Many health practitioners in the field of IYCF are raising the question of whether a breastfeeding woman who gets infected with MPOX should CONTINUE or STOP providing breastmilk or breastfeeding. Some guidance has been written by reputable agencies. However, I highly recommend reading the following letter that was written in 2022: Is monkeypox virus transmissible by breastfeeding? Van de Perre P, Molès JP, Rollins N. Pediatr Allergy Immunol. 2022 Oct;33(10):e13861. doi: 10.1111/pai.13861. PMID: 36282140. It gives more guidance on how to approach the search of the answers to this question. I am aware you might not have access to this article so I have posted the text here below. I recommend to read especially the text in bold. Note, this letter is from 2022 and new guidance might have come up since.
To the Editor,
Since early May 2022, more than 92 non-endemic-prone countries
have been facing an outbreak of monkeypox virus (MPXV) infections. As of 7 September 2022, approximately 53,000 confirmed or suspected cases have been reported to World Health Organization (WHO) and/or European Centers for Disease Control.1 The virus circulating in non-endemic-prone countries is related to the West African Clade. However, the current outbreak shows some differences in clinical features compared to infections in Central and West Africa endemic-prone
areas. Most cases are non-severe with so far, only 18 deaths reported; in contrast, in endemic-prone areas fatality rates are commonly between 3% and 10%. The vast majority of persons affected in this outbreak
are male (and mainly men having sex with men), while in endemic
prone, MPXV countries women are almost equally affected. There
is however concern that many more women of childbearing age
will be affected if the extremely high household transmission rates
as seen in endemic areas are manifest in the present outbreak.
As for many other viral infections, children, pregnant/postpartum
women, and immunodeficient individuals from endemic areas
are at higher risk of developing severe, sometimes fatal forms of
MPXV infection. As observed in smallpox, it is very likely that infants
infected with MPXV present frequently with severe or lethal
forms of the disease. MPXV belongs to the poxviruses family and the Orthopox genus. Orthopoxviruses include 4 viruses of importance for human health: the variola virus responsible for smallpox, the vaccinia virus, the cowpox virus, and the MPXV. There is a 90% genomic homology between variola virus and MPXV. The four human orthopoxviruses share significant characteristics such as a mucocutaneous tropism, animal-to-human, and human-to-human
transmission routes. Known transmission routes involve skin-to-skin,
mucosa-to-skin, skin-to-mucosa direct contacts (especially with lesional and paralesional areas) as well as air droplets respiratory transmission from individuals with MPXV lung shedding and transmission from direct contact with contaminated fomites surfaces.
One of the haunting questions related to MPXV epidemiology is whether the virus can be transmitted through breastfeeding. We recently proposed a Koch's postulate-derived conceptual framework to establish whether viruses are transmitted through breastfeeding based on five criteria.2
1. There is evidence for viral infection in infants receiving breast
milk from infected mothers.
2. Virus, viral antigen, or viral genome is present in the breast milk of
infected mothers.
3. The virus in breast milk is capable of replication.
4. Other relevant transmission routes (e.g., by transplacental, airborne
droplets, arthropod bites, and blood-borne routes) potentially associated
with breastfeeding have been reasonably ruled out.
5. Transmission by breast milk can be reproduced by oral inoculation
in an animal model.
We searched the literature for evidence related to each of these criteria to examine the likelihood of MPXV transmission through breastfeeding. First, we searched the literature for data related to MPXV –where
almost no data was available –then broadened the search to human orthopoxviruses taking into consideration their likely shared routes of transmission. Here, we summarize the available evidence for each criterion:
1. One very likely case of perinatal transmission of MPXV has
been reported in Democratic Republic of Congo (DRC) in 1988
from a woman with likely MPXV infection at 24 weeks of gestation
and her neonate with a generalized skin infection; infant
feeding practices were not, however, described.3 More recently,
symptomatic neonatal infection as a result of mother-to-
child
MPXV infection has been confirmed in DRC.4 Furthermore,
congenital cases of smallpox have been described in India,
but again with no data on infant feeding modalities.5 More
meaningful is the case of vaccinia transmission within a family
following vaccination, even when social distancing practices
were observed, starting from the vaccinated person to his wife
and then to her breastfed baby.6 No attempt was reported
to detect vaccinia virus DNA or viral particles in breast milk
and direct contact of the infant's oral mucosae with lesions
on both maternal areolas remains the more likely route of
transmission.6 This case report supports the current Centers
for Disease Control and Prevention (CDC) recommendations
that a woman who received smallpox vaccine during pregnancy
or breastfeeding should avoid breastfeeding and handling any
baby for at least 3–4
weeks.7 CDC further recommends that
while breast milk supply can be maintained through expression, the expressed milk should be discarded. Criteria 1 is therefore
not fully satisfied.
