NYSDOH Policy Statement: Situations Where Breastfeeding is Contraindicated or Not Advisable

Revised January 2018

Introduction

This policy is to provide healthcare providers with information on situations when breastfeeding is not advisable or contraindicated due to the health of the mother or her infant and/or temporary cessation of breastfeeding is recommended.

Background

It is well known that breastfeeding is beneficial to both the infant and mother in many ways.  Human milk provides the most complete form of nutrition for infants, including premature and sick infants.  Breastfeeding protects against a variety of diseases and conditions in infants and children, as well as benefiting the mother by decreasing postpartum bleeding and the risk of breast and ovarian cancers.  The New York State Department of Health joins multiple national and international organizations in support of exclusive breastfeeding because of the short and long-term health benefits for women and their infants.  The American Academy of Pediatrics (AAP) recommends “exclusive breastfeeding for about 6 months, followed by continuation of breastfeeding as complimentary foods are introduced for 1 year or longer as mutually desired by mother and infant”.1

There are instances, however, when breastfeeding or a mother’s own breastmilk is contraindicated or not advisable based on recommendations of key professional organizations and government entities concerned with the care of pregnant or postpartum women and their infants.  These recommendations, which are described in this document, include clinical considerations when temporary cessation of breastfeeding is advised and situations when breastfeeding or use of a mother’s own breastmilk is medically contraindicated due to maternal or infant health considerations.

The healthcare provider should initiate discussions about feeding options during the antepartum (prenatal) period.  Women for whom breastfeeding is contraindicated or who have situations when temporary cessation is advisable should receive full support and appropriately-tailored information from providers and staff who care for the mother and/or her infant.

Information about a woman’s decision regarding breastfeeding, any contraindications to, or reasons for temporary cessation of breastfeeding should be documented in the patient’s record.  When a woman is not breastfeeding for medical contraindications, staff should be aware that she may face social, familial or personal pressures to consider or continue to breastfeed and that there may be personal reasons she may not wish to share this information with all staff, friends or family.  Encouraging the new mother to develop, in advance, an explanation for why she is not breastfeeding may help her to avoid disclosing the reasons behind her decision and protect her and her newborn’s privacy.

Medical Contraindications for Breastfeeding

There are a few medical contraindications to breastfeeding, and these include:

  • An infant who has the metabolic disorder of classic galactosemia (galactose 1-phosphate uridyltransferase deficiency).1
  • A mother living with human T-cell lymphotrophic virus type I or type II.1
  • A mother living with the human immunodeficiency virus (HIV).1

Women Living with HIV in the United States Should Not Breastfeed

Numerous organizations recommend that women living with HIV in the United States, where safe infant feeding alternatives are available, should not breastfeed or feed their own expressed breastmilk to their infants.  The New York State (NYS) AIDS Institute’s Perinatal HIV Prevention Committee clinical guidelines state: “Breastfeeding by HIV-infected women is not recommended, even when the mother is taking combination antiretroviral therapy (ART) and/or her viral load is undetectable.  The following factors increase the risk of HIV transmission via breastfeeding: higher levels of HIV RNA in breastmilk; inflammation of the breast (mastitis); longer duration of breastfeeding; or resumption of breastfeeding after abrupt weaning.  Although the risk of mother-to-child transmission of HIV is significantly lower with the use of combination ART and an undetectable viral load, neither infant antiretroviral prophylaxis nor suppressive maternal postpartum ART completely eliminates the risk of HIV transmission through breast milk.”2   Therefore, at this time, “Undetectable=Untransmittable (U=U)” does not apply to transmission though breastfeeding.3

