Contraindications to breastfeeding

When should I not breastfeed?

There are a few situations in which a mother should not breastfeed or give her baby expressed milk. These include receiving chemotherapy for cancer, radioactive iodine for a thyroid problem, or infection with Ebola viruses. Mothers may also need to wean because of alcohol and substance use disorders. Recommendations can vary for HIV and HTLV infections depending on where mothers live. Some conditions may require only a temporary stop: herpes simplex, chicken pox, breast abscesses, tuberculosis, brucellosis, and botulism. In some cases, the baby’s health may make breastfeeding impossible. Babies with classic galactosemia, for example, cannot tolerate breast milk. 

A) Breastfeeding is nearly always safe for the baby

There are only a few situations in which a mother should not breastfeed or give her expressed breast milk to her baby (AAP 2012).

Most mothers and babies who are sick should continue breastfeeding. 

There are only a few maternal medications that are not compatible (pose little or no risk to the baby) with breastfeeding.

Please talk with your health-care providers or breastfeeding specialists if you have any concerns or possible reasons not to breastfeed. 

B) Maternal issues that may require permanently stopping breastfeeding

Breastfeeding by mothers in the following situations can affect the baby and may require permanent weaning.

1) Chemotherapy

Mothers who need chemotherapy for cancer treatment face many barriers to breastfeeding and many challenges to re-establishing their health.

There is limited information about breastfeeding and chemotherapy (Anderson 2016; Pistilli 2013). Mothers receiving chemotherapy are generally advised not to breastfeed as chemotherapy drugs are toxic and may be present in significant levels in breast milk. 

Mothers may wish to breastfeed after receiving chemotherapy or between chemotherapy cycles. They would have to express and throw out the milk while receiving chemotherapy.

Before resuming breastfeeding, mothers need to consider how long each medication remains in their milk. Mothers should be extremely cautious and discuss the risk of each medication with their health care providers.

Resuming breastfeeding after chemotherapy can be difficult. Expressing for long periods can result in a reduced milk supply. Mothers may have additional reasons for a low milk supply including:

A baby may not want to resume breastfeeding after a long period of receiving replacement feeds or if the milk supply is low.

2) Radioactive iodine

Radioactive agents are used to diagnose or treat illnesses. Mothers may need to temporarily or permanently stop breastfeeding as these agents can be dangerous for the baby.

Mothers should not breastfeed after receiving sodium iodide 131 as it is radioactive and can hurt the baby. It is recommended than milk production stops one month beforehand to minimize the amount of radioactivity that gets into the breast and avoid the risk of contaminating clothing through leaking (NIH).

A mother treated with radioactive iodine needs to avoid close contact with her baby for up to one month after treatment, because the radioactivity in her body can be dangerous for the baby.

3) HIV- or HTLV-positive mothers

Recommendations on breastfeeding for HIV- and HTLV-positive mothers vary by region and country. The recommendations are based on the relative risks of babies getting these infections through breastfeeding and the health consequences of this and the risk of malnutrition, illness, and death posed by infant formula and other breast milk substitutes.

4) Ebola virus

Mothers who are ill with Ebola virus should not breastfeed and need to be separated from their babies until they are well. If a mother wishes to resume breastfeeding after she is well, her milk should be tested to see if it is safe (WHO 2020). Evidence of the Ebola virus in breast milk has been found up to one month after the mother became sick (Nordenstedt 2016).

If a breastfeeding mother and her baby are both diagnosed with Ebola virus infections, if the baby is under six months of age and does not have access to appropriate breast milk substitutes or cannot be properly cared for, breastfeeding can be considered (WHO 2020).

5) Severe softening of the mother’s bones

Breastfeeding can cause bone loss; this can be minimized by regular resistance and weight-bearing exercise.

A few mothers suffer broken bones when pregnant, breastfeeding, or expressing because they have lost too much calcium during pregnancy (Yun 2017). This corrects itself after the breasts stop making milk.

Various medications have been used to treat this (Kovacs 2015). Depending on the severity of their condition, some mothers are advised to wean (Ijuin 2017; Jia 2020).

6) Substance use disorders

Mothers who are dealing with a substance use disorder or regularly using alcohol may need to stop breastfeeding.

