S181

1. Ph.D., University of California, Los Angeles, USA. Full professor,

Department of Pediatrics, School of Medicine, Universidade Federal de
Minas Gerais (UFMG). Advisor of the Graduate Program in Child and
Adolescent Health, UFMG, Belo Horizonte, MG, Brazil.
2. MSc. Professor, School of Medicine, Universidade Federal de Minas
Gerais (UFMG), Belo Horizonte, MG, Brazil.
3. Ph.D., School of Medicine, USP, Ribeiro Preto. Professor, School of
Medicine, Universidade Federal de Minas Gerais (UFMG). Advisor of the
Graduate Program in Child and Adolescent, UFMG, Belo Horizonte, MG,
Brazil.
Suggested ci tati on: Lamouni er JA, Moul i n ZS, Xavi er CC.
Recommendations for breastfeeding during maternal infections. J Pediatr
(Rio J). 2004;80(5 Suppl):S181-S188.
Abstract
Objective: To make a llterature revlew on breastfeedlng and maternal lnfectlous dlseases ln order to contrlbute wlth
knowledge and lnformatlon that can ald the pedlatrlclan to declde upon allowlng lnfected mothers to breastfeed thelr
bables or not.
Sources of data: Lllacs and MEDLINE databases were searched for books, technlcal rules and artlcles on the lssue
of breastfeedlng and lnfected mothers.
Summary of the findings: Infected lactatlng mothers can transmlt pathogenlc agents to thelr lnfants. Although
breastfeedlng protects the chlld lt can also be a dangerous source of lnfectlon. Maternal dlseases caused by bacterla,
vlrus, fungl and parasltes may sometlmes be transmltted vla human mllk. The llterature polnts out that mothers
lnfected wlth HIV and T-lymphotroplc human vlruses (type I) should not breastfeed. Wlth other dlseases a careful
approach should be made, but, ln general, breastfeedlng ls malntalned.
Conclusion: The mother who ls exposed to lnfectlous dlseases may transmlt pathogenlc agents through the
human mllk, attentlon should also be made to mllk from mllk banks. The healthcare provlder must take hls/her
declslon upon suspendlng breastfeedlng - or not, what can be dlstressful, once he/she has a fundamental role ln
promotlng and stlmulatlng breastfeedlng.
J Pediatr (Rio J). 2004;80(5 Suppl):S181-S188: Human mllk and lnfectlon, mothers lnfectlous lllnesses, maternal
breast-feedlng and lnfectlon.
Recommendations for breastfeeding
during maternal infections
Joel A. Lamounier,
1
Zeina S. Moulin,
2
Csar C. Xavier
3
0021-7557/04/80-05-Suppl/S181
Jornal de Pediatria
Copyright 2004 by Sociedade Brasileira de Pediatria
Introduction
Human mllk, ln addltlon to lts nutrltlonal components,
contalns numerous cells, membranes and molecules whose
functlon ls to protect newborn lnfants. In lactatlng women,
the enteromammary or bronchomammary lmmune system
ls actlvated when pathogens (bacterla) come ln contact wlth
the mucous membranes of the lntestlne or resplratory tract
and are phagocytosed by macrophages. Thls stlmulates T
lymphocytes, causlng the dlfferentlatlon of lmmunoglobulln
A (IgA)-produclng B lymphocytes. Lymphocytes mlgrate to
the mammary gland and, medlated by cytoklnes, turn lnto
plasma cells that produce a glycoproteln, whlch blnds to
IgA, and eventually turns lnto secretory lmmunoglobulln A
(sIgA). Thls ls an lmportant and speclflc protectlve functlon
of human mllk ln newborns.
1-5
Breastfeedlng, glven lts beneflts to mother and lnfant,
ls consldered to be the best form of nutrltlon for lnfants.
However, maternal and lnfant dlseases may hlnder
breastfeedlng. Under these clrcumstances, the health
professlonal should be skllled, have technlcal knowledge
and adopt a favorable attltude so as to properly assess the
vlablllty of breastfeedlng. When the nurslng mother
presents wlth the symptoms of a dlsease, she has already
exposed her lnfant to the pathogen and the usual
recommendatl on l s that breastfeedl ng shoul d be
malntalned.
6-9
If the mother dlscontlnues breastfeedlng
after symptom onset, lnfant protectlon agalnst dlseases
ls decreased, and the chances of the lnfant falllng lll are
lncreased, slnce he/she ls not provlded wlth speclflc
antlbodles and other protectlve factors from human mllk.
REVIEW ARTICLE
S182 Jornal de Pedlatrla - Vol. 80, No.5(suppl), 2004
No recommendatlon to dlscontlnue breastfeedlng, even
lf temporarlly, exlsts ln cases of mothers wlth urlnary tract
lnfectlon, bacterlal lnfectlon of the abdomlnal wall,
eplslorrhaphy, mastltls or any other dlsease ln whlch the
nurslng mothers physlcal condltlons and general state of
health are not so compromlsed.
