Maternal infectious diseases, antimicrobial therapy or immunizations: Very few contraindications to breastfeeding

The Canadian Paediatric Society, Health Canada, the Dietitians of Canada and the Breastfeeding Committee for Canada, as well as the American Academy of Pediatrics, all recommend exclusive breastfeeding as the optimal method of infant feeding for the first six months of life for healthy, term infants.[1],[2] There are many benefits associated with breastfeeding: nutritional, immunological, psychological, developmental, environmental, social, economic and health-related (eg, a decreased risk of infectious diseases).[1],[2] To support breastfeeding, every effort must be made to minimize contraindications to breastfeeding, particularly unnecessary ones. The present article summarizes: the maternal infectious diseases for which continuing to breastfeed is recommended, the very few infectious diseases for which breastfeeding is not recommended, the rare instances where maternal antimicrobial therapy indicates a caution for breastfeeding, and when to continue breastfeeding as a mother, or her infant, receives a routine recommended immunization. Almost immediately after birth, infants acquire intestinal flora that are seeded from their mother's microbiota. An infant's microbiotal flora vary by mode of delivery[3] and are further shaped by genetics, environment, and the mode of feeding.[4] Breast milk influences the infant's intestinal microbiota by contributing maternal skin organisms as well as components that nurture some microbes and offer protection from others.[4],[5] Breast milk also directly influences development of the infant's immune system,[4],[5] and breastfeeding impacts health in many positive ways.[2] While breast milk can be a source of maternally derived commensal and pathogenic microorganisms,[5] there are very few maternal infectious diseases for which the cessation or interruption of breastfeeding is indicated.[2],[4],[5] When a nursing mother presents with symptoms of an infectious disease, she has already exposed her infant to the pathogen. Cessation of breastfeeding does not prevent exposure, and may instead decrease the infant's protection that comes through specific maternal antibodies and other protective factors found in human milk. Therefore, common maternal bacterial, fungal and viral infections in which the mother's health is not compromised are not contraindications to breastfeeding (Table 1). Selected maternal infections and corresponding breastfeeding management for healthy term infants For prophylactic management of an infant exposed to a mother with active tuberculosis, see Canadian Tuberculosis Standards, 7th edition (2013), Chapter 12: www.respiratoryguidelines.ca/tb-standards-2013 Selected maternal infections and corresponding breastfeeding management for healthy term infants For prophylactic management of an infant exposed to a mother with active tuberculosis, see Canadian Tuberculosis Standards, 7th edition (2013), Chapter 12: www.respiratoryguidelines.ca/tb-standards-2013 Maternal bacterial infections are rarely complicated by transmission to the infant through breastfeeding, with the possible exception of brucellosis.[6],[7] Mothers with mastitis or breast abscesses should be encouraged to continue breastfeeding.[2],[5],[8],[9] In instances of breast abscess where pain interferes with breastfeeding, the infant can continue to breastfeed on the nonabscessed breast.[5] Similarly, maternal tuberculosis (TB) is compatible with breastfeeding, provided the mother is not contagious or she has received two weeks of appropriate TB treatment.[2],[5] Because transmission of TB is airborne and the infection cannot be transferred in human milk, continuing to breastfeed while on TB therapy is not a problem. TB medications appear to be safe to use while breastfeeding.[10]–[12] The breastfed neonates of women on isoniazid therapy do not need pyridoxine supplementation, unless they are receiving isoniazid themselves.[11] If mother and infant are both taking isoniazid, there may be concerns about possible excessive drug concentration in the infant. Consultation with an expert is indicated. With parasitic infections such as malaria, breastfeeding should be continued provided the mother's clinical condition allows for it. While the antimalarials chloroquine, hydroxychloroquine and quinine are found in variable quantities in breast milk, all three are regarded as compatible with breastfeeding unless the infant has glucose-6-phosphate dehydrogenase (G6PD) deficiency, in which case withdrawal of quinine is advised.[12] Similarly, primaquine should not be used unless both mother and infant have normal G6PD levels. Precautions to minimize insect-borne infections should be encouraged. Insect repellents help to reduce mosquito bites, which may transmit malaria or viruses such as West Nile. There are no reported adverse events following use of repellents containing diethyltoluamide or icaridin/picaridin in breastfeeding mothers.[13] While maternal fungal infections such as candidal vaginitis can lead to infant colonization, this is not a contraindication to breastfeeding, nor is maternal treatment with topical or systemic antifungal agents such as fluconazole.[12] For most maternal viral infections, ongoing breastfeeding is recommended with few exceptions (Table 1).[2],[14],[15] In cases of maternal HIV infection, breastfeeding is not recommended in resource-rich settings such as Canada, where a safe and culturally accepted replacement is available,[2] because HIV transmission from mother to infant is well documented. Emotional support for the mother who cannot breastfeed may be required. In some instances, financial support for purchasing formula may also be necessary. In resource-limited regions of the world, and based on evaluation of current best evidence, the WHO recommends that HIV-positive mothers or their HIV-exposed infants take antiretroviral drugs throughout the period of breastfeeding and continue to breastfeed until the infant is 12 months old. The infant can reap the benefits of breastfeeding with minimal risk of becoming infected with HIV.[16],[17] Breastfeeding is also not advised for mothers with human T-lymphotropic virus type 1 or 2 infection.[2],[15] In mothers with latent cytomegalovirus (CMV) infection, the virus reactivates in breast milk during the postpartum period and can be transmitted to the infant with breastfeeding . However, transmittal does not pose a risk to the term infant because serious disease is prevented by placentally transferred maternal antibody.[2] Even in preterm infants, the value of breastfeeding appears to outweigh the potential risks of severe disease from breast milk-acquired CMV infection in the neonatal period. A definitive association with delayed development or sensorineural hearing loss has not been proven.[2],[18] Thus, breast feeding is recommended with both maternal latent and active CMV infection. There are very few instances in which maternal therapy with commonly used antimicrobial agents precludes continuation of breastfeeding.[2],[12],[19]–[22] Even maternal therapy with tetracycline, aminoglycosides or quinolones is not an indication to withhold breastfeeding. The National Library of Medicine in the United States provides a web-accessible, regularly updated database with drug information for breastfeeding mothers called LactMed at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. Selected maternal antimicrobial therapies and corresponding breastfeeding management for healthy term infants Selected maternal antimicrobial therapies and corresponding breastfeeding management for healthy term infants Breastfeeding is not a contraindication to the administration of routine recommended vaccines to the infant or the mother. Breastfeeding during immunization can help mitigate the infant's pain and should be encouraged.[23] This document was reviewed by the Canadian Paediatric Society's Drug Therapy and Hazardous Substances Committee. Members: Robert Bortolussi MD (past Chair); Natalie A Bridger MD; Jane C Finlay MD (past member); Susanna Martin MD (Board Representative); Jane C McDonald MD; Heather Onyett MD; Joan L Robinson MD (Chair); Marina I Salvadori MD (past member); Otto G Vanderkooi MD Liaisons: Upton D Allen MBBS, Canadian Pediatric AIDS Research Group; Michael Brady MD, Committee on Infectious Diseases, American Academy of Pediatrics; Charles PS Hui MD, Committee to Advise on Tropical Medicine and Travel (CATMAT), Public Health Agency of Canada; Nicole Le Saux MD, Immunization Monitoring Program, ACTive (IMPACT); Dorothy L Moore MD, National Advisory Committee on Immunization (NACI); Nancy Scott-Thomas MD, College of Family Physicians of Canada; John S Spika MD, Public Health Agency of Canada Consultant: Noni E MacDonald MD Principal author: Noni E MacDonald MD Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.

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