A 33-year-old woman, gravida 2 para 2, is evaluated 5 days after an emergency cesarean delivery that was performed for fetal distress. Her postoperative course has been complicated by endometritis that is currently being treated with intravenous gentamicin and clindamycin. The patient received no prenatal care during this pregnancy and came to the hospital in active labor. She would like to breastfeed but had difficulty breastfeeding her first child and switched to formula at 6 weeks postpartum, after she developed lactational mastitis. The patient uses cocaine several times a week. Temperature is 36.7 C (98 F) and blood pressure is 110/60 mm Hg. Admission laboratory results are as follows:
| Urine drug screen | cocaine |
| Hepatitis B surface antigen | positive |
| Hepatitis B core antibody, IgM | negative |
| Hepatitis B core antibody, IgG | positive |
| Hepatitis B surface antibody | negative |
| Hepatitis B virus DNA | undetectable |
| Hepatitis C virus antibody | positive |
After delivery, the infant received both hepatitis B immunoglobulin and the hepatitis B vaccination. Which of the following is a contraindication to breastfeeding in this patient?
Breastfeeding contraindications | |
Maternal |
|
Infant |
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*In developed countries where formula is readily available. | |
Breast milk is recommended as the exclusive source of nutrition for infants age <6 months due to infant and maternal health benefits. Compared with formula feeding, infant benefits include improved nutrition, gastrointestinal function, host defense, and psychological well-being. Maternal benefits include accelerated recovery from pregnancy, weight loss, prolonged postpartum anovulation, and decreased risk of breast and ovarian cancer.
Despite its advantages, breastfeeding is contraindicated in certain maternal and infant conditions. Maternal contraindications to breastfeeding include active untreated tuberculosis, varicella infection, herpetic breast lesions, current chemotherapy, and active substance use (eg, cocaine, phencyclidine). Cocaine passes into breast milk and may cause infant intoxication and withdrawal symptoms (eg, irritability, tremors). In addition, cocaine may cause long-term neurobehavioral problems (eg, hyperactivity, cognitive delay).
Galactosemia, caused by impaired infant galactose metabolism, is the only absolute contraindication to breastfeeding that is neonatal in origin. Infants with other inborn errors of metabolism may breastfeed intermittently but require close monitoring of metabolite levels.
(Choices B and C) Although hepatitis C viral RNA is detectable in maternal colostrum, transmission of hepatitis C via breast milk has not been documented. Infants of mothers with hepatitis B can safely breastfeed if administration of the hepatitis B immunoglobulin and initiation of the hepatitis B vaccination series has occurred. It is recommended that mothers with hepatitis B and C breastfeed. However, they should abstain from breastfeeding if their nipples are cracked or bleeding.
(Choice D) Neither a history of mastitis nor active mastitis is a contraindication to breastfeeding. Women with mastitis who are in too much discomfort to breastfeed can either pump or manually express their breast milk.
(Choice E) Gentamicin is poorly distributed into breast milk and is safe during lactation. Clindamycin is excreted into breast milk but is not associated with adverse neonatal effects; therefore, it is not contraindicated.
Educational objective:
Breastfeeding is the recommended source of nutrition for infants age <6 months. However, there are contraindications to breastfeeding that include active untreated tuberculosis, varicella infection, herpetic breast lesions, current chemotherapy, and active substance use (eg, cocaine, phencyclidine).