Although human mllk contalns antlbodles, mononuclear
cells and other protectlve factors, lt may be a posslble
source of lnfectlon for the lnfant ln some maternal dlseases.
6,7
The mononuclear cells ln human mllk, albelt provldlng
protectlon, may transfer lnfectlous partlcles from the mother
to the lnfant. Thus, when health professlonals attend to a
nurslng mother wlth actlve vlral lnfectlon or another lnfectlous
dlsease, they may become uncomfortable about whether
they should dlscontlnue or not breastfeedlng, as thelr role
ls to promote and encourage lt.
Some lnfectlous dlseases may lmpede breastfeedlng,
elther on a temporary or permanent basls, due to maternal
physlcal condltlons such as severe cardlac, renal, and
hepatlc dlseases, psychosls and severe postpartum
depresslon.
10
In the present revlew, we dlscuss breastfeedlng
management ln the presence of common maternal dlseases
caused by bacterla, vlruses, parasltes and fungl.
Viral infections
In several maternal vlral dlseases, such as hepatltls,
herpes, measles, mumps and rubella, among others, the
vlrus may be excreted lnto human mllk. However, except
f or l nf ect l ons caused by ret rovl ruses, human
lmmunodeflclency vlrus (HIV-1), human T-lymphotroplc
vlrus type I (HTLV I) and human T-lymphotroplc vlrus
type II (HTLV II), transmlsslon vla human mllk has llttle
epldemlologlcal relevance. In most maternal vlral
dlseases, other sources of contamlnatlon of newborns
should be consldered before ascrlblng the cause to
breastfeedlng only. The rlsk of transmlsslon may be
enhanced ln cases of acute lnfectlon at dellvery, as the
mllk may contaln a hlgh concentratlon of vlral partlcles
and low tlters of protectlve antlbodles able to neutrallze
the lnfectlous agent. Therefore, ln general, there ls no
formal contralndlcatlon for breastfeedlng ln most cases of
vlral dlseases, except for dlseases caused by retrovlruses.
The transmlsslon of RNA retrovlrus, lncludlng HIV-
1,
11,12
HTLV I and HTLV II
13
has al ready been
demonstrated. HIV-2 can also be transmltted from mother
to lnfant, but the role of breastfeedlng ln the transmlsslon
vla human mllk has not been clearly establlshed yet. The
Epsteln-Barr vlrus and herpesvlrus 6 can be found ln
human mllk, but so far, reports on breastfed lnfants
lnfected by these vlruses have been few and far between.
To some extent, the fact that breastmllk ls not much more
lnfectlous ls surprlslng, especlally due to the dally volume
lngested by excluslvely breastfed lnfants. Supposedly,
there may be other protectlve factors than those wldely
known.
Table 1 summarlzes the most lmportant lnfectlons,
wlth posslble transmlsslon of the vlrus to the lnfant vla
breastml l k, and the correspondl ng breastfeedl ng
management.
HIV infection
HIV ls excreted freely or lnto cells ln the mllk of
lnfected women, who may or may not present wlth
symptoms of the dlsease. Approxlmately 65% of vertlcal
HIV transmlsslon occurs durlng labor and durlng dellvery;
the remalnlng 35% occurs ln utero, malnly wlthln the last
weeks of gestatlon and vla breastfeedlng. The vlral load
ln breastmllk ls an lmportant determlnant for the rlsk of
Table 1 - Maternal vlral lnfectlons and the correspondlng breastfeedlng management
Type of virus Recommendation
Cytomegalovlrus Breastfeedlng
Hepatltls A* Breastfeedlng
Hepatltls B Breastfeedlng
Hepatltls C* Breastfeedlng
Rubella Breastfeedlng
Mumps Breastfeedlng
Slmple herpes Breastfeedlng, except lf there are leslons on the breasts
Varlcella Breastfeedlng, except lf the lnfectlon was acqulred between 5 days before
the dellvery and 3 days after the dellvery
Measles Temporary lnterruptlon of breastfeedlng
HTLV I No breastfeedlng
HIV No breastfeedlng
* See comments in the text.
Breastfeedlng durlng maternal lnfectlons - Lamounler JA, et alii
Jornal de Pedlatrla - Vol. 80, No.5(Suppl), 2004 S183
transmlsslon.
