When should a mother not breast feed her baby?

There are very few conditions when a mother cannot breast feed. In special but rare cases, women may be advised not to breast feed at all or express the milk.

The benefits of breastfeeding cannot be emphasised. Breastfeeding, besides boosting the immunity of the baby, also enhances the bond between the mother and child. It also reduces the risk of breast and ovarian cancer as well as heart disease in mothers.

Despite these benefits, there are times when a mother has to weigh between the benefits of breastfeeding and the risk of transmitting disease to her newborn baby.

The case of HIV

*Akello* was diagnosed with HIV during her first trimester of her pregnancy. She had to start taking ARVs immediately to ensure that the virus is not transmitted to her unborn child. This enabled her to deliver an HIV free baby.  However, after delivery, the single mother could not afford her own food so she skipped taking her ARVs. She also could not afford formula milk so she continued breastfeeding her baby.

“It was so painful seeing my child starving and being a teenage mother, I did not know what to do. When I went back to the hospital, my child had contracted the virus. I feel so bad that such an innocent child is infected,” she sadly notes.

Being an HIV positive mother brings its own set of challenges and concerns. However, with the right information, support and guidance, you can still experience the joy and benefits of breastfeeding while safeguarding the health of your child.

Dr Daniel Muyanja, the director of clinical services at the Joint Clinical Research Centre (JCRC),  says HIV positive mothers can breastfeed and give their babies an equal feeding opportunity but there are factors that they should consider.

Although mother-to-child transmission of HIV is preventable through antiretroviral treatment during pregnancy and postpartum, the Centers for Disease Control and Prevention (CDC) remarks that there were more than 150,000 new infections in children (0 – 14 years) worldwide in 2020.

The United Nations Programme on HIV/AIDS (UNAIDS) 2021 Spectrum estimates indicate there were 5,500 new childhood HIV infections in Uganda due to mother-to-child transmission, with half of those infections occurring among infants born to mothers who stopped HIV treatment during pregnancy and breastfeeding.

According to the 2018–2023 Uganda National Elimination Plan II, mother-to-child transmission of HIV accounts for 18 percent of all new infections in Uganda and is the primary source of infections among children.

Dr Muyanja says, “There is a routine test known as the DNA PCR test done for HIV- exposed infants the age of six weeks to look out for HIV DNA for early infant diagnosis. The second test is usually done at nine months and if they both turn out to be negative, then the mother should stop breastfeeding at one year and wean off the child with other foods. This is done to reduce the risk of HIV transmission.”

The third test is usually done at six weeks after stopping breastfeeding and when the baby is 18 months, the baby is then ready for the first HIV antibody test. However, if the second test was positive, then the mother can continue breastfeeding until the baby is two years old.

According to Dr Andrew Kazibwe, the head of medical services at The Aids Support Organisation (TASO) Uganda, there are categories of mothers who cannot breastfeed and these should go for replacement feeding. This is an assessment that should be done by the health worker. The feeding should be affordable, feasible, sustainable and safe.

The replacement feeding involves buying formula milk, having as many bottles, making the right composition of the milk and keeping it at the right temperatures.

“If this type of feeding is going to be a burden to the mother, then she should breast feed but ensure that the baby gets a prevention therapy (prophylaxis) of ARVs and a septrin syrup. Also, the mother should have a viral load that is undetectable and ensure that she gets no sores on her breasts while she is breastfeeding,” Dr Kazibwe advises.

These would help in the reduction of the risk of transmission of the HIV virus to the new born baby in what is known as elimination of mother to child transmission of HIV/ Aids.

When and when not to breastfeed

There are very few conditions when a mother cannot breastfeed. During simple infections and ailments such as common colds, gastrointestinal infections among others, babies can be breastfed if proper precautions and hygiene measures are followed.

According to the CDC, all infants born to HBV-infected mothers should receive hepatitis B immune globulin (HBIG) and the first dose of hepatitis B vaccine within 12 hours of birth. The second dose of vaccine should be given at age 1–2 months, and the third dose at age 6 months.

The infant should be tested after completion of the vaccine series, at age nine to 12 months (generally at the next well-child visit), to determine if the vaccine worked and that the infant is not infected with hepatitis B virus through exposure to the mother’s blood during the birth process.

“However, there is no need to delay breastfeeding until the infant is fully immunised. The risk of HBV mother-to-child transmission through breastfeeding is negligible if infants born to HBV-positive mothers receive the HBIG/HBV vaccine at birth."

When is it risky?

According to the CDC, mothers with cancer who are taking cancer chemotherapy medications also cannot breastfeed their babies. Cancer chemotherapy drugs hamper cell division and rapidly growing cells. This may severely damage the growth of the baby if passed on via breast milk. Cancers as such are not a contraindication for breastfeeding.

Mothers who are undergoing radiation therapies especially of the chest are also not allowed to breastfeed until their therapy regimen is over.

Mothers with untreated and active tuberculosis infections are not advised to breastfeed. They may breastfeed after their infection is cured or brought under control so that it does not spread to the infant.

A mother who has HIV and is not on antiretroviral therapy (ART), or is on ART but has not achieved sustained viral suppression during pregnancy (at a minimum throughout the third trimester) or at the time of delivery, or is unable to maintain sustained viral suppression postpartum.

Neither breastfeed nor express

A mother should temporarily not breastfeed or express milk for their infants if she is infected with brucellosis, has suspected or confirmed Ebola virus disease, monkey pox, is undergoing diagnostic imaging with radiopharmaceuticals, has an active herpes simplex virus (HSV) infection with lesions present on the breast but the child can breastfeed directly from the unaffected breast.

Such a mother may be able to resume breastfeeding after consulting with a physician to determine when their breast milk is safe for their infant after getting their ailments treated. These mothers should be provided with lactation support to learn how to maintain milk production and feed their infants with pasteurized donor human milk, previously expressed breast milk (if appropriate), or formula, while temporarily not breastfeeding.

Can only express milk

Dr Muyanja says, “A mother who has untreated, active tuberculosis may not breastfeed but can express milk for her infant. The mother can receive the BCG vaccine to prevent the passing on of the disease. She can resume breastfeeding after two weeks of appropriate treatment and continue until she completes her treatment.”

Mothers with active chicken pox infection can express their milk but resume breastfeeding after consulting with a physician to determine when there is no longer a risk of spreading infection to the baby.

Mothers who express milk need lactation support to maintain milk production while not breastfeeding.

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