When Shouldn't You Breastfeed?

Are you wondering whether you should start or continue breastfeeding because you are on medication, have an infection, are undergoing x-rays or some other reason? The fact is that for the vast majority of these situations you can and should continue to breastfeed your baby.

Of course, there are certain situations where it is best to discontinue breastfeeding. The American Academy of Pediatrics has listed the few situations where suspending breastfeeding is necessary in their policy statement "Breastfeeding and the Use of Human Milk".

The few situations noted by the AAP include when the infant has galactosemia, the mother uses illegal drugs and the mother has untreated active tuberculosis. Most prescribed and over-the-counter medications are safe for the breastfed infant. Use of a few strong medicines such as radioactive isotopes, antimetabolites, cancer chemotherapy and agents and a few others may require the mother to interrupt breastfeeding temporarily. A number of books and tables describe which drugs are safe and which are not are available, including "the transfer of drugs and other chemicals into human milk", in Pediatrics 1994, by the AAP Committee on Drugs.

The AAP recommends suspending breastfeeding for women in the United States who are infected with HIV. However, they state that for many other countries that are at increased risk for infectious diseases and nutritional deficiencies, the great benefits of breastfeeding may outweigh the risk of the infant acquiring HIV. This statement gives us an indication of how strongly the AAP supports the benefits of breastfeeding.

Following is an excellent article on when you should and shouldn't breastfeed by one of the worlds experts on breastfeeding, Dr. Jack Newman, MD, FRCPC.

You Can Still Breastfeed
By Jack Newman, MD, FRCPC

Introduction
Over the years, many, many, many women have been wrongly told to stop breastfeeding. The decision about continuing breastfeeding when the mother must take a drug, for example, involves more than consideration of whether the medication appears in the mother's milk. It also involves taking into consideration the risks of formula feeding for the baby, which are substantial, the risks of not breastfeeding for the mother, which are substantial, and other issues as well. For example, feeding a breastfeeding baby by bottle for the time the mother is on medication (rarely less than 5 days), will very often result in the baby refusing the breast forever or at least becoming very difficult on the breast. On the other hand, it should be taken into consideration that some babies just will not take bottles, so the advice to stop is not only usually wrong, but impractical as well. Furthermore, it is easy to advise the mother to pump her milk when she is not feeding the baby, but adequate pumping is often very difficult to do for some mothers, with the result that the mothers may become very painfully engorged, which may further lead to serious complications.

Breastfeeding and Maternal Medication
Most drugs appear in the milk, but only in very tiny amounts. Although a very few drugs may still cause problems for infants even in tiny doses, this is not the case for the vast majority. Mothers who are told they must stop breastfeeding because of a certain drug should ask to be prescribed an alternative medication which is acceptable for breastfeeding mothers. In this day and age, it is rarely a problem to find such an alternative. If the prescribing physician does not know how to proceed, s/he should get more information. If the prescribing physician is not flexible, the mother should seek another opinion.

Most drugs may be considered safe for the mother to take and continue breastfeeding if:

they are commonly prescribed for infants. Examples are amoxycillin, cloxacillin, most antibiotics.

they are considered safe in pregnancy. Drugs enter directly into the baby's bloodstream when used during pregnancy. The baby generally gets much higher doses at a much more sensitive period during pregnancy, than during breastfeeding. This is not an absolute, however, as during pregnancy, the mother's liver and kidneys will get rid of the drug for the baby.

they are not absorbed from the stomach or intestines. These include many drugs which are given by injection. Examples are gentamicin, heparin, lidocaine or other local anaesthetics used by dentists.

The following frequently used drugs are also generally safe during breastfeeding:

acetaminophen (Tylenol, Tempra), alcohol (in reasonable amounts), aspirin (in usual doses, for short periods), most antiepileptic medications, most antihypertensive medications, tetracycline, codeine, most nonsteroidal antiinflammatory medications, prednisone, thyroxine, propylthiouracil (PTU), warfarin, tricyclic antidepressant medications, sertraline (Zoloft), paroxetine (Paxil), other antidepressants, metronidazole (Flagyl), Nix, Kwellada.
Medications applied to the skin, inhaled or applied to the eyes or nose are almost always safe for breastfeeding.
You can still breastfeeding after general, regional or local anaesthesia. As soon as you are up to it. Medications you might take afterwards for pain are almost always permitted.
Immunizations given to the mother do not require her to stop breastfeeding (including with live viruses such as german measles, Hepatitis A and B).

Get reliable information before stopping breastfeeding. Once you have stopped it may be very difficult to restart, especially if the baby is very young.