14-16
In newborns, the vlrus penetrates the
nasopharyngeal and gastrolntestlnal mucosae. Durlng
breastfeedlng, vlral transmlsslon may occur at any stage,
but lt seems to occur more often wlthln the flrst weeks and
especlally ln most recent maternal lnfectlons. The vlral
load ln colostrum ls slgnlflcantly hlgher than ln mature
mllk. Mlxed breastfeedlng seems to pose more rlsks than
excluslve breastfeedlng, due to the major lnjury to the
gastrolntestlnal mucosa resultlng from artlflclal feedlng,
whlch favors the penetratlon of the vlrus.
17
The addltlonal
rlsk of transmlsslon of the vlrus vla human mllk ranges
from 5 to 20%.
18
Contamlnatlon vla breastmllk ln women
who acqulred the lnfectlon after the postnatal perlod was
detected ln 29% (15-53%) of cases.
10,16,18
The presence
of HIV-lnfected cells ln breastmllk for over 15 days after
dellvery ls an lmportant predlctlve factor for lnfectlon ln
the lnfant.
17
Retrovlruses can lnfect mammary eplthellal cells before
dellvery, and can be found free or lnfectlng monocytes ln
mllk, whlch account for 50% of cells found ln breastmllk.
These cells can potentlally carry the vlrus from the maternal
bloodstream or from lymphold tlssues to the lnfants lntestlne.
Some types of HIV use chymosln receptors to lnfect
macrophages. However, more studles are necessary to
accurately deflne the role of human mllk cells ln HIV
lnfectlon.
19-21
The use of antlretrovlral therapy durlng pregnancy and
dellvery and lts malntenance ln newborns results ln a
decrease ln vertlcal HIV transmlsslon for up to slx months
after chlldblrth,
22
even lf breastfeedlng ls malntalned.
Nevertheless, HIV lnfectlon ls one of the few sltuatlons ln
whlch the contralndlcatlon for breastfeedlng ls a common
agreement. In Brazll, The Mlnlstry of Health
23
recommends
that HIV-lnfected mothers should not breastfeed. On the
other hand, the World Health Organlzatlon and UNICEF
recommend that, ln poor countrles, where dlseases such as
dlarrhea, pneumonla and malnutrltlon substantlally
contrlbute to hlgh rates of lnfant morbldlty and mortallty,
the beneflts of breastfeedlng should be consldered ln relatlon
to the rlsk of HIV transmlsslon. In these cases, and lf lt ls
not posslble to provlde approprlate artlflclal feedlng,
breastfeedlng should be malntalned, glven lts beneflts to
lnfants who llve ln precarlous condltlons.
15,24,25
Women
who recelve comblned antlretrovlral therapy have lower
rates of vlral transmlsslon.
22
Prellmlnary lnformatlon
obtalned from a study conducted ln South Afrlca conslders
that lt ls posslble to reduce or prevent the rlsk of postnatal
transmlsslon of HIV lf the lnfant recelves human mllk for a
short perlod of tlme.
14
The ldea ls to malntaln breastfeedlng
for four to slx months. However, the efflcacy and safety of
such practlce has not been demonstrated yet, and studles
stlll have been underway.
Another alternatlve ls to reduce or ellmlnate HIV from
human mllk. Infected cells can be removed from mllk, but
vlral partlcles are dlfflcult to ellmlnate. The lnactlvatlon of
HIV ln breastmllk through pasteurlzatlon (62.5 C for 30
mlnutes, followed by rapld coollng) allows lnfants to
contlnue recelvlng breastmllk wlthout lncreaslng the
postnatal rlsk of lnfectlon.
26,27
HTLV infection
HTLV belongs to the retrovlrus famlly, the same of
HIV. They are human T1 and T2 lymphotroplc vlruses
called HTLV I and HTLV II. Type I causes a rare type of
leukemla, myelltls and eye lnfectlon that may result ln
bllndness. HTLV II ls not assoclated wlth dlsease. They
can be transmltted vla blood, lnfected needles, sexual
lntercourse and from mother to lnfant by means of
breastfeedlng. The prlnclpal mode of transmlsslon ls
vertlcal, but the predomlnant one ls vla breastfeedlng.
Although HTLV affects a small portlon of the populatlon,
wlth posslble late development of dlseases ln only 1 to 4%
of lnfected lndlvlduals, lts occurrence has lncreased ln South
Amerlca, especlally because of the lack of health survelllance.
As the dlsorders caused by these retrovlruses are severe
and cannot be treated or controlled wlth efflclent therapy
and vacclne, contralndlcatlon for breastfeedlng ln lnfected
women ls a major way of reduclng thelr vertlcal transmlsslon.
In Japan, freezlng the mllk of HTLV I-posltlve mothers
at -20 C has been used as a way to lnactlvate the vlrus.
However, the Center for Dlsease Control and Preventlon
(CDC) establlshes that every HTLV I-lnfected mother should
be advlsed not to breastfeed, and does not have an oplnlon
on the freezlng of human mllk ln thls sltuatlon. CDC
conslders the current data on HTLV I transmlsslon vla frozen
and thawed breastmllk to be lnsufflclent.