Prevention of HIV Infection in Women Who Are Breastfeeding

Acquiring HIV while breastfeeding significantly increases the chance of mother-to-child HIV transmission due to the mother’s viremia and increased infectivity during acute HIV infection. The NYS AIDS Institute’s Perinatal HIV Prevention Committee recommends that a risk reduction plan should be in place for breastfeeding women who are at significant risk for HIV acquisition to reduce the incidence of acute infection and subsequent transmission to their infants.  Risk factors include having a new diagnosis of a sexually-transmitted infection, a partner known to be infected with HIV, or using injection drugs.  A discussion of HIV pre-exposure prophylaxis (PrEP), which is a biomedical intervention using antiretroviral medications [tenofovir disoproxil fumarate/emtricitabine (TDF/FTC)] in non-HIV infected individuals to reduce their risk of acquiring HIV infection, should be included in the plan.  Prevention of acute infection in a breastfeeding woman outweighs any theoretical concerns due to toxicity in the infant from TDF/FTC exposure during breastfeeding.  Evidence to date suggests that the use of TDF is safe during breastfeeding and that PrEP drug exposure to infants through breastmilk is much lower than fetal antiretroviral drug exposures that occurs in utero in women who are on combination antiretroviral drug therapy.2

Maternal Conditions Where Breastfeeding Is Not Advisable, but a Mother's Own Expressed Breastmilk Can Be Provided

Maternal conditions where breastfeeding is not advisable include:

  • Having untreated, active tuberculosis.  The mother’s expressed breastmilk can be fed to the infant because there is no concern about the spread of tuberculosis through the milk.  Breastfeeding may resume after a minimum of 2 weeks of treatment when the mother is determined to no longer be infectious.1
  • Varicella.  If the mother develops varicella-zoster infection (chickenpox) 5 days before through 2 days after delivery, she should be separated from her infant.  The infant would be considered exposed to, and at high risk for acquiring, chickenpox, and in need of prophylaxis with varicella immune globulin.  The mother can feed the infant her expressed breastmilk in the interim (i.e., until she is considered to be non-infectious and all the lesions have become scabbed and crusted, and with no new vesicles appearing).1
  • Having active herpetic lesions on breast(s).  Breastfeeding should be avoided until all lesions are healed; if unilateral lesions are present, breastfeeding may continue on the unaffected breast. Lesions should be covered to prevent exposure to the infant.  The mother can feed expressed breast milk to her infant as there is no concern of herpes transmission through the milk.1

Temporary Cessation of Breastfeeding Due to Maternal Conditions and Mother's Expressed Breastmilk Should Not Be Used

Temporary cessation of breastfeeding should be considered when the mother:

  • Is taking certain medications, such as radioactive isotopes, antimetabolites, cancer chemotherapy, some psychotropic medications and a small number of other medications.4,5   The risks/benefits of breastfeeding for each such medication needs to be considered.
  • Is undergoing radiation therapies.  However, such nuclear medicine therapies require only a temporary interruption in breastfeeding.6
  • Has Hepatitis C.  If nipples and/or surrounding areola are cracked or bleeding, the woman should not breastfeed or use expressed breastmilk until nipples are healed.7
  • Has active, untreated brucellosis.  Women should not breastfeed or provide expressed breastmilk for feeding until no longer contagious.1

Special Situations Where Recommendations for Breastfeeding Need to be Individually Tailored

Temporary cessation of breastfeeding should be considered when the mother:

  • Is currently using illicit drugs (e.g., cocaine, heroin), unless specifically approved by the infant and mother’s healthcare provider on a case-by-case basis.4   Mothers should be actively receiving care.
  • Is using prescription controlled substances, unless specifically approved by the infant’s healthcare provider on a case-by-case basis with close observation for side effects (e.g., Xanax).8
  • Has a history of an opioid use disorder.  Women who are stable on opioid agonist pharmacotherapy should be encouraged to breastfeed.  If they relapse, however, they should be counseled to suspend breastfeeding.9
  • Is using medical or recreational marijuana.  Pregnant and lactating women should be encouraged to discontinue use of marijuana.  Cannabis use, however, is not considered an absolute contraindication to breastfeeding.10

Infant Conditions Where Breastfeeding Can Be Initiated with Feeding Modifications

