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Is Breast Always Best? Features
Ellen Kamman, Johannesburg, South Africa
Photo: Kristen Watts by Jade Beall Photography

 

When facing difficult decisions is breast always best?

Human milk is the natural food for babies, uniquely meeting their changing needs. There is plenty of evidence showing that babies who receive human milk have better short term and long term health outcomes than babies who receive alternative infant foods. At La Leche League meetings, we often discuss how babies (and mothers!) benefit from breastfeeding, and what the possible consequences are if we use alternatives.

What about a situation where breastfeeding could involve exposing the baby to potential harm? This can happen when a mother has an infectious disease that can be passed on via her milk, or has to take medication, for example. In most cases, breastfeeding can continue without interruption. Sometimes your health care professional may recommend you stop breastfeeding temporarily or permanently.

I don’t want my baby to be exposed to anything that could possibly be dangerous. Shouldn’t I just stop breastfeeding?

When faced with a decision like this consider the following. Something that is often not discussed at all is the risk of not breastfeeding. For many people, this is uncomfortable to think about. We all know breastfeeding is best for babies, but to say that the alternative is worse and has risks is often considered to be judgmental. However, it is important to acknowledge the differences between human milk and its alternatives. If we see them as equal, then any risk factor added to the breastfeeding equation would tip the balance in favor of the alternative.

Think of the decision as a scale. In a normal situation, the breastfeeding side would be higher—breastfeeding is good for babies, and the side of artificial infant feeding would be lower. The height difference between the two sides of the scale is not the same for every baby in every situation. The risk of artificial infant feeding is considered much higher for babies in developing countries or disadvantaged communities, where clean water and electricity are not always available. There is also evidence that premature babies are at higher risk when given artificial infant food. The older they are, and the more robust their little bodies become, the impact of not breastfeeding in the long term will be less and less. But older babies can also cope better with medications and other substances that they might be exposed to though breast milk.

I have to start medication, and my doctor says I can’t take it while breastfeeding. My baby is four months old and has never taken a bottle. He has given me tablets to dry up my milk.

It is often very stressful for a mother to be told that she has to stop breastfeeding, especially when this happens unexpectedly and before she or her baby are ready to wean.

When a mother needs to take medications, there are a few things to consider:

  • Will the medication harm my breastfeeding baby?
  • Will weaning harm my breastfeeding baby or me?
  • What are my options?

In many cases, the first question is the only question that is raised when you need to take medication. But the other factors need to be considered too.

Some medications are prescribed to babies, so trace amounts of these medications passing into the milk are unlikely to affect the baby negatively. Other medications don’t pass into breast milk in significant quantities. Some medications are not absorbed easily when administered orally, so even if they were to pass into the milk, the baby may not necessarily absorb them. Whether or not medication taken by the mother will harm the breastfeeding baby depends on many factors. Your LLL Leader can access resources that specifically deal with these issues, and pass on information to you that can help you make a decision.

Weaning a baby can have short term and long term effects on mother and baby. Babies may not tolerate alternatives well. They will no longer receive immune factors via mother’s milk, which can expose them to a higher risk of infections. The negative effects of weaning the baby will depend on age and health status prior to weaning. For a mother, weaning prematurely can have immediate effects of breast discomfort and mastitis, and long term effects, such as increased risk of certain illnesses. And that’s before even talking about the emotional side!

A number of options should be discussed before permanent weaning is suggested. You can discuss these with your health care provider and your LLL Leader.

  • Is it absolutely necessary to take the medication?
  • Can the treatment be postponed until your baby is older or weaned?
  • Are there safer alternatives? Older medications usually have more of a “track record” and more information is available about their use by breastfeeding mothers. Medications with shorter half-lives, high protein binding, low oral bioavailability, or high molecular weight are less likely to pass to your baby.
  • Can the baby’s exposure be reduced (for example by taking the medication at a time when your baby is less likely to drink)?
  • Would temporarily interrupting breastfeeding be an option? With this option, you could use previously stored breast milk if available, or temporarily use artificial infant formula. There would be a risk that your baby could refuse the breast afterwards, and expressing milk would be necessary to protect your milk supply (“pump and dump”).

My doctor says I have a condition that could be passed on to my baby and not to breastfeed.

This is a tough situation. To reach a decision, look at the risks involved, and whether these risks weigh heavier than the risks involved with not breastfeeding your baby. In some cases, the exposure to your baby is not just via breast milk, and interrupting breastfeeding may not have much influence on the risk of transmission. For example, if you have a cold, your baby could be exposed, because you are coughing in his vicinity, and not just via your milk. In fact, chances are that your baby is exposed already and continued breastfeeding will help your baby fight a possible infection.

So it is important to look at a) is the disease transmitted via breast milk, b) how risky is the disease for the baby, and c) how risky is alternative feeding for the baby. Again, this is different for every mother and every baby and should be assessed on an individual basis. Your LLL Leader can supply information that you can discuss with your health care provider.

Image of mother breastfeeding toddler next to daughter

It is often very stressful for a mother to be told that she has to stop breastfeeding, especially when this happens unexpectedly and before she or her baby are ready to wean.

What about HIV? Surely with such a deadly virus, mothers should not breastfeed?