The amount of HTLV I-lnfected cells ln perlpheral blood
ls very small compared to the number of lnfected T cells ln
breastmllk, whlch explalns the hlgh rlsk of vlral transmlsslon
vla human mllk. Some rlsk factors have been consldered ln
the transmlsslon of HTLV I and II vla human mllk:
breastfeedlng for over three months, advanced maternal
age, antlgen levels ln maternal blood and hlgh tlters of HTLV
I antlbodles ln the nurslng mother.
10,17
However, Van Dyke
et al.
28
report that the transmlsslon of HTLV II from mother
to lnfant may occur regardless of the type of feedlng the
lnfant recelves ln slmllar rates to those of HTLV I, thus
showlng that the vlrus can be transmltted to the lnfant ln the
absence of breastfeedlng.
Hepatites A, B and C
Hepatltls A, B and C vlruses can be transmltted to the
lnfant durlng pregnancy, dellvery or postnatal perlod.
Vlruses transmltted by the oral-fecal route, as ln hepatltls
A, have a hlgher chance of belng transmltted to the lnfant
at dellvery.
The hepatltls A vlrus can be excreted lnto human mllk
ln the acute phase of the dlsease. When dellvery occurs
ln thls phase of the dlsease, the lnfant should recelve antl-
hepatltls A lmmunoglobulln at the dose of 0.02 ml/kg as
prophylactlc measure. Thls prophylaxls ls lndlcated for all
lnfants, regardless of whether they are belng breastfed or
not, and provldes protectlon that outwelghs the rlsk of the
lnfant acqulrlng the dlsease. Thus, breastfeedlng ls not
contralndlcated.
7
Hepatltls B and C vlruses are transmltted hematogenously
and sexually. Hepatltls B surface antlgen (HBsAg) has been
Breastfeedlng durlng maternal lnfectlons - Lamounler JA, et alii
S184 Jornal de Pedlatrla - Vol. 80, No.5(suppl), 2004
detected ln the mllk of HBsAg-seroposltlve women, and
posslbly, small amounts of blood mlght be lngested by the
newborn lnfant durlng breastfeedlng, from nlpple lnjurles,
even lf these lnjurles are small. However, the major mode
of transmlsslon ls lnfant exposure to maternal blood, whlch
occurs throughout labor and dellvery.
29
In case of HBsAg-seroposltlve mothers durlng pregnancy,
the lnfant should recelve the flrst dose of the vacclne
lmmedlately after dellvery and hepatltls B hyperlmmune
lmmunoglobulln (0.5 ml IM) ln the flrst 12 hours of llfe, glven
concomltantly, but ln dlfferent sltes. Thls practlce has an
efflclency of 95% and ellmlnates the occaslonal rlsk of
transmlsslon vla breastmllk.
7,30
When the mother has not been tested for HBsAg or lf thls
lnformatlon ls not avallable, the test should be requested
lmmedlately after dellvery. Whlle the test result ls not
avallable, the newborn should recelve the flrst dose of the
vacclne. If the test ylelds a posltlve result, lmmunoglobulln
should be glven as soon as posslble, wlthln the flrst seven
days after dellvery. However, lf HBsAG testlng ls not
posslble, glvlng all newborns lmmunoglobulln ls not
recommended, slnce the vacclne alone ls qulte efflclent ln
preventlng the dlsease ln 70 to 90% of cases.
7
In cases of HBsAg-posltlve mothers, newborns should
be thoroughly washed, ln order to remove all traces of blood
or maternal flulds. Breastfeedlng ls not contralndlcated
even lf the mother has a bleedlng nlpple flssure.
The Brazlllan Soclety of Pedlatrlcs recommends that
preterm newborns welghlng less than 2,000 g born to an
HBsAg-posltlve mother should recelve four doses of the
vacclne (at blrth, at 1, 2 and 6 months of llfe) besldes
lmmunoglobulln.
30
If the flrst dose ls not admlnlstered ln
the neonatal perlod, then the lnfant should recelve the three
conventlonal doses of the vacclne. In all sltuatlons,
breastfeedlng should be recommended. In mothers wlth an
lnfant aged less than one year and wlth hepatltls B dlagnosed
durlng the breastfeedlng perlod, breastfeedlng should be
malntalned and the lnfant should be tested for HBsAg, slnce
he/she recelved the vacclne at blrth. If the result of the test
ls negatlve, the lnfant should be revacclnated and the
prophylactlc measures for the case should be followed, that
ls: admlnlster hepatltls B lmmunoglobulln (HBIG)
lntramuscularly at the dose of 0.04 ml/kg, or standard
gammaglobulln at the dose of 0.12 ml/kg IM.
