Breastfeeding
Medical conditions that could affect breastfeeding
Medication, medical conditions and breastfeeding
Some medications taken by the mother can pass into breastmilk, but for many women the benefits of taking certain medication outweigh the risks. Evidence indicates that the possible risks of medication used during breastfeeding are significantly lower than during pregnancy because a nursing baby receives a lower dose than the fetus during pregnancy (BMJ Clinical Review 2014).
There are, however, some situations where the potential risks of the medications or condition mean that it's safer and so not advisable to breastfeed for example women with HIV infection or those taking some cancer medications. The American Academy of Paediatrics suggests that radioactive compounds and anticancer drugs should be avoided during lactation (2013).
In the UK, the National Institute for Health and Care Excellence (NICE) Guidelines gives advice and information on particular medical conditions and breastfeeding. LactMed is another reliable source of information that is geared to the healthcare practitioner and nursing mother. It includes information on the levels of drugs and other chemicals in breastmilk and infant blood, and the possible adverse effects in the nursing infant.
All women who have a medical condition that requires medication, and are considering breastfeeding, are advised to speak to their midwife, health visitor, pharmacist, GP, obstetrician or consultant about their particular circumstances and concerns.
There are some medical conditions and treatments related to breastfeeding such as mastitis, poor infant attachment, nipple damage, and fungal infection. These breastfeeding difficulties are considered separately under the following headings: see The milk coming in, Sore nipples, Dealing with difficult times and When breastfeeding doesn’t work out. Below, we illustrate the experience of women who were unable to breastfeed due to two very different medical conditions: HIV and Raynaud’s.
HIV and breastfeeding
The World Health Organisation (WHO) guidelines on HIV and infant feeding recommends that HIV positive mothers with infants who are HIV negative (or whose status is unknown) should either avoid breastfeeding altogether, or breastfeed when on antiretroviral therapy (ART) to lower the risk of HIV transmission (2010). HIV positive mothers in resource rich countries like the UK are advised to abstain from breastfeeding and use formula feed instead.
We talked to Kate and Hana, two HIV positive women who did not breastfeed their children born after they were diagnosed with HIV. Both women knew that an HIV infected mother can pass the virus to an uninfected baby through breastmilk so they followed medical advice.
During their pregnancies both women were carefully monitored by their HIV specialist, obstetricians and their HIV clinic consultant. The use of antiretroviral therapy (ART) ensured that Hana and Kate’s children were born HIV uninfected and Hana was able to have her children by normal delivery. Kate was deeply disappointed when told she needed to have a C section.
Hana says that breastfeeding was not an option but that at least she was able to have normal deliveries.
Hana says that breastfeeding was not an option but that at least she was able to have normal deliveries.
Breastfeeding is not even an option, no way, because everything it come from me it goes to them. So the best thing to do from start, I have to teach them how to use a bottle so I used to have, one was for three months I used to have a problem, you know, too much milk coming out and I have to, I can’t go out even unless I have to put on plastic, under the plastic I have to put protection otherwise, otherwise I’ll be wet.
Did they give you any medication to stop the milk?
No, no. They didn’t. They didn’t.
Okay.
So they said, he’s going to stop by himself.
How did you feel with the breast full of milk and unable to feed the kid?
I don’t feel anything because you know what, one thing is for the protection of my kids and I’m lucky enough, at least I could give them a natural birth, you know, so what else I could ask.
Okay, So breastfeeding wasn’t..
I was aware of it already. When, during pregnancy time I was already, I was already been told. Just completely I have to clear it out from my mind. This is not going to happen, so I knew it. So, if it’s for the protection of my kids, then I want, I just have to feed them milk.
But Kate’s attitude changed when she became pregnant with her third child. By then, she had accepted being HIV positive, and was more prepared to accept the limitations imposed by HIV on the experience of motherhood: the possibility of a C section and the used of baby formula instead of breastfeeding.
Both women appreciated the specialist medical care and the help they received from medical teams and HIV support workers during and after their pregnancies. Both found HIV support workers were an important source of support and information. Hana commented that during her pregnancies, she had come to rely a lot on her obstetrician consultant, in whom she had absolute trust.
In close-knit communities, people become suspicious that a woman is HIV positive if she becomes a mother, but doesn't breastfeed. Hana and Kate felt under the scrutiny of others; friends and even family members who wanted to know why they were not breastfeeding.
Hana didn’t tell friends or family the reason why she couldn’t breastfeed her children. If asked, she said her milk had dried up.
Hana didn’t tell friends or family the reason why she couldn’t breastfeed her children. If asked, she said her milk had dried up.
Okay, so people did ask?