In the case of HIV, which is transmitted via breast milk, the initial recommendation worldwide was that mothers should not breastfeed. Babies of HIV-positive mothers were put onto artificial infant formula from birth, so they wouldn’t be exposed to any risk of HIV. However, as more and more research was done, it became clear that these babies were not doing as well as expected. In developing countries, many babies were dying from pneumonia and diarrhea, and some had acquired HIV during pregnancy or at birth. Some studies showed that babies from HIV-positive mothers who were put on formula had a higher chance of dying before their second birthday, even if they had a lower chance of contracting HIV. This can be attributed to the fact that replacement feeding in poor resource settings carries higher risks than in developed countries.

Over time, and with more research and new medication protocols, it has been shown that the risk of transmission of HIV via breastfeeding is considered extremely low, especially when mother and/or baby are on antiretroviral therapy. So low, that the risk of NOT breastfeeding should be taken into consideration. In developing countries, this “balance of risks” has resulted in the World Health Organization updating their guidelines in favor of breastfeeding, EVEN in the context of HIV. This has resulted in some countries recommending exclusive breastfeeding to ALL mothers, even those with HIV, to promote infant and maternal health outcomes.

In developed countries like the USA, the health authorities still recommend against breastfeeding if a mother has HIV. There have even been reports of babies being removed from the family by social workers when an HIV-positive mother decided to breastfeed. One of the questions is that even in developed countries, where infant formula is provided to HIV-positive mothers, and where it can be safely prepared, the individual situation of each mother should be considered. What about the mother who lives in a situation where she can’t prepare formula safely? What about the babies who already got infected with HIV at birth? What about situations where replacement feeding may be safe one day, but something unexpected happens, like a flood, snow storm, or interruptions of power supply?

One should also consider the difference between public health recommendations and the individual situation of that mother. In developing countries, there may be cases where the individual situation of the mother and baby would make replacement feeding the safer option, despite the public health recommendation to breastfeed. Likewise, in developed countries, it may be safer for an individual mother to breastfeed, even though the health authorities recommend replacement feeding.

More and more experts feel that even in developed countries, breastfeeding may be the safest option for babies exposed to HIV.

Read more here: Breastfeeding for HIV-Positive Mothers.

What about the mother’s health?

Something that is often overlooked is the effect of breastfeeding on the health of the mother. If a mother doesn’t breastfeed, this has long term health implications. In the short term, abrupt weaning can lead to blocked ducts and mastitis. If weaning is necessary, it would help to allow for gradual weaning if this is at all possible.

Are there situations where breastfeeding is really impossible?

Yes, there are, but the situations where breastfeeding is completely contraindicated are very few and far between. These would include certain metabolic disorders of a baby and, for example, chemotherapy or radioactive medications in the mother.

Whose decision is it?
Can my doctor force me to stop breastfeeding?

Ideally, all the options should be discussed with a mother and the decision hers to make. Sometimes a mother finds that her health care provider did not present her with all the facts regarding continued breastfeeding. It can help to do your own research, and present some of your findings to your doctor. Sometimes the reason a health care provider recommends weaning is because she is worried that something might go wrong with the baby, and she might be sued. It can be helpful to confirm with her that you take full responsibility for your decision. Ultimately, the decision to wean or not wean is the mother’s decision. Only she can decide what is the best option for herself and for her baby. To reach this decision, she needs all the information she can get about the risks involved. A lactation consultant or La Leche League Leader is able to help you access this information.

Real life situation

M sent me a message. She was clearly distressed. She asked me to remove her from our Facebook group because looking at all the happy pictures of mothers breastfeeding made her really sad. She had been told by an emergency care doctor that she had to wean her baby within the next 24 hours, as she had to go for surgery a few days later. He had given her a script for medication to dry up her milk. Her baby was almost seven months old at the time, but she had planned to breastfeed until at least nine months. And now her medical condition would mean she would have to stop, and quickly too. We discussed several options: postponing the operation (which was not possible), drying up milk before the operation and restarting lactation after her recovery (suggested by the doctor as an alternative to complete weaning), pumping and dumping, and the possibility of the doctor cooperating and giving breastfeeding friendly medication and supporting her decision to continue. M was very happy with the option of pumping to keep up her supply while in hospital, and continuing breastfeeding afterwards. In the meantime, her baby would receive some formula—she was used to that already because mom was back at work and struggling to pump enough milk during the day. There was very little time to prepare and consult with the doctor before the operation, but M went into hospital a few days later with confidence that she could continue breastfeeding when the worst was over.

On the day of the operation, M sent me a picture: her baby with her in the hospital bed, latched on and blissfully drinking, within a few hours of the operation. The doctor had been more supportive than anticipated, and armed with all the information she had received, she felt confident to breastfeed her baby. M continued to breastfeed her baby until she was 11 months old.


Resources

Hale, T. W. Medications and Mothers’ Milk, 16th edition, 2014.

LactMed

Medications and Mothers’ Milk.

Morrison, P. Breastfeeding for HIV-Positive Mothers Breastfeeding Today Issue 26. 

Pearson-Glaze, P. breastfeeding.support Medications and Breastfeeding.

The Womanly Art of Breastfeeding, 8th Revised Edition.  Schaumburg, IL:  La Leche League International, 2010.

World Health Organization. Acceptable medical reasons for use of breast-milk substitutes 2009. 

World Health Organization. Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition 2013. ISBN 9789241505550 2013.

World Health Organization Guidelines on HIV and Infant Feeding. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. 2010. ISBN 978 924 1599535.


Ellen Kamman is a La Leche League Leader and IBCLC who lives in Johannesburg, South Africa with her husband and three children. Besides her volunteer activities in the field of breastfeeding, she works as a freelance data analyst. In her spare time she runs half marathons.

 


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