2. Vaccinia virus DNA and viral particle shedding have been demonstrated
in the milk of infected cow, and this virus has been shown
to be infectious.8 However, similar observations in humans for
any of the human orthopoxviruses are presently lacking. Criteria
2 and 3 are therefore not satisfied either.
3. No data are available that could validate criteria
4. However, a robust murine model involving non-traumatic inoculation of murine pups with contaminated milk exists that reproduces vaccinia virus transmission by breastfeeding, confirming therefore the fifth criteria.9
Based on the conceptual framework described above and noting
that more than two criteria are undocumented, there is insufficient evidence to infer that transmission of MPXV and/or of human orthopoxviruses takes place thought breastfeeding. More research is needed to determine possible routes and risks of mother-to-child
transmission of human orthopoxviruses through breast milk and breastfeeding. However, even if the occurrence of breast milk transmission of MPX is unknown, there is a high risk of mother-to-child(or child-to-mother) transmission while breastfeeding, due to direct contact with infectious skin or mucocutaneous lesions, including face-to-face, skin-to-skin, mouth-to-mouth, or mouth-to-skin contact. These considerations support the current WHO recommendations on infant feeding in the context of maternal MPXV infection that include case-by-case assessment of transmission risk and, when there is active maternal MPXV infection, the possibility of isolation of the mother from the infant to prevent transmission of the virus.10 Administration of expressed breast milk from a MPXV-infected woman to the infant may be hazardous because of the risk of contamination by mucocutaneous viral shedding during milk collection.
KEYWORDS
breast milk, breastfeeding, human orthopoxviruses, monkeypox
virus, mother-to-child-transmission
PEER REVIEW
The peer review history for this article is available at https://publo
ns.com/publo n/10.1111/pai.13861.
Philippe Van de Perre1
Jean-Pierre Molès1
Nigel Rollins2
1INSERM, Univ Montpellier, Etablissement Français du Sang, Univ
Antilles, Montpellier, France
2Department of Maternal, Newborn, Child and Adolescent
Health and Ageing, World Health Organization, Geneva,
Switzerland
Correspondence
Philippe Van de Perre, UMR 1058 "Pathogenesis and Control
of Chronic and Emerging Infections" INSERM –Université Montpellier –EFS –Université des Antilles, Inserm ADR Languedoc-Roussillon,
60, rue de Navacelles, 34394 Montpellier Cedex 5, France.
Email: philippe.vande-perre@inserm.fr
Editor: Carmen Riggioni
ORCID
Jean-Pierre Molès https://orcid.org/0000-0002-6863-6350
REFERENCES
1. https://www.who.int/publi catio ns/m/item/multi -count
ry-outbreak-of-monkeypox--external-situation-report--1---6-july-2022
2. Van de Perre P, Moles JP, Nagot N, et al. Revisiting Koch's postulate
to determine the plausibility of viral transmission by human milk.
Pediatr Allergy Immunol. 2021;32:835-842.
3. Jezek Z, Fenner F. Human Monkeypox. Karger; 1988.
4. Mbala PK, Huggins JW, Riu-Rovira T, et al. Maternal and fetal outcomes among pregnant women with human monkeypox infection in
the Democratic Republic of Congo. J Infect Dis. 2017;216:824-828.
5. Fenner F, Henderson DA, Arita I, et al. Smallpox and Its Eradication.
World Health Organization; 1988.
6. Garde V, Harper D, Fairchok MP. Tertiary contact vaccinia in a
breastfeeding infant. JAMA. 2004;291:725-727.
7. Drugs and Lactation Database (LactMed) [Internet]. Bethesda
(MD): National Library of Medicine (US); 2006. Smallpox Vaccine.
[Updated 2020 Jul 20]. Available from: https://www-ncbi-nlm-nih-gov.
proxy.inser mbibl io.inist.fr/books/ NBK50 1099/
8. Moreira Ludolfo de Oliveira T, Maldonado Coelho Guedes MI,
Rehfeld IS, et al. Detection of vaccinia virus in milk: evidence of a
systemic and persistent infection in experimentally infected cows.
Foodborne Pathog Dis. 2015;12:898-903.
9. Rehfeld IS, Maldonado Coelho Guedes MI, Soares Fraiha AL, et al.
Vaccinia virus transmission through experimentally contaminated
milk using a murine model. PLOS One. 2015;10:e0127350.
10. WHO. Clinical management and infection prevention and control of
monkeypox. Interim rapid response guidance 10 June 2022. WHO
reference number: WHO/MPX/Clinical_and_IPC/2022.1.