There are a few infant conditions where breastfeeding should be initiated and continued with guidance from the infant’s pediatrician, including:

  • Phenylketonuria.  Breastfeeding can take place with supplementation with a low-phenylalanine formula.1 These infants require regular monitoring of their blood phenylalanine level and adjustment of the amount of breastmilk provided.
  • Glucose 6-Phosphate-Dehydrogenase Deficiency (G6PD).  Drugs and foods that can cause hemolysis in a G6PD infants should be avoided while breastfeeding, including fava beans, henna, and dapsone, nitrofurantoin, phenazopyridine, primaquine, dimercaprol and methylene blue.1

Lactation Support During Temporary Cessation of Breastfeeding

Lactation support during the period of temporary cessation of breastfeeding is important to maintain breastmilk supply and to avoid the risk of engorgement or mastitis.  Healthcare providers should educate women and provide lactation counseling, and/or referrals to qualified lactation counselors to ensure women are informed on how to establish and maintain their breast milk supply.  The use of a breast pump (a personal-use electric or hospital-grade electric) during this period is critical to support breastfeeding.  Continued support is also needed to help the mother/infant re-establish breastfeeding.  Healthcare providers should write a prescription for a breast pump, which is covered by most health insurance programs, including NYS Medicaid.  Healthcare providers should also educate women about the use and cleaning of a breast pump and the collection and storage of breast milk.

Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Income-eligible women who qualify for WIC should be referred to their local WIC agency.  WIC provides nutrition advice, nutritious foods for both mother and baby including formula, breastfeeding support and referrals to other services.

WIC provides lactation support by staff with expertise in breastfeeding education and lactation counseling.  WIC staff conduct breast pump assessments to ensure that participants have the appropriate pump to meet their needs, and provide instructions in the use of a breast pump, and the care and storage of pumped breastmilk.  WIC can also provide breast pumps to participating women.

Discharge Instructions for Women and their Infants

Upon discharge, birth hospital staff should:

  • Assess whether the mother is enrolled in WIC, and if not, make referrals for all income-eligible women and infants.
  • For women who choose to breastfeed, refer to community lactation support groups, including La Leche League, Mocha Moms, and WIC, as appropriate.
  • For women who choose to formula feed, provide individual instruction in formula preparation, frequency of feeding including feeding cues, feeding techniques, and information on infant growth and development.
  • Provide home care instructions on the care of the infant.
  • Schedule or arrange and provide contact information for follow-up appointments with the mother’s and her infant’s providers and WIC appointments.
  • Determine whether sources of nutrition for the infant and mother will be available and are sufficient.  If this is in doubt, the attending practitioner or provider and an appropriate social services agency should be notified. 11 All efforts should be made to ensure the mother has adequate nutrition for the infant upon discharge from the hospital.

