A 2-month-old female came to clinic for her health supervision visit. She was doing well in all areas including breastfeeding. The past medical history showed a mother who was Southeast Asian and who was Hepatitis B surface antigen positive. The infant had received Hepatitis B Immunoglobulin and Hepatitis B vaccination within 4 hours of delivery.
The pertinent physical exam showed a developmentally appropriate infant with growth parameters in the 50-75%. Her examination was normal including no jaundice or hepatomegaly. The diagnosis of a healthy infant with normal growth and at risk for vertical transmission (during pregnancy/delivery) of Hepatitis B was confirmed. During staffing with the attending physician, the resident noted that he was unsure if Hepatitis B was a contraindication to breastfeeding. He had reviewed the American Academy of Pediatrics website and had confirmed that breastfeeding was permitted. Together the staff and resident reviewed the proper protocol from the State Department of Public Health for immunizing the infant for Hepatitis B and when follow-up laboratory evaluation including serology was recommended. The child received her regular set of vaccinations including Hepatitis B and was to return at 4 months of age.
Hepatitis B is a viral disease transmitted through blood and blood-derived fluids. It has not been noted to be transmitted by breastmilk. Chronic hepatitis B has a high prevalence rate (>8%) in all areas of Africa, Southeast Asia, much of the Middle East, parts of the Amazon River basin and the Caribbean. Chronic Hepatitis B can cause chronic liver disease, cirrhosis, and liver cancer.
Incubation is about 90 days for acute infection. Only about 30-50% of patients with acute Hepatitis B infection may be clinically symptomatic. Some patients particularly those that are young (<5 years) or immunosuppressed are often asymptomatic. Anorexia and malaise precedes jaundice by 1-2 weeks. Jaundice, abdominal pain, nausea and emesis are frequent symptoms. Other symptoms may include arthritis, joint pain and rashes. The case-fatality rate for acute Hepatitis B infection is about 1%. Acute Hepatitis B infection causes chronic Hepatitis B infection in 30%-90% of persons infected as infants or young children but this decreases to <5% of adolescents and adults.
Breastfeeding has numerous advantages for both the infant and mother. Since it is the main way nature intended for infants to be fed, it should not be surprising that there are few definitive contraindications to breastfeeding that are recommended. Most mothers should breastfeed infants through common illness such as viral illnesses, cystitis, mastitis, vaginitis, etc. Women presenting with many of these problems have most likely already exposed the infant, and withholding breastfeeding may actually decrease the maternal antibodies and other protective factors in the milk the infant would receive. Infants born to a Hepatitis B surface-antigen positive mother are recommended to breastfeed.
Even when there are definitive contraindications for breastfeeding, weighing the risks and benefits for both the mother and infant, may still, on the whole, promote breastfeeding over formula feeding. A good example of this is HIV (Human Immunodeficiency virus). In developing countries where diarrheal illnesses and other infectious diseases can cause high mortality in infants, the benefits to the infant of breastfeeding by an HIV+ mother outweighs the risks of possible transmission of the virus. However, this balance goes in favor of formula feeding in developed countries where diarrheal and other illnesses are a much smaller percentage of morbidity and mortality.
Maternal and infant exposure to heavy metals (e.g. lead, mercury, arsenic, cadmium, etc.) and environmental contaminants (e.g. PCB, PBB, etc.) in low levels usually are not breastfeeding contraindications. Of course if the mother’s own physical condition does not enable her to breastfeed (e.g. severe illness, trauma, mental instability, etc.) then formula feeding would obviously be recommended. Most drugs are compatible with breastfeeding, but depend on the agent and timing. LactMed is a drug database with breastfeeding safety information
According to the American Academy of Pediatrics and the Canadian Pediatric Society, the following are considered definitive contraindications to breastfeeding:
- Infants with Special Dietary Requirements
- Phenylketonuria – may be partially breastfed
- Maternal Infectious Disease
- Cytomegalovirus – may or may not breastfeed depending on individual circumstances
- Herpes – if active on breast, may use other breast if not affected
- HIV – may or may not breastfeed depending on individual circumstances
- Human T-Lymphotropic Virus type 1 or 2 infection
- Tuberculosis – if not contagious or may resume feeding after two weeks of treatment
- Maternal Drugs – See LactMed for full drug information
- Chemotherapy agents – certain agents, discontinue breastfeeding for as long as they remain in the milk
- Drugs of abuse – discontinue breastfeeding until drugs are out of maternal system
- Primaquine and Quinine – contraindicated if either infant or mother has G6PD
- Metronidazole – discontinue breastfeeding until at least 12-24 hours after medication
- Sulfa drugs – may be a problem in infants with jaundice or G6PD, stressed or premature
- Radioactive isotope – discontinue breastfeeding for as long as the radioactivity is in the milk
Questions for Further Discussion
1. What are common breastfeeding problems for infants?
2. What are common breastfeeding problems for mothers?
3. What are the local laws regarding breastfeeding?
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: General Pediatrics | Infectious Diseases | Neonatology | Nutrition / Dietetics | Pharmacology / Toxicology
- Age: Newborn
To Learn More
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American Academy of Pediatrics Policy Statement. Breastfeeding and the Use of Human Milk. Pediatrics. 2005;115:496-506. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496#SEC3 (rev. 2/2005, cited 8/18/2010).
Canadian Pediatric Society. Maternal Infectious Diseases, Antimicrobial Therapy or Immunizations: Very Few Contraindications to Breastfeeding. Can J Infect Dis Med Microbiol. 2006 Sep-Oct; 17(5): 270-272.
Available from the Internet at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095084/ (rev. 2006, cited 8/18/2010).
Centers for Disease Control Traveler’s Health Yellow Book. Hepatitis B.
Available from the Internet at http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/hepatitis-b.aspx (rev. 7/27/2009, cited 8/18/2010).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital