When Should One Discourage Breast-feeding

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300 PEDIATRICS Vol. 67 No. 2 February 1981

COMMENTARY

When

Should

One

Discourage

Breast-feeding

Breast-feeding has advantages in terms of psy-chosocial aspects, maternal considerations, and in-fant factors.’ Within these same broad areas, I

want to address circumstances in which

reserva-tions about breast-feeding should be considered.

In terms of infant conditions, galactosemia is clearly an absolute contraindication to

breast-feed-ing. Breast milk is a rich source of lactose, and the

very survival of infants with galactosemia is depen-dent on their receiving a non-lactose-containing formula. Of course, galactosemia is a rare disorder,

occurring in approximately 1:60,000 births.

Phenylketonuria is often mentioned as another contraindication to breast-feeding. Breast milk, however, has relatively low levels of phenylalanine; in fact, infants who are exclusively breast-fed may receive a phenylalanine intake near the amount reconunended for treating phenylketonuria.4 Total or partial nursing can therefore be encouraged through close monitoring of the infant’s phenylala-nine levels.

The premature infant in the newborn intensive

care unit constitutes one circumstance in which I do discourage breast-feeding in the sense of

dis-suading the mother from believing that she must

provide for the total nutritional needs ofher infant.

To expect the mother of an infant who is premature,

in,

and perhaps on a ventilator to easily provide sufficient breast milk through manual or mechani-cal expression is to set that woman up for additional feelings of inadequacy and guilt. There simply is no

substitute for the vigorous sucking of a healthy

infant to stimulate the secretion of breast milk. I

encourage women who want to nurse to practice

manual expression and breast massage often, so that when their baby is able to nurse at the breast, all systems will be primed. The emphasis is on the contribution of the mother’s efforts to the mother-infant relationship, not on any “life-saving” quail-ties of breast milk. Mothers who choose to provide breast milk primarily for the nutritional support of their infants are less successful in producing milks Even when a mother brings only a few milliliters of

breast milk to the newborn intensive care unit she should be reassured that even these drops are

mi-raculous in view of the stressful circumstances and

the fact that the baby is not yet at the breast to speed the milk along.

Several well-respected scientists in the field of lactation have, in the past, recommended that women with a personal or family history of breast cancer not nurse their infants. The basis for this

hair-raising recommendation was the discovery of

“virus-like particles” and RNA-dependent DNA po-lymerase activity in breast :ii6 The fear was that

these findings implied the presence of a

cancer-inducing virus in human milk, analogous to the

Bittner virus which causes a mammary carcinoma in certain strains of mice. The viral particles were reported to be present in a high proportion of women having a personal or family history of breast cancer. Only when a control group was examined was it learned that the suspicious particles were

present in an equal proportion of women without any cancer history!7 Moreover, the presence of re-verse transcriptase activity is now considered to be a normal feature of lactating breast tissue.6

There is abundant epidemiologic data as well to support the conclusion that there is no increased

incidence of breast cancer in female infants who are

breast-fed.’#{176}

Serious illnesses in the mother prompt concern

for two reasons. First, there are clearly times when the mother is too sick physically to breast-feed and should therefore be supported in her decision not to nurse. Second, even when the mother’s ifiness is not debilitating, she may harbor infections that pose a threat to her infant. Sputum-positive tuber-culosis in the mother is the most obvious example. For mothers who have hepatitis B during pregnancy and those who are asymptomatic carriers, the AAP Committee on Infectious Diseases has taken the following position:

Breast feeding should be avoided if artificial milk for-mulas and adequate refrigeration facilities are available.

However, breast-feeding is indicated for infants living in areas of the world where hepatitis, type B, infection is

highly endemic and artificial formulas and refrigeration

are not available.”

Controversies surrounding other maternal infec-tions (such as herpes viruses and group B

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COMMENTARY 301

coccus) are concisely reviewed in Ruth Lawrence’s

book, Breast Feeding: A Guide for the Medical

Profession

(CV Mosby, St Louis, 1980). According

to Dr. Jerome Klein (personal communication),

many of these issues wifi also be addressed in the

next edition of the Redbook to be published in 1981.

I have had the experience on several occasions of

attending on the newborn nursery when a woman

with a thought disorder delivered her baby and wanted to nurse. The staff-medical, nursing, and

social service-is thrown into a tizzy. Should the

baby be allowed out with the mother? Should the mother be allowed to nurse? One does not have to be an expert in constitutional law to appreciate the legal and ethical infringement on human rights that

these questions imply. From a medical viewpoint,

one can have serious concerns about the appearance in breast milk of certain psychoactive drugs, partic-ularly lithium. However, in terms of the

implica-tions for the mother-infant relationship and for the

psychiatric disorder, discouraging a woman from nursing makes little sense to me. Denying access to

the baby would impose a justifiable paranoia on

whatever underlying thought disorder exists.