7) Allergic reaction to breastfeeding

An extremely small number of mothers will develop a life-threatening allergic reaction to breastfeeding (lactation anaphylaxis) within days and weeks after delivery. If this cannot be controlled with medication, mothers may need to wean (Pescatore 2019).

C) Maternal issues that may require temporarily stopping breastfeeding

1) Herpes simplex

The herpes simplex virus can cause blisters; the liquid in the blisters contains the virus. Babies can become infected by contact with the blisters when they breastfeed on an infected nipple and areola.

Newborns and young babies who develop herpes infections (neonatal herpes) can suffer major effects and even death. This is most common in the first month after delivery.

If a mother has active herpes simplex blisters on her nipples and areolas and is breastfeeding a baby under six months of age, she should not breastfeed until the blisters have opened and dried up. This is usually within 10 days. While the milk is safe, expressing will likely allow the virus to contaminate it. Mothers need to express and throw out the milk until the baby can resume breastfeeding.

2) Herpes zoster (chicken pox and shingles)

Herpes zoster is the virus that causes chicken pox. Mothers who develop a chicken pox infection between five days before and two days after birth of the baby should be separated from their babies. Expressed milk can be given to the baby. If it develops before or after that time, mothers should continue to breastfeed.

After a person recovers from chicken pox, the virus can stay asleep in nerves. Occasionally, it is re-activated and comes out of a nerve, creating a line of blisters and pain along the path of the nerve, around one side of the face or body. This is called shingles. The blisters of both chicken pox and shingles contain Herpes zoster virus particles.

The blisters of shingles should not be in direct contact with the baby. The risk to the baby is reduced if the baby has been vaccinated against chicken pox. Contact is safe once the blisters have opened and dried.

3) Hepatitis B and C and bleeding nipples

There is a low risk of a mother transmitting hepatitis B to her baby if the baby is immunized within 12 hours after birth (CDC 2015).

Hepatitis C is not transmitted through breastfeeding but may be transmitted through blood.

Some authorities recommend that a mother who has bleeding nipple damage and hepatitis B or C infection should avoid breastfeeding and express and throw out her milk until her nipples have stopped bleeding but there is not enough research to make this a firm recommendation (CDC 2018; CPS 2008; Cottrell 2013).

4) Breast abscesses

Babies should not breastfeed if they are in direct contact with pus or infected tissue from a breast abscess.

5) Tuberculosis

The tuberculosis bacterium is spread through droplets in the breath. If a mother has infectious tuberculosis, she needs to avoid being with her baby until testing shows she is no longer contagious, usually two weeks after starting medication. The baby can drink her expressed milk.

Tuberculosis rarely infects the breast. Breastfeeding from a breast infected with tuberculosis should be delayed until treatment has killed all the bacteria.

6) Brucellosis

Brucellosis is an infectious disease caused by bacteria. Various animals, including sheep, cows, goats, pigs, elk, moose, wild hogs, and dogs, may be infected with brucellosis. Humans become infected when they eat undercooked meat or unpasteurized or raw dairy products, breathe in the bacteria, or the bacteria is in contact with wounds or wet surfaces of the body.

Brucellosis can cause a range of problems including:

  • Fevers
  • Joint infections
  • Swelling of the heart, liver, or spleen
  • Nervous system problems

Mothers with untreated brucellosis should not breastfeed, since the bacteria can be transmitted to the baby. Breastfeeding can resume after treatment (Arroyo Carrera 2006; Dadar 2021).

7) Botulism

Botulism is a rare and possibly deadly disease caused by a toxin released by the bacterium Clostridium botulinum. As babies have a weakened immune system, they are more likely to become infected than older children. These bacteria can be found in honey and is why it should not be given to babies under one year of age.

A mother with botulism should not breastfeed or feed breast milk to her baby until she is well as the toxin may be transferred through breast milk.

8) Mothers who have acute poisoning with chemicals or metals

Breast milk has been found to contain environmental contaminants such as persistent organic pollutants, pesticides, dioxins, and heavy metals. However, the levels are generally low and the benefits of breastfeeding for mother and baby nearly always outweigh the risks.

Mothers with acute poisoning from chemicals such as lead, may need to temporarily express and throw out their milk until they are treated and the source of the chemical is identified.

