Current Global Recommendations Regarding Breastfeeding with Ebola Virus for Mothers and Infants

By Kathleen Marinelli, MD, IBCLC, FABM
ILCA Board of Directors Director of Professional Development

Screenshot 2014-11-07 20.10.02As 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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)
  8. 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.
  9. 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.
  10. 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.

References

  1. http://www.cdc.gov/vhf/ebola/hcp/recommendations-breastfeeding-infant-feeding-ebola.html (accessed 11/5/2014)
  2. http://www.ennonline.net/infantfeedinginthecontextofebola2014 (accessed 11/5/2014)
  3. 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. 

7 Responses to Current Global Recommendations Regarding Breastfeeding with Ebola Virus for Mothers and Infants

  1. Amanda 10 November 2014 at 10:58 #

    What about women that do have access to these items that aren’t in remote areas? Why dont we go ahead and inform women that can heat the breast milk long enough to kill the virus and still preserve nutrients? At what temp is that done? and exactly how would one handle this milk express presumably by a breast pump?

    • kmarinellimd 10 November 2014 at 22:29 #

      Thanks Amanda for your great question. There are papers from the HIV literature describing how to home pasteurize mother’s milk. My reading of attempting pasteurization in these conditions from the information I cited and an ENN on-line listserve I have been reading with interest is that where these women are getting sick with Ebola, the conditions are so difficult in terms of how quickly they become sick, how terribly sick they become, if they are lactating, loss of milk supply likely comes quickly due to degree of sepsis, shock and dehydration (although as i stated without documentation, this is somewhat conjecture). Due to the extremely high infectivity of the virus itself, the milk is highly infective, and if it is being expressed, has to be handled with the extreme caution we are seeing in the press of how these patients and anything they come into contact with are being handled. With the shortages of personnel to care for the patients, i suspect attempting to pasteurize milk is a very low priority. But it will be interesting to hear if in fact it has been attempted and what happens if it has. I continue to follow anything that comes across, and I think we will be learning more about this for (unfortunately) a very long time.

  2. Liz Brooks JD IBCLC FILCA 10 November 2014 at 11:32 #

    Thank you, Kathie, for helping us to understand, in plain English, what we know (and don’t know) about Ebola transmission, and lactation.

  3. Ahmie Yeung 10 November 2014 at 13:26 #

    Is there any possibility of encouraging women who have survived ebola, and are past the 8 week mark, to relactate and milk-share with vulnerable infants to potentially pass on the antibodies as is being done with blood transfusions from survivors? In addition to potentially helping more babies survive, it could be a step toward emotional healing for those mothers who lost their own babies to ebola.

    • kmarinellimd 10 November 2014 at 22:38 #

      Thank you Ahmie for your thoughts. It would seem to make sense wouldn’t it that they would secrete antibodies to Ebola in their milk? It is tough to know the answer. From what I have been able to glean in my reading, encouraging women who were lactating when then became infected and survive is recommended. Again, there is little documented, so we really don’t know what condition these women are in. We believe no pregnant women have survived. If a woman with established lactation has been infected and survived we have no record. We know they would be so weak, so malnourished, that their bodies’ first priority would be just to gain strength. There is a fair amount written on how malnourished and dehydrated the survivors are, and protocols for nourishing them. I don’t know how difficult relactation would be under these circumstances. We have so much to learn. I keep sending all my hopes and prayers to those who are fighting this battle themselves, and all those who are selflessly fighting it for those who need them.

  4. david550709 10 November 2014 at 14:40 #

    Importante información,el ébola sí se transmite por leche materna.  Dr. David Camarena Enríquez 5 de Febrero 44-108 Col. Centro C:P: 47400 Tel. 4747423361 Lagos de Moreno Jalisco

    Aviso de Privacidad: Este correo electrónico contiene información del Dr. David Camarena Enríquez especialista en Pediatría,  la cual es privada, confidencial y se encuentra amparada por el Secreto Profesional. El presente correo está destinado para uso exclusivo del Dr.  DAVID CAMARENA ENRIQUEZ o de la identidad al cual está dirigido. Si el lector de este mensaje no es el destinatario, se le informa que tiene estrictamente prohibido divulgar, modificar, reproducir, usar, hacer pública o copiar esta información. Si usted recibe este correo electrónico por error, elimínelo o informe de inmediato a los teléfonos o correo antes citados. En cumplimiento a la Ley Federal de Protección de Datos Personales en Posesión de los Particulares y su Reglamento, DAVID CAMARENA ENRIQUEZ manifiesta que toda la información recibida por este medio de comunicación, es protegida, confidencial y destinada exclusivamente para la prestación de servicios profesionales de índole médico profesional y/o personal. Toda información relacionada con el presente Aviso de Privacidad, así como cualquier acto referente al Acceso, Rectificación, Cancelación y Oposición al Uso de Datos Personales proporcionados por este conducto, deberá comunicarse con el Dr. DAVID CAMARENA ENRIQUEZ, a los números telefónicos o domicilio antes designados.  

    • kmarinellimd 10 November 2014 at 22:45 #

      Dear Dr. Enriquez, Thank you for your communication. I am very aware that Ebola is transmitted by human milk itself. It is as I have said a very infectious bodily fluid. I appreciate your concern in making sure we were all aware. Muchas gracias, Kathleen Marinelli

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