Yeah, they ask and then my answer is always just something. I’m not going to give them, you know, why and how.
Raynaud’s is a condition that affects the blood vessels primarily in the fingers and toes. Raynaud’s is characterised by episodic attacks called vasospastic attacks that cause the blood vessels to constrict. Vasospasm can also occur in the nipples of lactating mothers. When a vasospastic attack occurs in the nipples, the nipple goes white or blue and is painful. Nipple vasospasm pain can range from minor discomfort to severe pain and so may or may not affect breastfeeding. Known triggers for vasospasm attacks include poor attachment, nipple damage (e.g. cracked nipple) or an infection (e.g. nipple thrush); and exposing the nipples to cold air (see notes 2,3,4,5).
Most people tend to develop this condition before the age of 25 and women are more likely than men to be affected by the condition – and so it commonly affects women of childbearing age. Some researchers estimate as many as 20% of all women in their childbearing years have Raynaud’s (The Raynaud’s Association 2018).
We talked with Jessy who has recently discovered that she was affected by Raynaud’s disease. She was only able to breastfeed both her children for a short period because of severe pain that she described as ‘burning and throbbing’ and damaged nipples. Jessy was able to breastfeed her first child for ten days, and her second child for fifteen days.
The GP diagnosed Jessy’s cracked and bleeding nipples as ‘thrush’. By chance Jessy found out she suffers from Raynaud’s and that it could affect the nipples of lactating mothers.
The GP diagnosed Jessy’s cracked and bleeding nipples as ‘thrush’. By chance Jessy found out she suffers from Raynaud’s and that it could affect the nipples of lactating mothers.
The second time or both times?
Both times, but the first time I didn’t see, the first time I thought I was going to lose my nipple because the nipple was really coming apart of the breast and the second time it was just the skin was just completely broken and it was blood in my shirts like, I was literally dripping blood…
So I only recently discovered - I have problems with my tissue. My tissue doesn’t heal as quick as it should. My blood doesn’t flow, I have a circulatory problems and then it affects, as much as it affects my hands it affects my breast tissue which makes it really painful.
Jessy felt under pressure from one midwife to carry on breastfeeding her baby but the health visitor was more understanding.
Jessy felt under pressure from one midwife to carry on breastfeeding her baby but the health visitor was more understanding.
…and their target was that I was a mum that must, mum must breastfeed, no matter what. Her nipples were bleeding, it doesn’t matter. She was in pain? It doesn’t matter. She was almost getting post-natal depression from all the stress? It doesn’t matter. She must breastfeed. And that’s what, what I felt like it was really terrible. In, in fact I got, they got like, they were turning up at my house, they were calling me, like every so often to check that I was breastfeeding. Then, the last thing it was, the last straw was that they make me pay to a woman to come and give me a personal lesson in breastfeeding.
So I was just like and then and my husband at that time, he stepped up and then he, he basically kicked them out and said, and sat with me and said, “What are you doing? You should stop, this is not good for you”. And then it was lucky when the midwife hand me over to the health visitor, one of the health visitor was really still like pushing me, pushing me, “You must breastfeed, you must breastfeed, you must breastfeed”. But then the second health visitor came to me and say, “Listen, the most important thing is a mummy’s OK. If the mum is not OK, how are you going to look after your baby? So don’t worry, my children grew up in, on formula, OK? And, don’t tell anyone I said it, I said so”. And then it was all, OK so she makes me feel better.
When pregnant with her second child, Jessy made careful preparations to ensure breastfeeding was successful, but sadly, she had the same experience as with her first baby. She felt devastated that she was unable to breastfeed.
When pregnant with her second child, Jessy made careful preparations to ensure breastfeeding was successful, but sadly, she had the same experience as with her first baby. She felt devastated that she was unable to breastfeed.
After the birth?
After the birth. So I was breastfeeding fine no problem. He was having no troubles at all. I, he was latching perfectly. Everything was fine. As soon as I came back from hospital the painkillers started wearing, wearing off. Then every time I have to breastfeed him even when he was latched properly, it was just like - I just talk to myself and I say, “Sharp pain”. So I started doing breathing and I was like ok it might go. I started talking to people and they kept telling me, “No it will be, it will go, it will, it will go away”. I showed people the - well like a friend, I had a friend who’s a doula and she was [hush] helping me with the breastfeeding.