D) Issues of the baby that may require stopping breastfeeding

Some mothers need to permanently or temporarily stop breastfeeding or providing expressed milk because of their baby’s health problems.

1) Permanent weaning

Babies with certain types of genetic diseases (including galactosemia, phenylketonuria, congenital lactase deficiency) may not be able to fully or partially breastfeed. It depends on the illness and its severity.

Babies who have a confirmed and significant allergy to cow’s milk or other protein in breast milk may not be able to continue breastfeeding or receiving breast milk if the allergic item cannot be removed from the mother’s diet because it cannot be identified or if the mother cannot make the necessary changes.

2) Temporary weaning

Babies who may need to temporarily stop breastfeeding or receiving breast milk include those who are:

  • Severely allergic to food-related items in their mother’s milk until it can be identified and removed.
  • Critically ill and cannot tolerate feeds by mouth.
  • Awaiting surgery that will begin within four hours and require general anesthesia.
  • Have a temporary loss of the enzyme lactase because of severe illness.

Some babies may get an upset tummy if they take in significant amounts of blood. This may happen if the mother has bloody colostrum or significant nipple damage.

If this happens, the red blood cells can be removed. Alternatively, the colostrum or milk can be frozen for later use.

References

Anderson PO. Cancer Chemotherapy. Breastfeed Med. 2016 May;11:164-5
 
American Academy of Pediatrics (AAP), Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129(3)
 
Arroyo Carrera I, López Rodríguez MJ, Sapiña AM, et al. Probable transmission of brucellosis by breast milk. J Trop Pediatr. 2006 Oct;52(5):380-1
 
Centers for Disease Control and Prevention (CDC). Hepatitis B or C Infections. Atlanta: Centers for Disease Control and Prevention; 2018 Jan 24 [cited 2020 Jan 11].
 
Cottrell EB, Chou R, Wasson N, et al. Reducing risk for mother-to-infant transmission of hepatitis C virus: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158(2):109-13  

Dadar M, Shahali Y, Alamian S. Isolation of Brucella melitensis biovar 1 from human milk confirms breastfeeding as a possible route for infant infection. Microb Pathog. 2021 May 21:104958
 
Ijuin A, Yoshikata H, Asano R, et al. Teriparatide and denosumab treatment for pregnancy and lactation-associated osteoporosis with multiple vertebral fractures: A case study. Taiwan J Obstet Gynecol. 2017 Dec;56(6):863-866
 
Infectious Diseases And Immunization Committee, Canadian Paediatric Society (CPS). Vertical transmission of the hepatitis C virus: Current knowledge and issues. Paediatr Child Health. 2008 Jul;13(6):529-41

Johnson HM, Mitchell KB. Breastfeeding and Breast Cancer: Managing Lactation in Survivors and Women with a New Diagnosis. Ann Surg Oncol. 2019 Oct;26(10):3032-3039

Kovacs CS, Ralston SH. Presentation and management of osteoporosis presenting in association with pregnancy or lactation. Osteoporos Int. 2015 Sep;26(9):2223-41
 
Nordenstedt H, Bah EI, de la Vega MA, et al. Ebola Virus in Breast Milk in an Ebola Virus-Positive Mother with Twin Babies, Guinea, 2015. Emerg Infect Dis. 2016 Apr;22(4):759-60

Pescatore R, Mekkaoui S, Duffell B, et al. A Case of Lactation Anaphylaxis. Cureus. 2019 Aug 27;11(8):e5497

Pistilli B, Bellettini G, Giovannetti E, et al. Chemotherapy, targeted agents, antiemetics and growth-factors in human milk: how should we counsel cancer patients about breastfeeding? Cancer Treat Rev. 2013 May;39(3):207-11
 
United States National Institute of Health (NIH). National Library of Medicine, Toxnet, Drugs and Lactation Database (LactMed) [Internet]. Bethesda: U.S. National Library of Medicine; [date unknown] [cited 2018 Oct 10]

World Health Organization (WHO). Guidelines for the management of pregnant and breastfeeding women in the context of Ebola virus disease. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO
 
Yun KY, Han SE, Kim SC, et al. Pregnancy-related osteoporosis and spinal fractures. Obstetrics & Gynecology Science. 2017;60(1):133-137