Reference List

  1. American Academy of Pediatrics (AAP). Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2012; 129(3), e827-841. http://pediatrics.aappublications.org/content/pediatrics/129/3/e827.full.pdf (accessed 08/14/17)
  2. AIDS Institute Clinical Guidelines. Reducing HIV Transmission during Pregnancy, Labor and Delivery, and Postpartum Care Guideline. http://www.hivguidelines.org/pregnancy-and-hiv/reducing-mtct-in-pregnancy-labor-delivery-postpartum/#tab_4 (accessed 08/14/17)
  3. New York State Department of Health (NYSDOH). Ending the AIDS Epidemic in New York State. Undetectable=Untransmittable (U=U).  https://www.health.ny.gov/diseases/aids/ending_the_epidemic/
  4. Academy of Breastfeeding Medicine (ABM). ABM Clinical Protocol #7: Model Breastfeeding Policy. Breastfeeding Medicine 2010; 5 (4), 173-177. http://www.bfmed.org/SearchResults.aspx?cx=012624551319151876133%3ayl7jvs_jroc&cof=FORID%3a10&ie=UTF-8&q=Protocol+%237 (Search Policy #7) (accessed 8/14/2017)
  5. National Library of Medicine (NLM). Drugs and Lactation Database (LactMed) https://www.healthdata.gov/dataset/drugs-and-lactation-database-lactmed (accessed 8/14/2017)
  6. Centers for Disease Control and Prevention. Breastfeeding Diseases and Conditions: When should a mother avoid breastfeeding? Updated November 18, 2016. https://www.cdc.gov/breastfeeding/disease/ (accessed 8/14/2017)
  7. Centers for Disease Control and Prevention (CDC). Hepatitis B and C Infections, Hepatitis C Virus Infection. Is it safe for the HCV-positive mother to breastfeed if her nipples are cracked and bleeding? Updated June 17, 2015. https://www.cdc.gov/breastfeeding/disease/hepatitis.htm  (accessed 8/14/2017)
  8. Academy of Breastfeeding Medicine (ABM). ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, Revised, 2015. Breastfeeding Medicine. November 3, 2015; 10: 135-141. http://www.bfmed.org/SearchResults.aspx?cx=012624551319151876133%3ayl7jvs_jroc&cof=FORID%3a10&ie=UTF-8&q=Protocol+%2321 (Search Policy #21) (accessed 8/14/2017)
  9. American College of Obstetrics and Gynecologists (ACOG). Opioid use and opioid use disorder in Pregnancy. Committee Opinion No. 711. Obstet Gynecol 2017;130 (2):488-489. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co711.pdf?dmc=1&ts=20170809T2216122144 (accessed 08/14/17)
  10. American College of Obstetrics and Gynecologists (ACOG). Marijuana use during pregnancy and lactation. Committee Opinion No. 637. Obstet Gynecol 2015;126:234-238. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co637.pdf?dmc=1&ts=20170809T2219190742 (accessed 08/14/17)
  11. New York State Department of Health (NYSDOH). Title 10, NY Codes Rules and Regulations (NYCRR) - Perinatal services. (c) General requirements; (5) Discharge planning. https://regs.health.ny.gov/content/section-40521-perinatal-services (accessed 08/14/17)

Additional Resources Related to Breastfeeding

American Academy of Family Physicians (AAFP)

American Academy of Pediatrics (AAP)

American College of Obstetricians and Gynecologists (ACOG)

New York State Department of Health (NYSDOH)

National Institutes of Health (NIH)

Maternal Conditions Where Breastfeeding Is Not Advisable

  • Briggs GG, Freeman RK. Drugs in Pregnancy and Lactation, 10th edition, 2014, Lippincott William & Wilkins.

Medication Use and Breastfeeding

  • Rowe H, Baker T, Hale T. Maternal Medication, Drug Use, and Breastfeeding. Pediatric Clinics of North America 2013; 60: 275-294.
  • Hale T.W. Medications and Mothers’ Milk, 17th edition, 2016, Springer Publishing Co.

Nutrition and Breastfeeding

  • Valentine C, Wagner C. Nutritional Management of the Breastfeeding Dyad. Pediatric Clinics of North America 2013; 60: 261-274.

Pre-Exposure Prophylaxis (PrEP) to Prevent HIV Infection

  • Mofenson LM. Tenofovir, Pre-exposure Prophylaxis for Pregnant and Breastfeeding Women at Risk of HIV Infection; The Time is Now. PLoS Med 2016;13(9): e1002133. doi: 10.1371/journal.pmed.1002133.
  • Mugwanya K, Hendrix C, Mugo N, et al. Pre-exposure Prophylaxis Use by Breastfeeding HIV-Uninfected Women: A Prospective Short-Term Study of Antiretroviral Excretion in Breast Milk and Infant Absorption. PLoS Med 2016;13(9): e1002132. doi: 10.1371/journal.pmed.1002132.

Substance Use and Breastfeeding

  • Rowe H, Baker T, Hale T. Maternal Medication, Drug Use, and Breastfeeding. Pediatric Clinics of North America 2013; 60: 275-294.