4158 Herpes zoster shingles chickenpox

Experience

Perinatal varicella infection can lead to severe infection in the infant if the maternal rash develops 5 days or less before delivery, or within 2 days after delivery. Illness in the infant usually develops before 10 days of age, and is more severe because of lack of maternal antibodies. The infant should receive varicella zoster immunoglobulin (VZIG). The infant can be infected by aerosolized virus from lesions or the maternal respiratory track. Postnatal varicella can develop from non-maternal sources, and is usually mild if the mother has had varicella or the vaccination.

Varicella zoster virus (VZV) has not been cultured from the milk with either herpes zoster or chickenpox (Frederick 1986), but VZV-DNA has been identified in breast milk (Yoshida 1992). One case of suspected transfer of VZV to an infant via breastfeeding has been reported, but the virus may have been transmitted by droplet or exposure to the rash.

Recommendation. When the mother develops chickenpox 2-4 days after the birth, the baby is given varicella immunoglobulin and perhaps prophylactic acyclovir. The milk can be expressed and fed to the baby. If the mother becomes ill after this point, prophylactic measures are not needed and the baby can be breastfed. If the baby becomes ill, varicella infections normally proceed without complications. With herpes zoster, the baby may continue to be breastfed, but direct contact with the affected part of the skin should be avoided. With the readily available vaccine to prevent chickenpox and the approval of the varicella vaccine for adults to prevent zoster, these cases should be greatly reduced.

4.15.9 HIV infection

Experience

The overwhelming majority of HIV-positive children arc infected during the birth. Postpartum infection via breastfeeding has also been described. The virus has been delected in the mother's milk, especially among women with mastitis and infected infants (Pillay 2000. Semba 1999). On the other hand, the protective effect of substances in the mother's milk, such as maternal anti-HIV antibodies, lactoferrin, and secretory leukocyte protease inhibitors on a vertical transmission, has been discussed for a long time (Becquart 2000, van de Perre 1999). A South African study of 549 HIV-1 infected women showed that babies who were exclusively breastfed for 3 months did not have a higher transmission rate than non-breastfed babies (14.6% versus 18.8%). The highest rate of infection was among those babies who were partially breastfed and partially artificially fed (24.1%) (Cout-soudis 1999). Based on 4085 infants, the Breastfeeding and HIV International Transmission Study Group (Coutsoudis2004) has found out that, in contrast with earlier findings, the transmission risk remains stable during the whole lactation period. The cumulative probability of infection via breast milk after the neonatal period and up to the age of 18 months (late postnatal transmission) is 9.3%. This risk is similar to the early perinatal and neonatal infection risk. The authors summarize an overall risk of 8.9 per 100 infant years for becoming infected via breast milk. The infection risk is increased with lower counts of maternal CD4 + lymphocytes probably indicating a higher virus load. Male newborns were found to have a higher risk too. Mixed feeding is associated with a higher infection risk than is exclusive breastfeeding (Coovadia 2007), Therefore it has been suggested that exclusive breastfeeding be recommended for 4-6 months, followed by abrupt weaning, in regions where a lack of clean water presents a risk for the preparation of infant formula, No schedule has been agreed upon yet.

There are several studies comparing antiretroviral medication regimens (nevirapine versus zidovudine plus lamivudine) with various treatment intervals for the prevention of mother-to-child transmission (Gaillard 2004). However, antiretroviral drugs have a rather short half-life, carry the risk of side effects and resistance, and are expensive, Therefore, research has focused on vaccines and specific immunoglobulins to protect infants (Safrit 2004). In addition, simple measures are needed to pasteurize breast milk with adapted tech niques, e.g. the so-called Pretoria pasteurization. Apart from providing appropriate technical equipment, social acceptance of such measures is not always easy to achieve (Rollins 2004).

A randomized trial in Kenya covering 425 HIV-1-positive pregnant women found a relative risk of death of 3.2 for breastfeeding mothers versus formula-feeding mothers. There was an association between maternal death and subsequent infant death, even after HIV-1 infection status was controlled for. The metabolic burden of breastfeeding in women with inadequate nutrition intake was, among others, discussed as a causal factor (Nduati 2001).

There has been no change of the WHO/UNICEF recommendations of 1992 that the newborns of HIV-infected mothers in industrialized countries should not be breastfed because safe artificial feeding is available, and thus a postpartum HIV infection via mother's milk can be avoided (World Health Organization 1992). In regions where infant mortality due to the lack of clean water is above 40/1000, however, the advantage of preventing infections by using formula feeding would be neutralized. Conversely, breastfeeding is the more dangerous form of nutrition only in those countries where infant mortality due to deficient hygiene is below 40/1000 (Kuhn 2004).

Recommendation. Newborns of HIV-infected mothers should not be breastfed. Exceptions are in those regions in developing countries in which the preparation of infant formula with a lack of dean water presents a greater risk. In such areas, babies should be exclusively breastfed for at least 3 months but not longer than 6 months wherever possible.

New Mothers Guide to Breast Feeding

New Mothers Guide to Breast Feeding

For many years, scientists have been playing out the ingredients that make breast milk the perfect food for babies. They've discovered to day over 200 close compounds to fight infection, help the immune system mature, aid in digestion, and support brain growth - nature made properties that science simply cannot copy. The important long term benefits of breast feeding include reduced risk of asthma, allergies, obesity, and some forms of childhood cancer. The more that scientists continue to learn, the better breast milk looks.

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