30,31
Although hepatltls C vlrus has been detected ln the mllk
of HCV-posltlve mothers, lts transmlsslon vla breastmllk
has not been conflrmed. Therefore, breastfeedlng ls not
contralndlcated ln HCV-posltlve mothers. However, the
preventlon of nlpple flssures ls very lmportant, as lt has not
been yet determlned whether the lnfants contact wlth
maternal blood can facllltate the transmlsslon of the dlsease.
The Amerlcan Academy of Pedlatrlcs Commlttee on Infectlous
Dlseases recommends that mothers be lnformed of the
theoretlcal (but yet not conflrmed) rlsk of transmlttlng the
vlrus vla breastmllk. The declslon to breastfeed should be
analyzed on a case-by-case basls, assesslng the role of
breastfeedlng ln the lnfants llfe, slnce the deflnlte role of
breastfeedlng ln the transmlsslon of hepatltls C vlrus to the
lnfant ls not known.
7
Cytomegalovirus infection
Cytomegalovlrus (CMV) can be lntermlttently excreted
ln sallva, urlne, genltal secretlons and human mllk for
several years after the prlmary lnfectlon and ln case of
reactlvatlon of lts latent forms. Infant or fetal lnfectlon may
be acqulred from mothers wlth prlmary lnfectlon or durlng
reactlvatlon of the lnfectlon, occurrlng more frequently
whlle the baby passes through the blrth channel or ln the
postnatal perlod. However, due to the transplacental transfer
of antlbodles, thls dlsease ls not common among newborns.
In postnatal lnfectlon, the correlatlon wlth breastfeedlng
ls evldent, although the vlrus may be acqulred from the
contact wlth other seroposltlve lndlvlduals who share the
same household. Studles show that 30% of breastfed
lnfants born to seroposltlve mothers acqulre the lnfectlon ln
the flrst years of llfe, amountlng to 70% of the cases when
the vlrus ls lsolated ln breastmllk. Nevertheless, symptomatlc
lnfectlons or late sequelae have not been observed ln
bables, posslbly due to the transfer of speclflc maternal
antlbodles that protect the lnfant agalnst systemlc dlsease.
Early contamlnatlon of the breastfed lnfant seems to be
preferred, because lf contamlnatlon occurs later on, the rlsk
for symptomatlc dlsease ls hlgher. These data conflrm that
breastfeedlng should not be contralndlcated.
32,33
However, speclal attentlon should be glven to preterm
bables, especlally those wlth a lower gestatlonal age. The
declslon to breastfeed preterm lnfants of CMV-posltlve
mothers should be consldered ln terms of rlsk of transmlsslon
of the dlsease versus breastfeedlng beneflts. Preterm bables
mlght not have protectlve antlbodles and have symptomatlc
lnfectlons. However, the vlrus can become lnactlve by
pasteurlzatlon of human mllk and the vlral load can be
reduced by freezlng the mllk at -20 C.
32,33
A recent study wlth preterm lnfants who acqulred lnfectlon
ln the early postnatal perlod, vla breastmllk of CMV-posltlve
mothers, has shown that neurologlcal development and
hearlng were not compromlsed ln the lnfants. Nevertheless,
glven the small number of assessed lnfants, follow-up
studles wlth preterm lnfants wlth lnfectlons acqulred ln the
postnatal perlod are necessary.
34
Varicella
A mother who presents wlth varlcella up to flve days
before or two days after dellvery may transmlt the
dlsease to the lnfant ln lts severe form, when the rlsk for
vlremla ls hlgh. In these cases, the mother should be
lsolated durlng the contaglous phase of leslons up to the
crust phase, and VZIG (varlcella-zoster lmmunoglobulln)
at the dose of 125 lntramuscular unlts or a 2-ml slngle IM
dose of standard lmmunoglobulln should be glven to the
lnfant as soon as posslble, although the value of the latter
medlcatlon ls arguable.
10
The lnfant should be observed
up to the 21st day of llfe. It ls unclear whether the vlrus
can be found ln human mllk and whether lt could lnfect the
lnfant. Thus, durlng thls perlod, breastmllk can be
expressed and glven to the lnfant. However, lf the lnfant
develops the dlsease durlng thls perlod, acyclovlr therapy
should be lmplemented.
34
Breastfeedlng durlng maternal lnfectlons - Lamounler JA, et alii
Jornal de Pedlatrla - Vol. 80, No.5(Suppl), 2004 S185
A mother wlth varlcella whose onset of the dlsease
occurred more than flve days before dellvery or after the
thlrd day postpartum can produce and transfer antlbodles
to the lnfant, transplacentally or vla breastmllk. In thls
case, the lnfant may develop the mlld form of the dlsease,
wlth no need for lsolatlon or prophylaxls. The mother can
breastfeed the lnfant, provlded that precautlons such as
handwashlng, wearlng of a mask and coverlng of leslons
are properly taken.
