints, the heart and the central nervous system. Facial paralysis, though it can have several causes, should make the physician think of the possibility of Lyme disease. It is believed that the tick needs to be attached for many hours before the bacterium of Lyme disease can infect the bitten person.
Living Lyme disease bacteria have not been found in breastmilk, though immunological studies have found markers of the bacterium in the breastmilk. However, even if the bacterium does pass into the milk, it is extremely unlikely that the bacterium would pass the barrier of immune factors that prevent most viruses and bacteria from getting through to the intestinal wall and entering into the baby’s blood stream. The bacterium needs get past that barrier, and then penetrate the intestinal wall to get into the bloodstream of the baby to cause infection.
The question of whether the drug of choice for treatment of Lyme disease in the mother, doxycycline, is contraindicated during breastfeeding comes up frequently. It is not contraindicated during breastfeeding, though some experts recommend limiting treatment to 3 to 6 weeks. More recent evidence has not supported the need to limit the time of use for breastfeeding mothers.
Some non-infectious diseases
There is a host of inflammatory and autoimmune diseases such as rheumatoid arthritis, lupus erythematosus, idiopathic thrombocytopenic purpura, autoimmune hemolytic anemia, autoimmune thyroiditis, and many more, which are associated with and probably caused by antibodies against various tissues of the body. In the case of rheumatoid arthritis, it is the joints of the body; in lupus erythematosus to several different tissues of the body; in idiopathic thrombocytopenic purpura to the platelets in the blood which help stop bleeding and so on.
Many physicians seem to believe that the mother cannot breastfeed because the antibodies causing the diseases may enter the milk and cause the disease in the baby. This is patently false. There are several sorts of antibodies and the antibodies that may cause the above diseases are different from the antibodies that are normally found in breastmilk. The antibodies (sIgA) found in breast milk require a special added piece to allow these antibodies to get into the milk. In addition, they have another extra piece which prevents them from being destroyed in the acid milieu of the baby’s stomach. Approximately 95% of the antibodies found in breastmilk are of this sIgA sort. So, this reason for telling a mother not to breastfeed has no basis in fact.
Frequently, the reason for telling mothers not to breastfeed is the medication they must take not only for the above illnesses, but also medications prescribed for multiple sclerosis (probably the illness I get asked about most), and postpartum depression. As mentioned in a previous article, the vast majority of drugs do not require a mother to stop breastfeeding .
Do you need help with breastfeeding? Make an appointment with the International Breastfeeding Centre.
Copyright: Jack Newman, MD, FRCPC, Andrea Polokova, 2017, 2018, 2020