When Breastfeeding
Is Not Contraindicated
Jack Newman, MD, Pediatrics Hospital for Sick Children, Toronto, Canada, Assistant Professor, University of Toronto
from Breastfeeding Abstracts,
May 1997, Volume 16, Number 4, pp. 27-28.
As a health professional
who tries to help women overcome breastfeeding problems, I have two
great (and many small) frustrations. One is that the vast majority of
problems I encounter could have been prevented by skilled help during
the first few days. The other is that mothers are often told they must
interrupt or discontinue breastfeeding because of illness, medication
or infant problems, almost always unnecessarily. This is the greater
frustration because it means that the health professional advising the
mother does not believe that breastfeeding has any value, or has only
very little value. The mothers usually follow the advice because, naturally,
they want to do the best for their babies and they do not imagine that
the health professional would lead them astray.
I believe it is time we start
considering infant formula a drug. It is very different from human milk
which it replaces,1 and like most drugs, it has side effects
in the short, medium, and long term.2-12 Some of these side
effects are life-threatening7-12 while others have lifelong
effects on the child. The fact that many millions of babies have grown
up in presumably good health without ever tasting their mothers' milk
is a tribute to the amazing adaptability of the human being, but it
is not an argument for considering breastfeeding and artificial feeding
as equal or formula as without risk. The vast majority of people who
received chloramphenicol did not develop aplastic anaemia, yet the occurrence
of this terrible complication in 1 in 40,000 users was enough to put
this very useful antibiotic into noli me tangere ("do not
touch me") limbo for many years.
It is necessary to remember
as well that breastfeeding is the physiologic method of infant feeding,
perfected over hundreds of millions of years of mammalian evolution.
It is not up to breastfeeding advocates to "prove" that breastfeeding
is better. It is up to those who promote the intervention, i.e., feeding
other than breastfeeding, to prove their intervention is not harmful.
This has never been done.
There will never be an absolute
answer to many questions about breastfeeding being contraindicated;
for example, should a mother continue breastfeeding when taking drug
x? In every such instance, the risks on one side must be weighed
against the risks on the other - is it safer to continue breastfeeding
with the tiny amount of drug x in the milk or is it safer for
the baby for the mother to stop breastfeeding and give the baby formula?
Which has more risk? The answer depends on how seriously we take the
risks associated with artificial feeding.
Many health professionals
do not take the risks of artificial feeding seriously. For example,
the high rate of otitis media in our society is taken as a given,
a risk of infancy, rather than as a result of artificial feeding. The
risks for the mother must also be taken into account, not only engorgement
and the possibility of developing mastitis, but also the increased risk
of breast cancer.13-14 On that basis, it is fair to say
that breastfeeding is almost never contraindicated.
One particularly nagging
question often arises. Should mothers continue breastfeeding when they
require antidepressants? Many physicians would automatically say no,
and those few who would bother to check on the drug would find it listed
by the American Academy of Pediatrics under the heading "Drugs
Whose Effect on Nursing Infants Is Unknown But May Be of Concern."15
In our litigious society, this is sure to make a physician cringe. Indeed,
it is true we don't know the long-term effects of antidepressants on
breastfeeding infants. We also do not know all the long term effects
of not breastfeeding. We do know the effects of not breastfeeding include negative effects on the
central nervous system, the very concern cited by physicians who are
reluctant to counsel continued breastfeeding.4 Furthermore,
in these situations the relationship between the mother and the baby
is not of minimal importance, and the mother's mental health needs to
be considered as well. Almost all the mothers who contact me about antidepressant
medication express their distress in a surprisingly similar fashion:
"The only thing that is going well for me is the breastfeeding,
and now they want to take that away too."
There are some choices. Look
at the pharmacology. In theory, paroxetine, a selective serotonin reuptake
inhibitor (SSRI) antidepressant, could be the ideal antidepressant, if
one is required, for the nursing mother. Less than 1 percent of the
total drug in the mother's body is found in her circulation and about
95 percent of the paroxetine in the circulation is bound to plasma protein making excretion into the milk of significant amounts extremely unlikely.
Sertraline, another SSRI antidepressant, also is excreted into the milk
in insignificant amounts.16
Breastfeeding is too important
to the child, to the mother, to the family, and to society to sacrifice
it as easily as we sometimes do. Health professionals who care about
the health of mothers and children should make every effort to avoid
interruption of breastfeeding. Breastfeeding can almost certainly continue
in most situations, given a belief in its value and a little imagination
and ingenuity.
References
1. Newman, J. How breastfeeding
protects newborns. Sci Am 1995; 273:76-79.
2. Walker, M. A fresh look
at the risks of artificial feeding. J Hum Lact 1993; 9:97-107.
3. Cunningham, A. S., D.
B. Jelliffe and E. F. P. Jelliffe. Breastfeeding and health in the
1980s: a global epidemiologic review. J Pediatr 1991; 18:659-66.
4. Andraca, I. and R. Uauy.
Breastfeeding for optimal mental development. In Behavioral and
Metabolic Aspects of Breastfeeding, Ed. A. P. Simopoulos, J. E.
Dutra deOliveira and I. D. Desai. World Rev Nutr Diet. Basel,
Karger, 1995; 78:1-27.
5. Taylor, B. and J. Wadsworth.
Breastfeeding and child development at five years. Dev Med Child
Neural 1984; 26:73-80.
6. Pisacane, A., L. Graziano,
G. Mazzarella et al. Breastfeeding and urinary tract infection. J
Pediatr 1992;120:87-89.
7. Koletzko, S., P. Sherman,
M. Corey et al. Role of infant feeding practices in the development
of Crohn's disease in childhood. Br Med J 1989; 298:1617-18.
8. Aniansson, G., B. Alm,
B. Andersson et al. A prospective cohort study on breastfeeding and
otitis media in Swedish infants. Pediatr J of Infect Dis J
1994; 13:183-88.
9. Mitchell, E. A., R. Scragg,
A. W. Stewart et al. Results from the first year of the New Zealand
cot death study. NZ Med J 1991:104:71-76.
10. Davis, M. K., D. A. Savitz
and B. I. Graubard. Infant feeding and childhood cancer. Lancet
1988; 2:365-68.
11. Wright, A. L., C. J. Holberg,
L. M. Taussig and F. D. Martinez. Relationship of infant feeding to
recurrent wheezing at age 6 years. Arch Pediatr Adolesc Med 1995;
49:758-63.
12. Karjalainen, J., J. M.
Martin. M. Knip et al. A bovine albumin peptide as a possible trigger
of insulin-dependent diabetes mellitus. New Eng J Med 1992;
327:302-7.
13. Newcomb, P. A., B. E.
Storer, M. P. Longnecker et al. Lactation and a reduced risk of premenopausal
breast cancer. New Engl J Med 1994: 330:81-87.
14. Romieu, I., M. Hernandez-Avila,
E. Lazcano et al. Breast cancer and lactation history in Mexican women.
Am J Epidemiol 1996; 143:543-52.
15. American Academy of Pediatrics
Committee on Drugs. The transfer of drugs and other chemicals into
human milk. Pediatrics 1994; 93:137-50.
16. Mother Risk Programme,
Hospital for Sick Children, Toronto, Canada.
Page last edited Sun Oct 14 09:32:42 UTC 2007.