Breastfeeding and Maternal Illness
Very few maternal illnesses require the mother to stop breastfeeding. This is particularly true of infections. Most infections are caused by viruses. Most infections caused by viruses are most infectious before the mother realizes she is sick. By the time the mother has fever (or cold, runny nose, diarrhea, vomiting, rash etc), she has already passed on the infection to the baby. However, breastfeeding protects the baby against infection, and the mother should thus continue breastfeeding, in order to protect the baby. If the baby does get sick, he usually is less sick than if breastfeeding had stopped. But often mothers are pleasantly surprised that their babies do not get sick at all. The baby was protected by his mother's continuing breastfeeding.

The only exception to the above is HIV infection in the mother. Until we have more information, it is considered safer for the baby that the mother who is HIV positive not breastfeed, at least where the risks of bottle feeding are acceptable. There are situations, however, even in Canada, where the risk of not breastfeeding is elevated enough that the mother who is HIV positive should nevertheless breastfeed her baby. The final word is not in, however.

Most other maternal illnesses raise questions because of the drugs the mother might have to take. These should rarely be a problem (see above).

X-rays and scans: Ordinary X-rays do not require a mother to stop breastfeeding even when used with contrast (e.g. IVP). A CT scan, MRI scan, even when used with contrast do not require a mother to stop. A radioactive scan (e.g. lung scan, bone scan) does not require a mother to stop. The only exception is a thyroid scan. However, most of the time the scan does not have to be done. See below.

A not uncommon problem in the early months after delivery is a condition called postpartum thyroiditis, a temporary derangement in the thyroid gland's function. A useful test to help understand the condition is a thyroid scan. However, the test requires that radioactive iodine be given to the mother and this material must not be given to nursing mothers. The radioactive iodine will be found in the milk for weeks, and concentrated in the baby's thyroid. There are ways of dealing with postpartum thyroiditis without doing this test. The drugs a mother might have to take to treat postpartum thyroiditis are compatible with continued breastfeeding (e.g. propranolol, propylthiouracil)

Breast Problems
Mastitis (breast infection) and breast abscess are not reasons to stop breastfeeding. Although surgery on a lactating breast is more difficult, the surgery does not necessarily become easier if the mother stops breastfeeding, as milk continues to be formed for weeks after stopping breastfeeding.

Mammograms are more difficult to read if the mother is breastfeeding, but can still be useful. Once again, how long must a mother wait for her breast no longer to be considered lactating? Evaluation of a lump can be done by other means besides mammography. Discuss options with your doctor. Let him/her know breastfeeding is important to you. A needle biopsy, for example, can be done of a lump which is of concern.

New Pregnancy
There is no reason that you cannot continue breastfeeding if you become pregnant. There is no evidence that this does any harm to you, to the baby in your womb or to the one who is nursing. If you wish to stop breastfeeding, take your time and wean slowly.

Infant Problems
Breastfeeding rarely needs to be discontinued for infant illness. Through breastfeeding, the mother is able to comfort the sick child, and, at the same time, the child is able to comfort the mother.

Diarrhea and vomiting. Intestinal infections are rare in exclusively breastfed babies. (Though loose bowel movements are very common in exclusively breastfed babies). The best treatment for this condition if the baby gets it, is to continue breastfeeding. The baby will get better more quickly on breastmilk. The baby will do well with only breastmilk in the vast majority of situations, and will not require added fluids except in extraordinary cases.

Respiratory illnesses. There is a medical myth that milk should not be given to children with respiratory infections. Whether this is true or not for milk, it is definitely not true for breastmilk (and breastfeeding).

Jaundice. Exclusively breastfed babies are commonly jaundiced, even until the 3rd month, though generally the yellow colour of the skin is hardly noticeable. Rather than being a problem, this is normal. (There are causes of jaundice which are not normal, but these do not require stopping breastfeeding). If breastfeeding is going well, jaundice does not require the baby to stop breastfeeding. If breastfeeding is not going well, fixing the breastfeeding will improve the jaundice, whereas stopping breastfeeding even for a short time may completely destroy the breastfeeding. Stopping breastfeeding is not the answer. (See handout #7 Breastfeeding and Jaundice).

If the question you have is not discussed above, do not assume that you must stop breastfeeding. Do not stop, and get more information. Mothers have been told they must stop breastfeeding for reasons too inane to discuss.

This article may be copied and distributed without further permission

Handout #9. You Can Still Breastfeed. Revised January 1998

About the Author

JACK NEWMAN graduated from the University of Toronto medical school as a pediatrician in 1970. He started the first hospital-based breastfeeding clinic in Canada in 1984 at Toronto's Hospital for Sick Children. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa, and has published articles on the subject of breastfeeding in Scientific American and several medical journals. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa.