We read with interest the updated policy statement “Breastfeeding and the Use of Human Milk” that was published recently in Pediatrics.1 It is an important, comprehensive, and timely publication. However, we were surprised at some recommendations that were made, which could detract from the overall perceived goals of the publication, namely establishment of early breastfeeding, which will lead to successful lactation throughout the first year of age. Specifically, regarding “Contraindications to Breastfeeding,” varicella and H1N1 influenza were both included. We believe that the authors’ assertion that “mothers who develop varicella 5 days before through 2 days after delivery should be separated from their infants” is inappropriate. These infants certainly are at high risk of having acquired varicella transplacentally and, if not, could become infected postnatally. Yet there are effective measures that can prevent or ameliorate serious illness without instituting such an extreme measure. These infants should receive a single intramuscular dose of varicella-zoster immune globulin (VZIG) that is available by an expanded access protocol. If VZIG is not available, immune globulin intravenous (IGIV) is an alternative with potential but unproven efficacy. While in the hospital, airborne and contact precautions are maintained for these infants and their mothers; they are cared for together and in a negatively ventilated room until no longer infectious or at risk for developing varicella to prevent nosocomial transmission. This approach promotes optimal breastfeeding and immunoprotection via colostrum and breast milk. Nowhere in the referenced Red Book is there a recommendation to separate the mother and infant.
Because of universal immunization, varicella in pregnancy and at delivery is now uncommon. Our hospital delivers about 12 000 infants annually, and in the past 7 years, we have cared for 2 infants who were exposed to maternal varicella in the at-risk time period. Each of these infants received VZIG, neither was separated from the mother, and both had excellent outcomes. One infant developed varicella that was likely acquired transplacentally, but his case was mild and attenuated, and he did well without requirement for hospitalization or treatment. Certainly antiviral treatment with acyclovir also has been shown to be efficacious in these circumstances.
With regard to H1N1 influenza, similarly, the recommendation from the Centers for Disease Control and Prevention to temporarily isolate infants from mothers with H1N1 influenza until they are afebrile is based on no evidence. We have also kept these mothers and infants in the same room and allowed breastfeeding, with close attention to hand hygiene and wearing of a face mask by mother. None of the 42 infants managed in this manner developed influenza in the first month of age (American Journal of Perinatology, in press).
Another concern is the recommendation to provide pasteurized donor human milk if mother’s own milk is unavailable or its use is contraindicated requires additional study to determine if the benefits of donor milk are the same as those achieved with maternal milk. The committee’s lack of addressing and endorsing this huge knowledge gap is disappointing, and appropriately designed, randomized trials are needed.
- 1.↵American Academy of Pediatrics SoB. Policy statement breastfeeding and the use of human milk. Pediatrics. 2012;129(3). Available at: www.pediatrics.org/cgi/content/full/129/3/e827
- Pickering LK BC,
- Kimberlin DW,
- Long SS
- Copyright © 2012 by the American Academy of Pediatrics