Influenza and Lactation

CQ #260 - October 10, 2022

Anne Eglash MD, IBCLC, FABM

#LactFact

All vaccines are safe during lactation, and people with active influenza at birth should be encouraged to directly feed at the breast or chest. Oral oseltamivir is preferred for influenza treatment during lactation.

Recommendations for Prevention and Control of Influenza in Children 2022-2023
Pediatrics (2022) 150 (4) e202205975

What are guidelines for breastfeeding during influenza, and the use of influenza vaccines and medications during lactation?

According to Dr. Fauci, the USA should prepare for a ‘pretty bad flu season’ based on the severity of influenza in Australia, from April-September, 2022.

Let’s review breastfeeding during influenza illness, vaccines during lactation, and influenza treatment options during lactation.

Direct breastfeeding during influenza illness: Lactating parents with influenza illness are encouraged to directly feed at the breast or chest. This was emphasized by the American Academy of Pediatrics Committee on Infectious Diseases in their recently published ‘Recommendations for Prevention and Control of Influenza in Children’. They point out that breastfeeding after receiving the influenza vaccine during pregnancy provides influenza-specific antibodies (IgA) to prevent the infant. Even without the vaccine, human milk has innate antiviral mechanisms that protect the breastfeeding infant from severe illness. Breastfed infants are significantly less likely to die of respiratory infections as compared to infants who are fed human milk substitutes.

Influenza vaccination during lactation: All influenza vaccines, whether inactivated or live-attenuated are safe during lactation. The live-attenuated (intranasal) vaccine (LAIV) is approved for people 2 through 49 years of age. Both types of vaccines, when given during lactation, have been found to induce anti-influenza antibodies in breastmilk for at least 6 months. The LAIV vaccine triggered significantly more anti-viral activity in human milk than inactivated vaccines.

Influenza treatment during lactation: Anti-viral medications that are used to either treat influenza illness or prevent influenza for close contacts include oral oseltamivir, baloxavir marboxil, inhaled zanamivir, and intravenous peramivir. Oral oseltamivir remains first line treatment for lactating individuals. Although the level of baloxavir is expected to be low in human milk there is no evidence on the safety of its use during lactation. Despite there being no information on the use of inhaled zanamivir during lactation, it is not likely to be absorbed by the infant. There is also no information on the use of intravenous peramivir during lactation. Rat studies have demonstrated its presence in milk, approximately 0.5-fold as compared to maternal blood, yet it is unlikely to be absorbed by the infant gut.

Can you answer the following question?

What are the recommendations for peripartum management of a dyad when the parent has influenza at the time of birth? Choose accurate statement(s):

The American Academy of Pediatrics (AAP) Committee on Infectious Diseases states that for infants born to mothers with confirmed influenza illness at delivery, breastfeeding is encouraged.
The current US Centers for Disease Control (CDC) guidelines (2020-2021) recommend that facilities separate the birth parent and newborn when the birth parent has confirmed influenza illness at delivery.
The current CDC guidelines recommend giving donor milk and not the parents’ own milk when the birth parent has confirmed influenza illness at delivery, because the influenza virus can be spread via breastmilk.
The AAP Committee on Infectious Diseases recommends pumping and feeding expressed breastmilk if the parent and/or the neonate is too ill to breastfeed.

Click here to view the answer to this question.

Correct Answers: A, B, and D (not C)

Recommendations for Prevention and Control of Influenza in Children 2022-2023
Pediatrics (2022) 150 (4) e202205975
Jessica M. Edney, Sari Kovats, Veronique Filippi, and Britt Nakstad

Abstract

This article does not have an abstract.

IABLE Comment by Anne Eglash MD, IBCLC, FABM

The Centers for Disease Control has not updated their 2020-2021 guidelines on peripartum care regarding when the birth parent has confirmed influenza illness at the time of delivery.

The CDC guidelines state that newborns infected with influenza are at increased risk for severe complications, including death. Therefore, the CDC recommends that facilities temporarily separate the parent and infant, in accordance with the mother’s wishes. Mothers should be encouraged to express their milk and give this milk to their infant. The optimal length of temporary separation has not been established and should be based on a case-by-case basis.

The CDC guidelines also have recommendations for families who choose to room-in, such as a 6-foot separation between the ill parent and infant, wearing a mask, and having someone else care for the infant in the room. Sound familiar?

In the 2019-2020 influenza season, 199 US children died of influenza, 87 of whom were under the age of 5, with many having at least 1 underlying condition putting them at higher risk. Interestingly, for decades the risk of infant death from respiratory syncytial virus (RSV) has been much higher than from influenza, but we never discuss separating the parent with confirmed RSV from their newborns.

We learned from the COVID-19 pandemic that hospital practices separating the birth parent and newborn decreased breastfeeding rates and led to unnecessary morbidity and mortality. We know that breastfeeding reduces the risk of death from respiratory illnesses. Even though the CDC ‘softened’ their guidelines by suggesting shared decision making with influenza-positive mothers regarding rooming-in, their guidelines favor separation. How are families treated when they decide to room-in during hospitalization in facilities that advocate for separation?

We have a small amount of evidence that separating a parent from their newborn does not increase the risk of neonatal illness or death from influenza. I suggest that the CDC needs to reconsider these guidelines to ENCOURAGE rooming-in and facilitate direct breastfeeding, to ensure the establishment of exclusive breastfeeding at hospital discharge. Separation does not save lives, but exclusive breastfeeding does.

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Comments (2)

Lj

October 11, 2022 at 3:44 PM

Hello IABLE –
As a community LC I find these contradictory guidelines very frustrating! It makes our jobs much harder and leaves lots of room for misinterpretation and potential for physicians to disagree with our advice. Just venting!
Thanks for throwing it all out there for everyone to examine.
LJ in El Paso (on the border of Texas and Mexico)

Chris Sheppard

October 11, 2022 at 4:09 PM

I don’t understand why mother and baby would need to be separated at birth if mother is influenza positive. Isolation together and mum and carers using droplet/contact precautions need to be a priority. Mum using an N95 mask strict hand washing etc etc would help to reduce viral spread also. With all the knowledge we have now about the importance of the first minutes/hours/days of skin/skin and close contact with mother. If mum is so sick, surely treated with appropriate medication and both mum and baby observed for fever etc. until full recovery.