Infectious Diseases and Immunization Committee, Canadian Paediatric Society (CPS) 

Abstract published in Paediatr Child Health 2006; 11(8): 489-491

Addendum (June 2011)

Index of position statements from the Infectious Diseases and Immunization Committee

MATERNAL INFECTIOUS DISEASES AND BREASTFEEDING
Human breast milk is not sterile; it frequently contains organisms found in the mother’s microbial skin flora (5). Normal healthy breastfeeding infants become colonized with their mother’s flora over time (6). While breast milk can be a source of maternally derived commensal and pathogenic microorganisms, there are very few maternal infectious diseases for which cessation or interruption of breastfeeding is indicated (2,7-9).

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).

Maternal bacterial infections are rarely complicated by transmission to the infant through breastfeeding. Mothers with mastitis or breast abscesses should be encouraged to continue breastfeeding (5,7,9). In instances of breast abscess where pain interferes with breastfeeding, the infant can continue to breastfeed on the nonabscessed breast. Similarly, maternal tuberculosis (TB) is compatible with breastfeeding, provided the mother is not contagious or she has received two weeks of appropriate TB treatment (7-9). Continuing breastfeeding while on TB therapy is not a problem, as these drugs appear to be safe for use with breastfeeding (8,10,11). Breastfed neonates of women on isoniazid therapy should receive a multivitamin supplement, including pyridoxine (12). If both mother and infant are taking isoniazid, then there are concerns about possible excessive drug concentration in the infant (12). 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 (10) unless the infant has glucose- 6-phosphate dehydrogenase (G6PD) deficiency, in which case withdrawal of quinine is advised (11). Similarly, primaquine should not be used unless both the 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 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 (8,11).

For most maternal viral infections, ongoing breastfeeding is recommended with few exceptions (Table 1) (7,8). With maternal HIV infection, in resource-rich settings such as Canada, where a safe and culturally accepted replacement is available, breastfeeding is not recommended because HIV transmission to the infant has been well documented (8,9,14-16). Emotional support for the mother to not breastfeed may be required; in some instances, financial support for formula purchase may be necessary as well. In more resource-limited settings, the optimal feeding method for infants whose mothers are HIV positive is still unclear (16). Breastfeeding is also not advised for mothers with human T-lymphotropic virus type 1 or 2 infection. (7,8). 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 (9). This does not pose a risk to the term infant because serious disease is prevented by placentally transferred maternal antibody. For premature infants, especially those less than 32 weeks gestation, breastfeeding from a CMV-positive mother is controversial. However, recent studies suggest that that the relative incidence and severity of CMV disease in such premature infants are low, and that the rate of CMV acquisition is not much different from the rate of acquisition in premature infants fed CMV-negative breast milk (17,18), providing further support for fresh breast milk feeding even if the mother is CMV positive (19).

MATERNAL ANTIMICROBIAL THERAPY AND BREASTFEEDING
There are very few instances in which maternal therapy with commonly used antimicrobial agents precludes continuation of breastfeeding (8,10,11) (Table 2). Even maternal therapy with tetracycline, aminoglycosides or quinolones is not an indication to withhold breastfeeding.

MATERNAL IMMUNIZATION AND BREASTFEEDING
Breastfeeding is not a contraindication to the administration of routine recommended vaccines to the infant or the mother (20).

ACKNOWLEDGEMENT: This document was reviewed by the Canadian Paediatric Society Drug Therapy and Hazardous Substances Committee>

REFERENCES

1. Canadian Paediatric Society, Nutrition Committee. [Principal author: Margaret Boland] Exclusive breastfeeding should continue to six months. Paediatr Child Health 2005;10:148.

2. Gartner LM, Morton J, Lawrence RA, et al; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115:496-506.

3. Ogundele MO. A viewpoint of mucosal immunity in relation to early feeding method. Intern J Food Sci Tech 2001;36:341-55.

4. Heinig MJ. Host defense benefits of breastfeeding for the infant. Effect of breastfeeding duration and exclusivity. Pediatr Clin North Am 2001;48:105-23.

5. Michie C, Lockie F, Lynn W. The challenge of mastitis. Arch Dis Child 2003;88:818-21.

6. Kawada M, Okuzumi K, Hitomi S, Sugishita C. Transmission of Staphylococcus aureus between healthy, lactating mothers and their infants by breastfeeding. J Hum Lact 2003;19:411-7.

7. American Academy of Pediatrics. Transmission of infectious agents via human milk. In: Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases, 26th edn. Illinois: American Academy of Pediatrics, 2003:118-21.

8. Lawrence RM, Lawrence RA. Breast milk and infection. Clin Perinatol 2004;31:501-28.

9. Lamounier JA, Moulin ZS, Xavier CC. [Recommendations for breastfeeding during maternal infections]. J Pediatr (Rio J) 2004;80(Suppl):S181-8.

10. American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other chemicals into breast milk. Pediatrics 2001;108:776-89.

11. Mathew JL. Effect of maternal antibiotics on breast feeding infants. Postgrad Med J 2004;80:196-200.

12. American Academy of Pediatrics. Perinatal Infections. In: Gilstrap LC, Oh W, eds. Guidelines for Perinatal Care, 5th edn. Illinois: American Academy of Pediatrics, 2002:285-329.

13. Centers for Diseases Control and Prevention. Updated Information regarding Insect Repellents <www.cdc.gov/ncidod/dvbid/westnile/RepellentUpdates.htm> and West Nile Virus, Pregnancy and Breastfeeding <www.cdc.gov/ncidod/dvbid/westnile/qa/breastfeeding.htm> (Version current at September 17, 2006).