So she was telling me, “He’s latching properly”. And I said, “Yes but the pain is getting unbearable”. And after ten days like my breasts were completely raw, bleeding and swollen. And every time he cried I was, I was really tense. My hands sweat. And I was trying, I was getting angry at people every time he wake, I felt that they weren’t, you know because he wanted to be fed. And I just - I was terrified…
I had everything I could possibly have, I had nipple cream, I had the training, I watched the video, I read the books, I have a doula with me, a friend, a friend I could trust. I have, I even bought nipple shields and I used everything I could, I did everything I could possibly do. But then I was still obsessed with the, “I’ve got to do it, this, my boobies are not going to win, I’m going to win, I’m going to be able…
I was using nipple shields, made of silicon - well, I used them a week after, after seven days just to give it a try because my, at the beginning, my aim was to be able to get him to latch and then I managed to get him to latch properly and then tried different, different position, the rugby ball, the front facing, sideways, every position possible until I found the one, the one that suitable for me that was the rugby ball. But then, I noticed that, that no matter what, how many massages I did, I gave to my breasts they were so sore. My nipples start, start cracking even when I, my, when I was continually keeping them with nipple cream, like Lanolin cream. I then, I noticed that they start bleeding and they would not stop bleeding the milk was, I tried to press the milk just to carry it, be, to carry on giving him milk [sighs] and the milk looked like strawberry milkshake, there was so much blood in that, I wasn’t able to give him that neither. Then I try to just use the breast that was less damaged for a while and tried to let the other one heal It, it seemed I was never, ever healing. And then it was that, that feeling of the fire, they were on fire, it was horrible. He felt like, every time they were out, I put him near my breast he felt like he was like a little shark or like a piranha [laughs] like just biting your breast, it was just oh. It was agony, agony, completely agony.
And during this time you were trying to do everything on your own? Trying to, trying to cope with this on your own. You didn’t want the health visitor or the midwife involved?
Yeah, no, I try, I was just like I got my friend, the wonderful doula to come and look at me. As soon as she came, “Oh yeah you’re latching fine, that’s the right way, that’s the right position”. I just went, “OK”, and I didn’t tell her, I didn’t seek her help anymore. I didn’t tell the midwife when they came, I just say yeah, “You’re breastfeeding?” “Yeah, yeah, I’m fine”. And I was just like hoping that, that he wouldn’t cry for a feed while she was there in my house. Then I just was trying to cope on my own, I didn’t, my partner wasn’t, he noticed, because he knows me, he noticed my change every time I have to do the breastfeeding and then, and then he start noticing that I was getting sadder and sadder, and sadder, and then, until, until I got to a point that every time I was breastfeeding he knew I was crying. He said, “You can’t carry on like that. This is, this is not right. This is not right. Just stop it please”. Off he went, got the formula, got the bottles, made the bottle, and then he just went, “It’s fine, and then you could, you will be able to sleep at night. Come on”. And then he made it look like it was great, but to me it was just, I was devastated. I felt like, really like the end of the world like oh, like I failed, like a failure.
When Jessy experienced painful breastfeeding with her second child, she didn’t ask for help from her midwife or health visitor.
When Jessy experienced painful breastfeeding with her second child, she didn’t ask for help from her midwife or health visitor.
Jessy believes that health professionals should make expectant mothers aware that in some cases breastfeeding is not possible.
A doctor at her place of work noticed Jessy’s hands and asked her about breastfeeding. It was the first time Jessy heard about Raynaud’s phenomenon of the nipple.
A doctor at her place of work noticed Jessy’s hands and asked her about breastfeeding. It was the first time Jessy heard about Raynaud’s phenomenon of the nipple.
And then I think it will be really, really helpful if future generations or, or the next generations of mums that go, who are suffering from the same as I do, can benefit from these information, or if the GPs know more about it. And then when a woman goes to see them they can say what it is, or if the midwives, the midwife are aware of these and they can help the mum if the choice, if the mum chooses to breastfeed.
In severe cases of nipple pain, health professionals can prescribe calcium channel blockers (Nifedipine). (See notes 3 4 5)
Notes
1. Committee on Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Hale TW, Pediatrics 2013,132:e796-809
2. Managing common breastfeeding problems in the community. Lisa H Amir. BMJ 2014;g2954 doi:10.1136/bmj.g2954 (Published 12 May 2014)
3. Guidelines on HIV and infant feeding 2010 Principles and recommendations for infant feeding in the context of HIV and a summary of evidence
4. The Royal Hospital Women’s Hospital Fact Sheet
5. Raynaud’s Phenomenon of the Nipple: A treatable cause of painful breastfeeding Jane E. Anderson et, al. Pediatrics 2004;113;e360
6. Vasospasm of the nipple - a manifestation of Raynaud’s phenomenon. Lawlor-Smith L et, al. British Medical Journal 1997, 314:644-45
Topic added: September 2015
Last reviewed November 2018.
Last updated November 2018.
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