Infectious Diseases

Most infectious diseases occurring in the mother are not contraindications for breastfeeding ( Tables 1 and 2 ). In most cases, by the time the diagnosis is made in the mother, the infant has already been exposed through contact with the mother or others in the household. There is extensive evidence that breastfeeding protects infants against many common infections, including upper respiratory or lower respiratory tract infection, otitis media, respiratory syncytial virus bronchiolitis, and gastroenteritis. To interrupt or stop breastfeeding in this scenario would only deprive the infant of potentially beneficial antibodies (secretory IgA), and antiinflammatory or immunomodulating substances contained in human milk.

In general, other mechanisms of transmission (blood or body fluids, contact, droplet, or airborne) are the more common risk for transmission of infection between a mother and her infant. In rare situations, temporary separation of the mother and infant (related to the risk of transmission via another mechanism) can be considered along with maintaining the milk supply and providing the infant with expressed breast milk (eg, active pulmonary tuberculosis, pertussis). There are a few rare and serious infections in the mother in which breast milk should temporarily not be provided to the infant until the mother is clinically well (eg, Ebola and Marburg hemorrhagic fevers). In other serious invasive infections (bacteremia, meningitis, osteomyelitis, septic arthritis) due to specific organisms ( Brucellosis , Group B Streptococcus, Staphylococcus aureus, Haemophilus influenza b, Streptococcus pneumonia or Neisseria meningitidis ), temporary suspension of breastfeeding from an infected mother should occur until an initial period (usually 24–96 hours) of treatment of the mother has occurred and there is evidence of some clinical improvement. Mastitis and breast abscesses are not considered invasive infections (see later discussion). In other rare situations in which specific infections involve the mother’s nipple or breast (eg, herpes simplex virus, tuberculosis), if the milk cannot be expressed and/or collected without contamination it should not be given to the infant until the mother is treated and the lesions resolved. The infectious agents are not in the breast milk unless contaminated at the time of expression. In some situations, prophylactic or empiric therapy for the infant against the identified organism can be considered and, once instituted, breastfeeding can continue (eg, azithromycin for pertussis, varicella immune globulin or acyclovir for varicella, immune serum globulin and vaccine for hepatitis A, rabies immune globulin and rabies vaccine for maternal rabies, isoniazid for pulmonary tuberculosis). The only real infectious contraindications to breastfeeding are human T-cell lymphotropic viruses (HTLV) I and II, and HIV-1 and HIV-2, in resource-rich regions. The WHO continues to recommend exclusive breastfeeding for at least 6 months for HIV-positive mothers in resource-poor regions, and combining complementary feeds and continued breastfeeding through the first 12 months of life, for improved overall survival, child growth and development, and greater HIV-free survival. In situations when the mother is too ill to breastfeed or severely immune suppressed, she should be encouraged to consider alternative feeding when that choice of feeding is affordable, feasible, accessible, sustainable and safe (AFASS criteria). Breastfeeding in resource-poor settings offers a significant mortality and morbidity benefit regardless of whether or not the infant becomes HIV infected because of the significant risk in many settings for other infections and malnutrition in the absence of breastfeeding. Exclusive breastfeeding reduces the risk of transmission of HIV from the mother to the infant compared with mixed feeding. Breastfeeding does not adversely affect the HIV-infected mother’s health. Now, there are possible situations in which ongoing breastfeeding by an HIV-1–infected mother while the mother, infant, or both receive effective antiretroviral medication regimens throughout the breastfeeding period can improve HIV-free survival of the infant. There are multiple prospective studies demonstrating the proof of this concept. The true efficacy of such an approach and an optimal regimen for prevention in various situations and/or locations has not been studied in well-controlled prospective trials. The WHO does state that continued breastfeeding with antiretroviral therapy for the mother or prophylaxis for the mother or infant is a strategy that, in certain situations, can offer the child the greatest chance of HIV-free survival. The American Academy of Pediatrics has not changed the recommendations for the United States; breastfeeding by an HIV-infected mother is proscribed. In Great Britain, the British HIV Association has commented that, in very rare instances, breastfeeding by an HIV-positive mother can be considered with effective antiretroviral treatment of the mother, infant, or both. There are limited data concerning the risk of transmission of HIV-2 via breastfeeding. Breastfeeding by mothers with confirmed HIV-2 infection should currently follow the guidelines for HIV-1 in the mother’s locale.

HTLV-1 and HTLV-2, which cause leukemia or lymphoma and chronic neurologic disorders, are associated with significant transmission through breastfeeding because both are present in human milk, associated with a longer duration of breastfeeding, and demonstrate an increased risk of transmission in breastfed infants in comparison with formula-fed infants. There are no immunologic or pharmacologic interventions currently available to prevent HTLV I and II infections; however, a shorter duration of breastfeeding, freezing and thawing breast milk, and complete avoidance of breast milk have shown decreased transmission to the infant. For each of these retroviruses (HIV-1, HIV-2, and HTLV I and II), avoidance of breastfeeding is one form of prevention that still requires that the use of a formula or alternative feeding meets AFASS criteria, whether the circumstances are in a resource-rich or resource-poor country.

