Dear Mija Ververs,

Thank you for bringing up this critical topic. It is an interesting and big issue in different humanitarian and developmental settings.

Before answering your question, I want to highlight some points 

What is Cholera?

Cholera is an acute watery diarrheal disease caused by intestine infection with the gram-negative bacteria Vibrio cholerae, either type O1 or O139. Both children and adults can be infected.  

Vibrio cholerae species are divided into 2 serogroups:

■ Vibrio cholerae O1, subdivided into Classical and El Tor biotypes.

■ Vibrio cholerae O139 serogroup which was first identified in 1992 in India.  

Mode of Transmission

Cholera is transmitted by the fecal-oral route.  Cholera is transmitted almost exclusively by contaminated water or food.

Reservoir

Humans are the main reservoir of Vibrio cholerae. Other potential reservoirs are water, some mollusks, fish, and aquatic plants.  

Malnutrition with Cholera Management

Key Messages:

• The nutritional status of patients with cholera should be assessed as management differs if the patient has SAM.
• All patients with cholera and SAM must be treated at a Cholera Treatment Centre (CTC) as rehydration should be addressed before nutrition care and treatment is initiated.
• The skin pinch may be less useful in patients with marasmus (severe wasting) or kwashiorkor (severe malnutrition with edema), or obese patients.
• Patients with SAM have altered physiology so they must be rehydrated slowly. IV fluids should only be used for SAM patients in shock because of the high risk of fluid overload and heart failure.
• Children with cholera and SAM must be treated for dehydration using low-osmolarity Oral Rehydration Salt (ORS). Do not use ReSoMal.
• During rehydration, closely monitor signs of fluid overload.
• Patients with cholera and SAM should be treated with the same therapeutic feeds, following the feeding protocol for patients with SAM and medical complications.
• As soon as the patient has recovered from cholera nutritional status should be re-assessed and the child referred to the SC.
• Breastfed infants should continue with breastfeeding as it is the safest source of nutrition

Now to answer your questions
Yes, It is important to explore past experiences to better guide the upcoming process.

• Q1. Should a cholera-infected mother on IV fluids breastfeed her child?

Ans. It depends on the severity level and consciousness of the mother.

  If the mother has signs of shock (cold hands with slow capillary refill (longer than three seconds) and/or weak or fast pulse) and is lethargic or unconscious: It is Severe Dehydration. Plan C, and IV rehydration is recommended. She is not recommended to breastfeed her child till she becomes alert and conscious.

Otherwise being cholera-infected doesn’t prevent mothers from breastfeeding their children. Breast milk is the safest and most sterile food of all.  

Treatment of Dehydration

Plan A: Oral rehydration therapy for patients with no dehydration

Plan B: Oral rehydration therapy for patients with moderate dehydration

Plan C: Intravenous rehydration for patients with severe dehydration

For Plan C-

• Start the intravenous (IV) treatment immediately, to restore normal hydration within 3 to 6 hours. Hang the infusion bag as high as possible to facilitate rapid flow. Large caliber catheters (16G, 18G) should be used. If large catheters cannot be placed, two parallel IV lines can be used, to ensure rapid administration of Ringer’s Lactate.
• Ringer’s lactate is the first choice out of all the IV fluids.
• If Ringer’s lactate is not available, normal saline or 5%glucose in normal saline can be used.
• Plain 5%glucose solution is not recommended.

Q2. Can breastfeeding mothers in a cholera outbreak receive an Oral Cholera Vaccine and still breastfeed?

Ans. Yes, She can

Q3. How to prepare food for infants 6 months and above during a cholera outbreak?

Ans. Environmental Health Issues is critical

Due emphasis is needed on: -

• Personal Hygiene
• Food safety
• Water quality
• Sanitation

Thank you for your post, dear colleague from Ethiopia. Our apologies for the misunderstanding. We are not seeking answers to those questions in our post (as we have them, and thanks also for your contribution). The questions were merely an example.  We are seeking questions on any programmatic challenges any field practitioner may have dealing with IYCF and Cholera. We hope to generate sufficient questions from field workers, so we can better shape our tools and/or redesign some existing guidance. 

Thank you for your post, dear colleague from Ethiopia. Our apologies for the misunderstanding. We are not seeking answers to those questions in our post (as we have them, and thanks also for your contribution). The questions were merely an example.  We are seeking questions on any programmatic challenges any field practitioner may have dealing with IYCF and Cholera. We hope to generate sufficient questions from field workers, so we can better shape our tools and/or redesign some existing guidance. 

Hi All, I worked in two cholera outbreak while I was a nurse with MSF, so I thought I would write back based on my experience of what would be useful to know. The questions I thought of are based on what I think I needed to know as a CTC lead if presented with a mother and infant/child 0-23 months.

• If the mother has clear signs of cholera but the child doesn’t, should I admit them both into the CTC? My concern here would be putting the child at risk of infection. Do I need an isolation unit within the (already isolated) CTC/U?
• If the mother has diarrhoea, but it may or may not be cholera or it may be a mild case, do I admit them both? I’ve seen some cases in the past where I wasn’t sure if the patient had gastro rather than cholera; also, cholera (from my understanding) can range from the very severe cases to milder cases that only require ORS. If the mother may or may not have cholera, or is a milder case, does that change my decision to admit both?
• Is it safe for an infant/child to breastfeed if the mother has cholera? This question may not be so useful to you – a very quick scan of the MSF and WHO guidelines show that yes, mothers should continue to breastfeed. But it is a question I would ask myself.
• If the woman is severely dehydrated, will the infant get sufficient breastmilk? How will I know if the infant is not getting sufficient, and what should I do if I suspect the child isn’t getting enough? Bottle feeding is dangerous enough at the best of time, but in a CTC I would be very concerned.
• How do I protect the child from being infected if I don’t think the child has cholera? How susceptible are infants and young children? Are the signs and symptoms the same as for an older child? How do I protect a non-mobile infant vs a toddler who is walking, especially if the mother is very sick and can’t keep an eye on the child (and as the dad of two, I know how much trouble a toddler can get into when you take your eyes off them for 10 seconds…). Are the regular prevention strategies (copious amounts of chlorine) safe for infants? What are the precautions for a breastfed only child vs a child who is complementary feeding?
• What are the treatment protocols for children under 2 years? This may be a bit off topic, as it is not actually related to IYCF, rather just the age group.
• For the older child (12-23 months), what if another relative wants to bring the child in to breastfeed but then at other times wants to keep the child away from the CTC? Is that dangerous? Does it put the community at risk?
• What about women with children turning up at a community rehydration points with children? What messages should we pass to them?
• Should any of the above be different depending on whether it is a CTC or CTU?

Basically, I would be trying to balance the risk of the child falling into malnutrition vs the risk from cholera. Anything to help me make decisions in that respect would be helpful. Hope these are useful