14. Canadian Paediatric Society, Infectious Diseases and Immunization Committee. [Principal author: Susan King] Evaluation and treatment of the human immunodeficiency virus-1-exposed infant. Paediatr Child Health 2004;9:409-17.

15. Read JS; American Academy of Pediatrics, Committee on Pediatric AIDS. Human milk, breastfeeding, and transmission of human immunodeficiency virus type 1 in the United States. Pediatrics 2003;112:1196-2003.

16. Bulterys M, Fowler MG, Van Rompay KK, Kourtis AP. Prevention of mother-to-child transmission of HIV-1 through breast-feeding: Past, present, and future. J Infect Dis 2004;189:2149-53.

17. Yasuda A, Kimura H, Hayakawa M, et al. Evaluation of cytomegalovirus infections transmitted via breast milk in preterm infants with a realtime polymerase chain reaction assay. Pediatrics 2003;111:1333-6.

18. Miron D, Brosilow S, Felszer K, et al. Incidence and clinical manifestations of breast milk-acquired Cytomegalovirus infection in low birth weight infants. J Perinatol 2005;25:299-303.

19. Schanler RJ. CMV acquisition in premature infants fed human milk: Reason to worry? J Perinatol 2005;25:297-8.

20. Health Canada, National Advisory Committee on Immunization. Canadian Immunization Guide, 6th edn. Ottawa: Health Canada, 2002:19.

INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE (November 2006)
Members: Drs Simon Richard Dobson, BC Children’s Hospital, Vancouver, British Columbia; Joanne Embree, University of Manitoba, Winnipeg, Manitoba (chair); Joanne Langley, IWK Health Centre, Halifax, Nova Scotia; Dorothy Moore, The Montreal Children’s Hospital, Montreal, Quebec; Gary Pekeles, The Montreal Children’s Hospital, Montreal, Quebec (board representative); Élisabeth Rousseau-Harsany, Sainte-Justine UHC, Montreal, Quebec (board representative); Lindy Samson, Children’s Hospital of Eastern Ontario, Ottawa, Ontario
Consultant: Dr Noni MacDonald, Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia
Liaisons: Drs Upton Allen, The Hospital for Sick Children, Toronto, Ontario (Canadian Pediatric AIDS Research Group); Scott Halperin, IWK Health Centre, Halifax, Nova Scotia (IMPACT); Monica Naus, BC Centre for Disease Control, Vancouver, British Columbia (Health Canada, National Advisory Committee on Immunization); Larry Pickering, Centers for Disease Control and Prevention, Atlanta, Georgia, USA (American Academy of Pediatrics, Committee on Infectious Diseases)
Principal author: Dr Noni E MacDonald, IWK Health Centre, Halifax, Nova Scotia

ADDENDUM (June 2011)

Since the publication of this practice point in 2006 (1), the World Health Organization (WHO) has published new recommendations on breastfeeding in HIV-positive mothers in resource-limited settings (2).The Canadian Paediatric Society endorses these recommendations. In brief, and based on an evaluation of the evidence in resource-limited settings such as are found in some developing countries, the WHO recommends that HIV-positive mothers or their HIV-exposed infants take antiretroviral drugs throughout the period of breastfeeding and until the infant is 12 months old. The infant can benefit from breastfeeding with very little risk of becoming infected with HIV.

For maternal HIV infection in resource-rich settings such as Canada, where a safe and culturally accepted replacement is available, breastfeeding is not recommended because HIV transmission to the infant has been well documented (1).

REFERENCES

1. MacDonald NE; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Maternal infectious diseases, antimicrobial therapy or immunizations: Very few contraindications to breastfeeding. Paediatr Child Health 2006;11(8):489-91.
2. World Health Organization. HIV and infant feeding: Revised principles and recommendations. Rapid advice, November 2009 <http://whqlibdoc.who.int/publications/2009/9789241598873_eng.pdf> (Version current at May 30, 2011).
   

INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE
Members: Drs Robert Bortolussi, IWK Health Centre, Halifax, Nova Scotia (Chair); Jane C Finlay, Richmond, British Columbia; Susanna Martin, Royal University Hospital, Saskatoon, Saskatchewan (Board Representative); Jane C McDonald, The Montreal Children’s Hospital, Montreal, Quebec; Heather Onyett, Queen’s University, Kingston, Ontario; Joan L Robinson, Edmonton, Alberta
Liaisons: Drs Upton D Allen, The Hospital for Sick Children, Toronto, Ontario (Canadian Pediatric AIDS Research Group); Janet Dollin, University of Ottawa, Ottawa, Ontario (College of Family Physicians of Canada); Charles PS Hui, Children’s Hospital of Eastern Ontario, Ottawa, Ontario (CPS Liaison to Health Canada, Committee to Advise on Tropical Medicine and Travel); Nicole Le Saux, Children’s Hospital of Eastern Ontario, Ottawa, Ontario (Canadian Immunization Monitoring Program, ACTive); Larry Pickering, Atlanta, Georgia, USA (American Academy of Pediatrics, Committee on Infectious Diseases); Marina I Salvadori, Children’s Hospital of Western Ontario, London, Ontario (CPS Liaison to Health Canada, National Advisory Committee on Immunization); John S Spika, Ottawa, Ontario (Public Health Agency of Canada)
Consultants: Drs Noni E MacDonald, IWK Health Centre, Halifax, Nova Scotia; Dorothy L Moore, The Montreal Children’s Hospital, Montreal, Quebec
Principal author: Dr Noni E MacDonald, Halifax, Nova Scotia