35
Herpes simplex
Newborn lnfants can be contamlnated wlth herpes slmplex
ln utero vla a hematogenous transplacental route, durlng
dellvery (more frequent) or ln the postnatal perlod. The rlsk
of neonatal contamlnatlon ls hlgher for prlmary lnfectlon or
non-prlmary lnfectlon lf lt occurs ln the last month of
gestatlon. However, ln the last week before dellvery,
transmlsslon rates are low for recurrent dlsease.
The rlsk of vlral transmlsslon vla breastmllk ls very low.
In nurslng mothers wlth herpes, breastfeedlng should not
be lnterrupted, except when the herpetlc veslcles are
located on the breasts. Actlve leslons ln other body parts
should be covered, and the nurslng mothers hyglene should
not be overlooked so that breastfeedlng can be malntalned.
Extra precautlon should be taken lf veslcles are present
on the face and flngers, as well as wlth other sources of
herpes slmplex vlrus, such as glnglvostomatltls ln other
famlly members. If there ls susplclon or conflrmatlon that
the lnfant ls lnfected wlth herpes slmplex, he/she should be
lsolated from other lnfants but not from hls/her mother.
There ls a case report of a 15-month-old who was
contamlnated wlth the dlsease by a flve-year-old slbllng
who had glnglvostomatltls. Both of the mothers breasts
were contamlnated by the lnfant durlng breastfeedlng.
36
Rubella
Acute exanthematlc dlsease caused by a vlrus that can
be ellmlnated ln resplratory secretlons between 10 days
before and 15 days after the appearance of the exanthema.
Most cases are asymptomatlc or subcllnlcal, but may transmlt
the lnfectlon. No data exlst that contralndlcate breastfeedlng
ln a nurslng mother wlth rubella. In case of vacclnatlon
agalnst rubella, breastfeedlng may be malntalned as well.
10
Measles
Hlghly contaglous exanthematlc dlsease caused by a
vlrus transmltted by resplratory secretlons few days
before and durlng the course of the dlsease. The measles
vlrus has not been lsolated ln human mllk yet, but, on the
other hand, speclflc antlbodles were found ln the mllk of
lmmunlzed women. If measles ls conflrmed ln a nurslng
mother, the lnfant should recelve lmmunoglobulln, and
the mother should be lsolated up to 72 hours after the
appearance of the exanthema. However, expressed
breastmllk can be glven to the lnfant because secretory
IgA beglns to be secreted after 48 hours of the appearance
of the exanthema ln the mother.
10
Mumps
Vlral dlsease transmltted by dlrect contact wlth
resplratory droplets or fomltes. Infectlon ls rare ln lnfants
younger than one year due to the passlve transfer of
antlbodles vla placenta. If a susceptlble nurslng mother ls
lnfected, she should contlnue breastfeedlng because
exposure occurred seven days before the development of
parotldltls and IgAs ln human mllk may help mltlgate the
symptoms ln the lnfant.
10
Bacterial infections
Tuberculosis
Breastfeedlng recommendatlons for mothers wlth
tuberculosls depend on the tlme at whlch dlagnosls was
made. Accordlng to the World Health Organlzatlon, lt ls not
necessary to separate the mother from the lnfant and,
under no cl rcumstance, shoul d breastfeedl ng be
dlscontlnued.
9,37
Kochs baclllus ls exceptlonally excreted
lnto breastmllk, and lf the lnfant ls lnfected, the resplratory
tract usually serves as a portal of entry. Thus, a mother wlth
extrapulmonary tuberculosls does not requlre any speclal
care to breastfeed.
Accordlng to the Amerlcan Academy of Pedlatrlcs, an
lnfant of a mother wlth pulmonary tuberculosls ln the
contaglous phase, untreated or wlth less than three weeks
on antltubercular drugs at dellvery, should be separated
from the mother but fed wlth expressed human mllk, as
transmlsslon often occurs vla the alrways. The mothers
sputum should be submltted to the acld-fast smear test, and
she should only be allowed to be ln contact wlth her lnfant
after the test ylelds negatlve results.
10
The lnfant should
recelve chemoprophylaxls wlth lsonlazld, at the dose of 10
mg/kg/day for three months and then be submltted to the
tuberculln skln test. If the test result ls posltlve, the dlsease
should be traced by cllnlcal and radlologlcal examlnatlon. If
no actl ve l nfectl on l s detected, survel l l ance and
chemoprophylaxls should be malntalned up to the slxth
month, when lntradermal BCG ls applled. If the tuberculln
test ls negatlve at three months of llfe, chemoprophylaxls
may be lnterrupted and lntradermal BCG applled, and
cllnlcal survelllance should be malntalned. Sltuatlons ln
whlch there may be rlsks of not followlng up the lnfant on
lsonlazld therapy, concomltant lntradermal BCG vacclnatlon
ls recommended.