Transmission of Brucella from human to human is exceedingly rare and there are only a handful of cases that describe breastfeeding or breast milk as a possible source of infection for the infant. Brucella is readily identified in animal milks but has been cultured from human milk in only one reported case. Other, more likely, routes of transmission include direct contact with infected animals or their unpasteurized milk or milk products. Other uncommon routes of infection include intrauterine infection, exposure during delivery, blood transfusion, bone marrow transplantation, and sexual contact. Documented Brucella infection in a mother is a situation in which temporary suspension of breastfeeding should occur. Breast milk should not be given to the infant until at least 72 to 96 hours of maternal treatment of Brucella with evidence of clinical improvement. Then the use of breast milk can be resumed or breastfeeding continued if the mother is able.

Although invasive Candida infection occurs in premature, low-birth weight or very-low birth weight infants, mild mucocutaneous infection is the most common form of this infection in infants. Several aspects of mammary candidosis or candidiasis remain areas in need of further study including; how to make the clinical diagnosis, the significance of associated pain, and the presence or absence of Candida albicans isolated from human milk of symptomatic and asymptomatic women. Candida does survive to a large extent in frozen-thawed breast milk. The direct contact during breastfeeding of the infant-mother dyad is the probable source of ongoing recolonization and reinfection. Simultaneous treatment of the dyad should occur when one or both of the pair are symptomatic. Treatment of mucocutaneous candidiasis and mammary candidiasis can begin with topical agents, including nystatin, clotrimazole, miconazole, econazole, terconazole, ciclopirox, or gentian violet solution. Various other topical preparations (mupirocin, grapefruit seed extract, or mixtures of mupirocin, betamethasone, and miconazole) have been recommended for the mother’s breast without available clinical trials for efficacy and toxicity. Systemic therapy is sometimes necessary, and oral fluconazole is the most commonly used preparation because of its favorable side-effect profile. Other antifungal agents can be considered if systemic or invasive disease is present in the infant or mother because of other predisposing factors. Risk factors predisposing for candidal infections in the mother or infant should be addressed (eg, eliminating antibiotic use as soon as possible). Breastfeeding can continue without cessation in the full-term infant with the professional assistance of someone knowledgeable in the management of breastfeeding.

Local infections of the breast, mastitis or breast abscess, are not contraindications to continued breastfeeding. Antimicrobial therapy should be chosen with consideration of the most common organisms (penicillin-resistant Staphylococcus aureus , Streptococcus , Escherichia coli ) and agents that are compatible with breastfeeding. In most instances the infecting organism has not been identified unless a culture has been done. Possible factors predisposing to mastitis or milk stasis should be addressed and effective milk-removal strategies encouraged along with more frequent breastfeeding. Pumping and discarding the milk for a short period while optimizing continued effective milk removal has been recommended for invasive Group B Streptococcus infection in the mother or infant. In most scenarios, appropriate empiric therapy has already been initiated for 1 to 2 days before culture results are available and no temporary interruption of breastfeeding or breast milk is indicated. As long as drainage from the abscess does not directly contact the infant’s mouth, continued breastfeeding from the affected breast is appropriate.

It is infrequently useful to culture breast milk to guide decision-making about ongoing therapy and breastfeeding. If there is an initial failure of empiric therapy (after 48–96 hours of therapy) for mastitis, frequent recurrences of mastitis despite apparently appropriate therapy, or pain out of proportion to the clinical findings, then culturing the breast milk (collected as a “midstream collection” after gently cleaning the nipple and areola) may provide culture and sensitivity information to alter subsequent antimicrobial therapy. Material obtained from a discrete abscess that has been drained should always be cultured. Culturing breast milk may also be appropriate in outbreak or epidemiologic investigations.

Immunization of the mothers with common live virus vaccines (eg, varicella vaccine; measles, mumps, and rubella vaccine) is not a contraindication to initiating or continuing breastfeeding. Yellow fever vaccine and smallpox vaccine should not be given to breastfeeding mothers, although it is acceptable (if truly necessary) to give Japanese encephalitis vaccine, typhoid live vaccine, and rabies vaccine. The use of the inactivated influenza vaccine should be encouraged for breastfeeding mothers. Refer to the Centers for Disease Control and Prevention Web site for additional information.

Medical Conditions in the Infant

Galactosemia is a rare disorder, identified by neonatal screening in most states, which is caused by deficiency of galactose 1-phosphate uridyltransferase (GALT) enzyme ( Table 3 ). There are several genetic variants of the disease due to mutations in the GALT gene. “Classic” galactosemia is the most severe, necessitating strict diets without any lactose, whereas other variants (with the Duarte allele, D1, or D2) have milder disease with reduced enzyme activity and can be managed with a less restrictive diet. It may be appropriate in the first 14 days of life to avoid any lactose-containing milk or formula (pumping and saving breast milk for possible later use) until the exact genetic diagnosis can be made. When possible, in situations with only reduced GALT enzyme activity, a modified diet can balance the use of breast milk and a non–lactose containing formula can maintain blood galactose-1-phosphate (gal-1-p) levels less than 3 to 4 mg/100 mL. These infants should be managed by a geneticist and a genetic nutritionist, along with someone knowledgeable in breastfeeding.

Table 3

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