Archive | Breastfeeding in Emergencies

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. 

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The Legacy of a Hurricane

By Regina Roig-Romero

HurricaneAndrew 2

Every year at about this time, I think of Hurricane Andrew. Sometimes I wonder why. Twenty-one years ago, I was inside the tropical buzz saw known as Hurricane Andrew, a Category 5 storm that hit South Florida in August of 1992. When a storm of that strength is just outside your door, the smartest thing you can do is suppress your curiosity and not look out your windows, which hopefully are boarded up anyway. And we were smart, so from that frightening night what I mostly remember are the sounds – the storm, whistling like an oncoming train about to roll full-speed ahead into the closet we were hiding in, and the knowledgeable, calming voice of meteorologist Bryan Norcross on my radio. I remember the darkness. And I remember my 16 month old daughter nursing….and throwing up.

But Hurricane Andrew wasn’t just a personal milestone in my life; it was also a professional one, my first serious venture into my future as a public health IBCLC. That night was all about Andrew’s sounds, but from the moment the sun returned to our skies, its sights took over. South Florida – indeed the country – could not remember when the nation had last witnessed such devastation from a natural disaster.  Three of our five La Leche League (LLL) Leaders lost their homes to Andrew. I – a newcomer to breastfeeding advocacy, having only become a Leader one year earlier – was one of the two that didn’t. Once we were all finally able to see what had just happened to our city, those of us in LLL were immediately panic-stricken at the prospect of the city’s newborns being fed infant formula under such conditions – no water, no electricity, no refrigeration, no grocery stores. It was as if overnight we had all been transported to a 3rd world country and were now living inside of Gabrielle Palmer’s book, The Politics of Breastfeeding.  “Well, not in my town, and not on my watch,” I thought, so I had an idea – take all of the money that LLL folks from around the country had donated to us, spend it buying copies of the Womanly Art of Breastfeeding, and then give them away for free in South Miami-Dade where the storm had hit worst.

It seemed like a great idea and so we bought the books and packed them – along with our idealism and our kids – into our cars and set out for “tent city”:  the huge collection of tents in Homestead where many of the instantly-homeless were now living. And that is when I came across the most enduring sight, for me, of Hurricane Andrew:  a huge green tent full of infant formula, can after can after can of it piled high and being given away. Our books seemed so tiny and unimportant by comparison! Just as defining for me was the virtual wall of disinterest that we were met with when we tried to explain to the powers that be that after a disaster breastfeeding is even more important than it is before it. But our passion and idealism fell on deaf ears; I felt afterwards like we’d failed miserably to make a difference.

My idealism died in tent city; two things replaced it: the conviction that the most important thing we can do to promote breastfeeding after any disaster is to normalize breastfeeding *before* it, and an intense and mercilessly unrelenting desire to make a difference that drives me to this very day. Twenty-one years later I am an IBCLC with 17 years’ experience as a Lactation Consultant for the Women, Infants and Children (WIC) program, a public health professional on the brink of graduating with a Master’s degree in Public Health, a member of the National WIC Association’s Breastfeeding Promotion Committee, and a Board Director of the International Board of Lactation Consultant Examiners. I neither imagined nor planned any of it. But it all began with Andrew – with the whistling wind, the frustration of failure, the implacability of apathy, and a tent full of formula. No wonder I still think about that hurricane…..

ReginaRoig-Romero_IBLCE BOD picRegina Maria Roig-Romero was a La Leche League Leader for several years beginning in 1991, and is currently the Senior Lactation Consultant for the WIC breastfeeding program in Miami, Florida. She has assisted as an IBCLC in the program’s creation, development and leadership since its inception in 1996; in 2011-2012 she led the implementation of a worksite lactation support program at the health department in Miami. From 2002-2011, she successfully mentored thirteen Peer Counselors to become IBCLCs. In 2011, Regina served as an invited member of the USDA Food & Nutrition Service Expert Panel on the revision of the Loving Support Peer Counselor Training curricula. Her major speaking engagements include: the National WIC Association’s (NWA) Washington Leadership Conference & Breastfeeding Summit in 2010, two Spanish-language sessions at the 2012 ILCA annual conference, and an upcoming presentation on perceived milk insufficiency at the American Public Health Association Annual Meeting in November 2013.  Regina was appointed to the NWA Breastfeeding Promotion Committee in August 2012, and was elected to the Board of Directors of the International Board of Lactation Consultant Examiners in September 2012. In December 2013, she will graduate with a Master of Public Health (MPH) degree in Health Promotion and Disease Prevention from Florida International University.

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