By Kathleen Marinelli, MD, IBCLC, FABM
ILCA Board of Directors Director of Professional Development
As the global community comes to grips with the Ebola epidemic, most of the press and information available pertains to surveillance, recommendations for quarantine, containing the geographic spread, determining risk of exposure, protection of health care workers, and support and treatment of those diagnosed with the deadly virus. Of particular concern to those in the maternal-child health, nutrition, and lactation fields is the effect of potential exposure and proven infection with the Ebola virus on pregnant and lactating women and their infants.
Compounding the difficulty with finding this information is the simple fact that we don’t really know the answers at the level of evidence-based medicine. This is our first experience with an Ebola epidemic of this proportion. Decisions are being made to direct clinical practice by authorities like the Centers for Disease Control and Prevention (CDC) and UNICEF and the World Health Organization (WHO) based on our knowledge of how other viruses act, anecdotal stories from the field, and an occasional clinical report. While we all want the answers yesterday, authorities are doing their best to guide practice to save lives, while not panicking health authorities into making decisions that will cause more harm than good.
The CDC has recently issued guidelines for field and partner organizations regarding how to advise breastfeeding women with likely or confirmed Ebola infection (1), as has the Emergency Nutrition Network (ENN) in collaboration with UNICEF/WHO/CDC/ENN, which has significantly more detail. (2)
Important points are:
- Pregnant women have a much higher mortality rate with Ebola than non-pregnant women. At this time, there have not been any reported cases of a pregnant woman infected with Ebola virus surviving.
- Data from the field are spotty. WHO, CDC, ENN and other agencies are trying to aid in improving data capture so that we can better understand the history of Ebola in different types of patients and thus make informed determinations such as related to breastfeeding.
- Ebola virus has been found in human milk (1 sample). (3) In earlier outbreaks, no infants born to infected women and/or who were breastfed have survived. Presence does not equal infectivity, but at this point we do not know in the case of Ebola.
- Virus remains in some bodily fluids, like semen and human milk, after the blood has cleared. For lactating mothers who recover from Ebola, and are able to maintain or resume lactation (another issue to be considered and dealt with due to the illness severity), it is not known when it is safe to resume breastfeeding. Recommendations are to have the milk tested every 2-3 days in a laboratory that tests blood. For many women this is not feasible related to where they live. The recommendation then being made is to refrain from breastfeeding for 8 weeks, although not based on any evidence.
- For detailed instructions on feeding, please refer to reference 2. Essentially, when safe alternatives to breastfeeding and infant care exist, mothers with probable or confirmed Ebola virus disease should not have close contact with their infant, which includes breastfeeding.
- If mother must stop breastfeeding, the mother must be helped to express her breastmilk to alleviate pain and prevent inflammation. The expressed milk must be treated as an infected bodily fluid and discarded as such. There are some suggestions to heat treat (pasteurize) the expressed milk for the baby, but equipment and thermometers to make sure the milk is heated to the proper temperature for the correct amount of time to destroy virus and preserve nutrients and immune factors are not readily available. Most mothers become rapidly so sick that expressing milk becomes very difficult.
- In resource-limited settings, non-breastfed infants are at increased risk of death from starvation and other infectious diseases. These risks must be carefully weighed against the risk of Ebola virus disease when deciding to breastfed or feed a substitute.(2)
- Wet nursing is very common in West Africa. However do not allow wet-nursing to avoid any possibility of infection of the infant by the wet nurse, or of the wet nurse by the infant.
- If both mom and child have confirmed Ebola, if mom is able, breastfeeding should continue. If mom becomes too ill, a safe alternative should be used.
- Orphans should be fed with a safe alternative.
ILCA recommends following the guidance for feeding of infants and young children given in these documents and continuing checking for updates to the CDC (1) and the ENN (2) papers as more information becomes available.
- http://www.cdc.gov/vhf/ebola/hcp/recommendations-breastfeeding-infant-feeding-ebola.html (accessed 11/5/2014)
- http://www.ennonline.net/infantfeedinginthecontextofebola2014 (accessed 11/5/2014)
- http://jid.oxfordjournals.org/content/196/Supplement_2/S142.full.pdf (accessed 11/5/2014)
Kathleen Marinelli has been a neonatologist for over 25 years, an IBCLC since 2000 and is a Fellow of the Academy of Breastfeeding Medicine (FABM). Although unable to practice clinical neonatology for over a decade due to a significant water-skiing accident, she has continued her life-long commitment to improving breastfeeding, the use of human milk, and the use of donor milk, everywhere but especially in the NICU through all of her volunteer roles, research, teaching both here in the US and abroad, and publishing papers, monographs and chapters.
She is an Associate Professor of Pediatrics at the University of CT Medical School, and a member of the Human Milk Research Center at CT Children’s Medical Center, in Hartford, CT. She graduated from Cornell University & Cornell University School of Medicine; and was a pediatric intern, resident, nephrology and neonatology fellow at Children’s National Medical Center, George Washington University, Washington DC. Additionally, she is founding Medical Director of the New England Mother’s Milk Bank and is currently co-Medical Director of the Mothers’ Milk Bank of the Western Great Lakes. She is a founding and current member of the Connecticut Breastfeeding Coalition, has been on the Board of the Academy of Breastfeeding Medicine for many years, and chairs its Protocol Committee. She has served as Chair of the United States Breastfeeding Committee, and was chosen to Chair the new US Baby-Friendly Hospital NICU Initiative.