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.
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16. Mother Risk Programme, Hospital for Sick Children, Toronto, Canada.