Breastfeeding

Medical conditions that could affect breastfeeding

Medication, medical conditions and breastfeeding
Some medications taken by the mother can pass into breastmilk, but for many women the benefits of taking certain medication outweigh the risks. Evidence indicates that the possible risks of medication used during breastfeeding are significantly lower than during pregnancy because a nursing baby receives a lower dose than the fetus during pregnancy (BMJ Clinical Review 2014).
 
There are, however, some situations where the potential risks of the medications or condition mean that it's safer and so not advisable to breastfeed for example women with HIV infection or those taking some cancer medications. The American Academy of Paediatrics suggests that radioactive compounds and anticancer drugs should be avoided during lactation (2013).
 
In the UK, the National Institute for Health and Care Excellence (NICE) Guidelines gives advice and information on particular medical conditions and breastfeeding. LactMed is another reliable source of information that is geared to the healthcare practitioner and nursing mother. It includes information on the levels of drugs and other chemicals in breastmilk and infant blood, and the possible adverse effects in the nursing infant.
 
All women who have a medical condition that requires medication, and are considering breastfeeding, are advised to speak to their midwife, obstetrician or consultant about their particular circumstances and concerns (NHS Choices 2015).
 
There are some medical conditions and treatments related to breastfeeding such as mastitis, poor infant attachment, nipple damage, and fungal infection. These breastfeeding difficulties are considered separately under the following headings: see The milk coming in, Sore nipples, Dealing with difficulties and When breastfeeding doesn’t work out. Below, we illustrate the experience of women who were unable to breastfeed due to two very different medical conditions: HIV and Raynaud’s.

HIV and breastfeeding
The World Health Organisation (WHO) guidelines on HIV and infant feeding recommends that HIV positive mothers with infants who are HIV negative (or whose status is unknown) should either avoid breastfeeding altogether, or breastfeed when on antiretroviral therapy (ART) to lower the risk of HIV transmission (2010). HIV positive mothers in resource rich countries like the UK are advised to abstain from breastfeeding and use formula feed instead.
 
We talked to Kate and Hana, two HIV positive women who did not breastfeed their children born after they were diagnosed with HIV. Both women knew that an HIV infected mother can pass the virus to an uninfected baby through breastmilk so they followed medical advice.
 
During their pregnancies both women were carefully monitored by their HIV specialist, obstetricians and their HIV clinic consultant. The use of antiretroviral therapy (ART) ensured that Hana and Kate’s children were born HIV uninfected and Hana was able to have her children by normal delivery. Kate was deeply disappointed when told she needed to have a C section. 
The impact that having a diagnosis of HIV had on their options regarding breastfeeding affected Hana and Kate differently. Hana’s two children were both born after she was diagnosed HIV positive, so at the time of both her pregnancies, she had been on ART therapy for some time. She felt that to avoid the transmission of the HIV virus to her children was more important than breastfeeding. So, abstaining from breastfeeding was not a problem for her. Kate on the other hand, found out she was HIV positive during the pregnancy with her second child, and went through her pregnancy in what she described as a ‘state of emotional shock’. She found it very difficult to accept the consultant’s advice to avoid breastfeeding. She complied but she felt utterly miserable.
But Kate’s attitude changed when she became pregnant with her third child. By then, she had accepted being HIV positive, and was more prepared to accept the limitations imposed by HIV on the experience of motherhood: the possibility of a C section and the used of baby formula instead of breastfeeding.
 
Both women appreciated the specialist medical care and the help they received from medical teams and HIV support workers during and after their pregnancies. Both found HIV support workers were an important source of support and information. Hana commented that during her pregnancies, she had come to rely a lot on her obstetrician consultant, in whom she had absolute trust. 
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In close-knit communities, people become suspicious that a woman is HIV positive if she becomes a mother, but doesn't breastfeed. Hana and Kate felt under the scrutiny of others; friends and even family members who wanted to know why they were not breastfeeding.
Raynaud’s phenomenon of the nipple
Raynaud’s is a condition that affects the blood vessels primarily in the fingers and toes. Raynaud’s is characterised by episodic attacks called vasospastic attacks that cause the blood vessels to constrict. Vasospasm can also occur in the nipples of lactating mothers. When a vasospastic attack occurs in the nipples, the nipple goes white or blue and is painful. Nipple vasospasm pain can range from minor discomfort to severe pain and so may or may not affect breastfeeding. Known triggers for vasospasm attacks include poor attachment, nipple damage (e.g. cracked nipple) or an infection (e.g. nipple thrush); and exposing the nipples to cold air (see notes 2,3,4,5).

In the UK, it is estimated that Raynaud’s phenomenon affects as many as 10 million people (NHS Choices 2015). Most people tend to develop this condition before the age of 25 and women are more likely than men to be affected by the condition – and so it commonly affects women of childbearing age.
 
We talked with Jessy who has recently discovered that she was affected by Raynaud’s disease. She was only able to breastfeed both her children for a short period because of severe pain that she described as ‘burning and throbbing’ and damaged nipples. Jessy was able to breastfeed her first child for ten days, and her second child for fifteen days.
At the time her first child was born, Jessy’s command of English was poor and she was unsure whether she had understood all the information given to her about breastfeeding. She also experienced different attitudes regarding support and understanding from health professionals. She felt hassled to continue breastfeeding despite the agonising pain.
When Jessy became pregnant with her second child, she felt better prepared: her understanding of English was greatly improved and she attended workshops, watched videos and read lots of information in preparation for breastfeeding.  But her second experience was much the same as her first. She had mastitis and experienced severe pain every time she nursed her baby. She persisted for two weeks but the pain caused her to wean the baby earlier than she would have chosen. This time, she did not seek support from health professionals.
The experience of painful breastfeeding seems to affect women in Jessy’s family - her mother was unable to breastfeed and her sister has managed, but with the use of nipple shields and painkiller injections. But despite her family history, she felt sad and experienced a deep sense of ‘being a failure’.
 
Jessy believes that health professionals should make expectant mothers aware that in some cases breastfeeding is not possible.  
She said that neither midwives or health visitors; nor the workshops she attended and all the information she read, mentioned vasospasm of the nipple as a possible cause of painful breastfeeding. Jessy said that such knowledge would have meant appropriate diagnosis, treatment, relief from pain and perhaps a more successful and fulfilled breastfeeding experience.
 
In severe cases of nipple pain, health professionals can prescribe calcium channel blockers (Nifedipine). (See notes 3 4 5)

Notes
1. Committee on Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Hale TW, Pediatrics 2013,132:e796-809
2. Managing common breastfeeding problems in the community. Lisa H Amir. BMJ 2014;g2954 doi:10.1136/bmj.g2954 (Published 12 May 2014)
3. Guidelines on HIV and infant feeding 2010 Principles and recommendations for infant feeding in the context of HIV and a summary of evidence
4. The Royal Hospital Women’s Hospital Fact Sheet
5. Raynaud’s Phenomenon of the Nipple: A treatable cause of painful breastfeeding Jane E. Anderson et, al. Pediatrics 2004;113;e360
6. Vasospasm of the nipple - a manifestation of Raynaud’s phenomenon. Lawlor-Smith L et, al. British Medical Journal 1997, 314:644-45

Topic added: September 2015

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