If staff members are concerned about the safety of the infant, having at the bedside an unfrightened, genuinely supportive person who is knowledgeable about breast-feeding and child care can be recom-mended. In fact, this should well be part of the routine for every mother!

The subject of drugs and breast-feeding has been extensively and recently reviewed.’2”3 I think that the specter of potential drug toxicity is sometimes used as an excuse to discourage breast-feeding by physicians who are ambivalent about the extensive

advantages of nursing. It is axiomatic that any drug which can enter the maternal bloodstream can

en-ter breast milk. The issue is not whether a given drug appears in milk, but how much and with what consequences for the infant. That a drug has been reported to have caused nasal stuffiness or somnol-ence or diarrhea in an infant does not in itself justify recommending that a woman not nurse! Many med-ications that are prescribed may be in the best interests of neither the baby nor the mother. As

one example, I received a call from a nurse asking if it was harmful for a mother to breast-feed while she was receiving Valium. A prescription had been

written for 10 mg every four hours because of her

“anxiety.” An amiable discussion with her family doctor resulted in the Valium being discontinued

and a successful referral being made to a marriage counselor.

When a mother requires treatment, one can con-sider altering the dosage, changing the scheduling of doses, substituting an alternate drug, and closely monitoring the infant for adverse effects.

Closely related to the issue of drugs is the concern about environmental contaminants in breast milk centering on the halogenated organochemicals-dichlorodiphenyltrichloroethane (DDT),

polychlo-mated biphenyls (PCBs), polybrominated biphen-yls (PBBs), mirex, heptachlor, and so on. These fat-soluble pollutants are concentrated as one moves up the food chain. Cows are strict vegetarians. Humans, on the other hand, consume beef, poultry, and fish, among other things. When stored fat is mobilized during lactation, so too are the lipophiic

contaminants.

In their respective reviews of PCBs and PBBs, Miller’4 and Finberg’5 took a risk-benefit approach

to conclude that the virtues of breast-feeding out-weighed the “as-yet undocumented toxicity” in the great majority of exposed individuals in this coun-try. I suggest that we must also consider a risk-risk analysis, that is, weighing the potential adverse effects of contaminated breast milk against the risk of not breast-feeding babies. Clearly, the infant will not escape exposure to potentially hazardous

sub-stances by avoiding breast milk! For example, one

pollutant with known toxicity after chronic low-dose exposure is lead.’6 The infant is apt to receive much higher levels of lead from formulas prepared with lead-contaminated tap water than from breast milk.’7 Another contaminant ofsome water supplies in this country is asbestos. There appears to be an increased frequency of gastrointestinal cancer after occupational exposures to asbestos.’7 In his review of intentional food additives, Weis&8 notes that there are more than 2,700 such additives including stabilizers and emulsifiers such as glycerol esters

and propylene glycol; preservatives such as buty-lated hydroxytoluene; and buffers, colors, flavor-ings, bleaching agents, and more. There is no

re-quirement for the processors to ifie their formula-tions with the Food and Drug Administration nor is there any monitoring of actual intake and adverse effects.

Concern about potentially hazardous low-dose exposures from infant feeding places one between the devil and the deep blue sea. Unless a woman has received an unusually intense exposure to a

pollutant, such as occurred with PBBs on certain

farms in Michigan, the presence of environmental contaminants in breast milk is not a reason to discourage women from nursing.

Parental occupations are another source of haz-ardous breast milk exposures. There are more than a hundred occupations involving organic lead, for example.’9 That workers may receive dangerous exposures to PBBs is evidenced by a recent report of primary hypothyroidism in such workers.#{176} One breast-fed infant developed obstructive jaundice

and hepatomegaly after his mother was exposed to

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LAWRENCE R. BERGER, MD, MPH Department of Pediatrics

University of New Mexico Albuquerque

tetrachloroethylene, a dry-cleaning agent.2’

Te-trachloroethylene is considered to be a chemical of

low hepatoxicity in adults, again demonstrating that

the growing infant has unique vulnerabilities to

chemical exposures.

Discouraging breast-feeding means to me that

the physician informs a mother who wants to nurse

her baby that breast-feeding is not advisable. I can think of no social circumstance in which that would

be an appropriate posture for the physician to

as-sume. The single parent, the teenage mother, the

woman who is working-each can incorporate

nurs-ing into her life-style if she desires.