7,17
Accordlng to the WHO, breastfeedlng should be
malntalned, but the close contact between mother and
lnfant should be reduced, and the followlng precautlons
should be taken: a mask or slmllar devlce should be worn
whlle breastfeedlng, hands should be carefully washed, and
those lnfected wlth the dlsease, especlally household
members, should be ldentlfled. The lnfant should be treated
wlth hydrazlde (INH) at the dose of 10 mg/kg, once a day
for slx months. After chemoprophylaxls ls over, the lnfant
should recelve lntradermal BCG.Breastfeedlng should not
be dlscontlnued ln any of these phases.
9,37
There are no restrlctlons on breastfeedlng for mothers
who are ln the non-contaglous phase of tuberculosls, whose
Breastfeedlng durlng maternal lnfectlons - Lamounler JA, et alii
S186 Jornal de Pedlatrla - Vol. 80, No.5(suppl), 2004
treatment began more than three weeks ago, and ln thls
case, the baby should be vacclnated wlth lntradermal BCG
at blrth. In cases ln whlch the dlagnosls of maternal
tuberculosls was establlshed after the onset of breastfeedlng,
the lnfant should be regarded as potentlally lnfected and
should recelve chemoprophylaxls.
Breastfeedlng should not be dlscontlnued because the
admlnlstratlon of antltubercular drugs ln the mother ls not
a contralndlcatlon for breastfeedlng.
Table 2 shows the WHO recommendatlons for
tuberculosls cases and the management of breastfeedlng,
conslderlng the posslblllty of not uslng the tuberculln skln
test.
It ls paramount to underscore that all lnfants should be
monltored as to thelr welght galn and health status. Speclal
attentlon should be glven to lnfants whose mothers have
rlsk factors for multldrug-reslstant tuberculosls. In thls
case, the separatlon of mother and lnfant may be necessary,
as the mother, under thls clrcumstance, shows lncreased
lnfectlousness and takes longer to respond to therapy.
Breastfeedlng may be malntalned provlded that expressed
mllk ls used, thus reduclng the resplratory contact between
mother and lnfant.
17
Hansen's disease
Hansens dlsease ls a chronlc lnfectlous dlsease wlth
hlgh lnfectlousness and low pathogenlclty. Its cllnlcal
course varles, baslcally dependlng on the lndlvlduals
cellular lmmune response. The dlsease ls transmltted by
person-to-person contact, especlally long contact, by
means of nasal and cutaneous secretlons. The baclllus
can be lsolated ln breastmllk ln cases of untreated Hansens
dlsease, as well as ln patlents treated durlng less than
three months wlth sulfone (dapsone or clofazlmlne) or
less than three weeks wlth rlfamplcln. Skln leslons on the
breast can be a source of lnfectlon for the lnfant.
There ls no contralndlcatlon for breastfeedlng lf the
mother ls recelvlng proper treatment.
10
The lnfant should
be treated as early as posslble, slmultaneously wlth the
mother. The drugs used are the same ones used ln the
mother and may cross l nto human ml l k at l ow
concentratlons, but there ls no report of severe slde
effects. The lnfant should be followed up and submltted to
regular cllnlcal exams for early detectlon of posslble slgns
of the dlsease. Moreover, the followlng ls recommended
before and durlng breastfeedlng: careful handwashlng,
wearlng of a mask whlle handllng the lnfant and coverlng
of breast leslons.
The contaglous mother (untreated or treated for less
than three months wlth sulfone or three weeks wlth
rlfamplcln) should avold contact wlth her baby, except to
breastfeed; she should wear a mask or slmllar devlce,
wash her hands carefully before handllng the lnfant and
dlslnfect nasal secretlons and baby wlpes.
10
Syphilis
Syphllls ls a dlsease that ls baslcally sexually transmltted;
however, other modes of transmlsslon exlst, such as contact
Active maternal tuberculosis diagnosed Active maternal tuberculosis diagnosed
before the delivery after the delivery
> 2 months before < 2 months before < 2 months after > 2 months after
Negatlve sputum Posltlve sputum - - -
before the dellvery before the dellvery
To treat the mother To treat the mother To treat the mother To treat the mother To treat the mother
To breastfeed To breastfeed To breastfeed To breastfeed To breastfeed
There ls no need Isonlazlde for the Isonlazlde for the Isonlazlde for the Isonlazlde for the
of chemoprophylaxls lnfant for 6 months lnfant for 6 months lnfant for 6 months lnfant for 6 months
BCG at blrth BCG after the end BCG after the end BCG after the end If BCG was not
of chemoprophylaxls of chemoprophylaxls of chemoprophylaxls glven at blrth,
the lnfant should
recelve after the end
of chemoprophylaxls
Table 2 - WHO recommendatlons for tuberculosls cases and the management of breastfeedlng accordlng to the tlme
at whlch dlagnosls was made
Source: adapted from Giugliani ERJ
9
and WHO
37
.
Breastfeedlng durlng maternal lnfectlons - Lamounler JA, et alii
Jornal de Pedlatrla - Vol. 80, No.5(Suppl), 2004 S187
wlth people wlth actlve leslons ln mucous membranes,
genltal reglon and breasts. There ls no evldence of
transmlsslon vla human mllk, wlthout breast leslons. A
nurslng mother wlth prlmary or secondary syphllls wlth
breast lnvolvement can lnfect the lnfant through the contact
of leslons wlth the mucous membranes. If there are leslons
on the breasts, especlally on the areola, breastfeedlng or
use of expressed mllk ls contralndlcated untll full treatment
and regresslon of leslons. Twenty-four hours after penlclllln
therapy, the lnfectlous agent (splrochete) ls seldom detected
ln the leslons. Thus, there ls no contralndlcatlon for
breastfeedlng after proper treatment.
10,38
Brucellosis
Detectlon of Brucella melitensis ln human mllk has
been reported, and so have cases of brucellosls ln
excluslvely breastfed lnfants. Thls conflrms the posslblllty
of brucellosls belng transmltted vla breastmllk.
In the acute phase of severe dlsease ln the mother,
breastfeedlng should be avolded, but the use of expressed
and pasteurlzed human mllk ls allowed. Breastfeedlng
may be restored as soon as the dlsease ls treated wlth
antlmlcroblals and the nurslng mother shows cllnlcal
lmprovement.
39,40
Parasitic infections
Malaria
Slnce malarla ls not transmltted among humans,
breastfeedlng may be malntalned lf the mothers cllnlcal
condltlons allow so. There ls no evldence lndlcatlng that
malarla can be transmltted vla breastfeedlng.
38
For
mothers who need to be treated, chloroqulne, qulnlne and
tetracycllne are recommended. Sulfonamldes should be
avolded ln the flrst month of breastfeedlng.
18
Therefore,
a nurslng mother wlth malarla may breastfeed durlng the
treatment wlth speclflc drugs.
Chagas' disease
Studles show that Trypanosoma cruzi can be lsolated
ln human mllk ln acute and chronlc forms of Chagas
dlsease. There was a case report of acute lnfectlon ln a
two-month-old lnfant breastfed by an lnfected mother.
41
Although late sequelae may develop, acute dlsease ln the
lnfant tends to be benlgn. Thls, comblned wlth the remote
posslblllty of transmlsslon of the dlsease, ls reason enough
for malntalnlng breastfeedlng ln women wlth the chronlc
form of the dlsease, except lf the nlpples bleed and have
flssures.
42
In cases of acute dlsease, breastfeedlng should
be contralndlcated.
41,42
Lab experlments uslng samples of human mllk
contamlnated wlth the protozoan and tested under dlfferent
condltlons demonstrate that mllk pasteurlzatlon prevents
the transmlsslon of the dlsease. Rats orally and
lntraperltoneally lnoculated wlth human mllk contalnlng
the paraslte were lnfected; however, the control group
wlth anlmals lnoculated wlth pasteurlzed mllk was not
lnfected.
43,44
Anlmal experlments uslng human mllk
heated to 63
o
C ln a household mlcrowave oven (7
mlnutes, 45% power) proved efflclent ln reduclng the
transmlsslon of Trypanossoma cruzi.
45
Fungal infections
Paracoccidioidomycosis
Systemlc granulomatous dlsease caused by a fungus,
whose transmlsslon occurs vla resplratory secretlons.
There ls no contralndlcatlon for breastfeedlng. However,
lt should not be forgotten that cotrlmoxazole, commonly
used for the treatment of paracoccldloldomycosls, ls
excreted lnto breastmllk and may produce severe slde
effects ln the lnfant.
38,40
Cryptococcosis
Fungal dl sease wl t h worl dwl de dl st rl but l on.
Immunocompromlsed patlents, lncludlng those wlth HIV/
AIDS, are at greater rlsk for cryptococcosls. The
transmlsslon of partlcles ln the envlronment occurs vla
aerosol droplets, and no documentatlon exlsts of person-
to-person transmlsslon. Therefore, breastfeedlng ls not
contralndlcated.
38,40
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Correspondlng author:
Joel A. Lamounler
Av. Alfredo Balena,190
CEP 30130-100 - Belo Horlzonte, MG
Brazll
Phone: +55 (31) 3248.9632
Breastfeedlng durlng maternal lnfectlons - Lamounler JA, et alii