Successful nursing is not an all-or-none

phenom-enon. A woman can nurse by providing breast milk

via a gavage tube, by bottle, or at the breast, by

giving breast milk to her baby once a day or 12

times, by having the baby weaned at two months

or two years. I define a successful nursing

experi-ence as one which the mother views as positive, not

something defined in terms of an arbitrary duration,

frequency, or breast milk container.

Our role in deciding how an infant will be fed

should be to play our A-C-E-S: A-to provide

ac-curate information; C-to convey the message that

the parents are competent care-givers, that they are

the most important individuals to make decisions

about their baby; E-to explore the parents’

atti-tudes and knowledge regarding infant feeding

choices; and finally, S-to support the parents in

whatever decision they make.

Physicians also have a political role to play in the

area of breast-feeding. We must learn to take

ac-curate occupational histories from parents, to

sus-pect that hazardous environmental exposures in our

own communities may have implications for

breast-feeding, and to realize that we may be the first

physician to ask whether a particular drug will have

adverse effects via breast milk. Where stringent

regulations covering the disposal and monitoring of

environmental wastes are threatened, we must

speak out as advocates for children. We should

demand a restructuring of the research priorities

that produce reams of articles on methotrexate

kinetics, while we must rely on case reports from

the 1920s to learn anything about certain drugs in

breast milk. Finally, we should be urging adoption

of exposure standards for

all

workers that will

protect the most susceptible individuals, the fetus

and newborn.

302 PEDIATRICS Vol. 67 No. 2 February 1981

REFERENCES

1. Newton N, Newton M: Psychologic aspects of lactation. N

EnglJMed 277:1179, 1967

2. Jelliffe DB, Jelliffe EFD: “Breast is best”: Modern meanings.

N Engi J Med 297:912, 1977

3. Berger LR: Factors influencing breast feeding. JCE Pediatr, September 1978, pp 13-29

4. Binder J, Johnson CF, Saboe B, et al: Delayed elevation of serum phenylalanine level in a breast-fed infant. Pediatrics

63:334, 1979

5. Auerbach KG, Avery JL: Relactation: A study of 366 cases.

Pediatrics 65:236, 1980

6. Vorherr H: Pregnancy and lactation in relation to breast

cancer risk. Semin Perinat 3:299, 1979

7. Chopra H, Ebert F, Woodside N, et al: Electron microscopic

detection of Simion-type virus particles in human milk.

Nature 243:159, 1973

8. Thomas DB, Lillienfeld AM: Geographic, reproductive and sociobiological factors, in Stoll (ed): Risk Factors in Breast Cancer, Vol II. London, W Heinemann Medical Books, 1976, pp 25-53

9. Morgan RW, Vakil DV, Chipman ML: Breast feeding, family history, and breast disease. Am J Epidemiol 99:117, 1974 10. McMahon B, Cole P, Brown J: Etiology of human breast

cancer. J Nati Cancer Inst 50:21, 1973

1 1. Committee on Infectious Diseases: Report of the Committee on Infectious Diseases, ed 18. Evanston, IL, American Acad-emy of Pediatrics, 1977, pp 119-120

12. Anderson P0: Drugs and breast feeding. Semin Perinat 3: 271, 1979

13. Anderson P0: Drugs and breast feeding: A review. Drug

Intell 11:208, 1977

14. Miller RW: PCBs and cola-colored babies. J Pediatr 90:510,

1977

15. Finberg L: PBBs: The ladies’ milk is not for burning. J

Pediatr 90:51 1, 1977

16. Needleman HL, Gunnoe C, Leviton A, et al: Deficits in psychologic and classroom performance of children with

elevated dentine lead levels. N Engi J Med 300:689, 1979 17. Miller RW: Carcinogens in drinking water. Pediatrics 57:

462, 1976

18. Weiss B: Food additives. In: Pediatric Nutrition Handbook.

Evanston, IL, American Academy of Pediatrics, 1979, pp

454-464

19. Chisolm JJ: Fouling one’s own nest. Pediatrics 62:614, 1978 20. Bahn AK, Mills JH: Snyder PJ, et al: Hypothyroidism in

workers exposed to polybrominated biphenyls. N Engi J Med302:31, 1980

21. Bagnell PC, Ellenberger HA: Obstructive jaundice due to a chlorinated hydrocarbon in breast milk. Can Med Assoc J

117:1047, 1977

GENERAL REFERENCES

Rogan WJ, Bagniewska A, Damstra T: Pollutants in breast milk.

N Engi JMed 302:1450-1453, 1980

Berlin CM: The excretion of drugs and chemicals in human milk,

in Yaffe S (ed): Pediatric Pharmacology. New York, Grune

& Stratton, 1980

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1981;67;300

Pediatrics

Lawrence R. Berger