13993038, 2022, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pai.13861 by Johns Hopkins University, Wiley Online Library on [30/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Dear Mija,
Thank you for sharing, I am not able to trace the article if you have the link could be interesting.
By the way, it's a question we had from around Africa yesterday during a meeting dedicated to MPox in Africa and according to my research in the interim guidance of 2022 here are the recommandation :
Feeding of infants in mothers infected with MPX
(1 recommendation)
WHO recommends that infant feeding practices, including whether to stop breastfeeding in a mother with
MPX, should be assessed on a case-by-case basis, considering the general physical status of the mother and
severity of disease, which could impact on the risk of transmission of MPX from mother to infant.
Remarks:
It is currently unknown whether the MPX virus or antibodies are present in the breastmilk of lactating women
The known risks associated with withholding the protections conferred by breastfeeding and the distress
caused by separation of mother and infant, must be given greater weight in a risk/benefit calculation than
the potential and unknown risk of infection from MPX in the infant
Protecting the child’s survival while maintaining the nutritional intake of the infant is the priority (e g avoiding
diarrhoeal illness associated with contaminated formula milk due to unclean water or unhygienic practices)
Infants of mothers with MPX should be closely monitored for signs and symptoms with the main goal of early
supportive care to prevent the development of severe disease and poor outcomes
General protective IPC measures should be taken by mothers with MPX when handling and feeding their
infants, e g washing hands before and after each feeding, wearing a mask (if possible) and covering any
lesions on the areola or on areas which have direct contact with the infant Alternatively, if only one breast has
lesions, mothers can express/pump from the breast with lesions on the areola and discard the milk and feed
from the non-affected breast In all cases, monitor the mother-infant pair closely for development of signs and
symptoms of MPX and treat accordingly
If the infant is less than 6 months and is separated from their mother who has MPX, the infant should be fed
with donor human milk or appropriate breastmilk substitutes, informed by feasibility, safety, sustainability,
cultural context, acceptability to mother and service availability
For infants 6–23 months of age who cannot access donor human milk or appropriate breastmilk substitutes,
whole cream animal pasteurised milk is appropriate as part a balanced diet along with complementary foods
Comprehensive assistance should be provided for any mother who stopped breastfeeding due to MPX (or any
other reason) for re-lactation to re-establish a milk supply and continue breastfeeding
In the event of replacement feeding with breastmilk substitute, it is essential to track the infant’s growth,
development and other illnesses as well as for signs and symptoms of MPX
If the mother of an infant or young child has been exposed to MPX and has no symptoms suggestive of
infection, the infant or child should not be separated They should continue breastfeeding while closely
monitoring for signs and symptoms of MPX
The key take away for me and it was also the message of yesterday is: analyse case by case the benefit risk before taking any decision, which I think should be largely spread among YICF and IFE / GNC recommandation to be share within one pager only with practical tips and key take away practic to be implemented by community helaht worker and any other people on the ground who might be in need of support.
Here the reference in french: https://iris.who.int/bitstream/handle/10665/360839/WHO-MPX-Clinical-and-IPC-2022.1-fre.pdf
Answered:
3 months agoThanks Chantal, I think the WHO information is very helpful. Great you shared the link here.
You asked for the link to the letter I shared. This letter is behind a paywall so it won't help if I share the link. Anyone can Google this citation: Van de Perre P, Molès JP, Rollins N. Is monkeypox virus transmissible by breastfeeding? Pediatr Allergy Immunol. 2022 Oct;33(10):e13861. doi: 10.1111/pai.13861. PMID: 36282140. It will bring you eventually to the paywall. I am happy to share the pdf file with you. Just send me an email.
Many questions regarding mpox and breastfeeding remain.
- Is sealing off the lesions while breastfeeding feasible and sufficient?
- We don't know whether the virus is in the breastmilk of an infected mother—even if traceable through testing, will it be viral particles or a replicable virus? It is fairly easy to study, yet it is so often not a priority for health agencies to determine, sadly.
Even if breastmilk is virus-free, how substantial is the risk of intra-household transmission as close contact is such an important mode of transmission mode.
To name a few questions.....
Answered:
3 months agoThank you Mija,
Let me rebon on that: Even if breastmilk is virus-free, how substantial is the risk of intra-household transmission as close contact is such an important mode of transmission mode.
- To name a few questions.....
This is why also we need clear guidance, suggestion from specialist, health one know how to protects the wound, but nutrition should jump in and work together with healht team to propose the best "IPC" measures we can to protect the child contamination by contact.
Best
C.
Answered:
3 months agoFor all who are looking for additional recent material from scientific papers, we also have:
(in all of these, breastmilk/feeding is discussed to some extent)
A healthcare provider unknowingly treated a patient with mpox and subsequently developed ocular mpox without rash. She breastfed during illness; her infant was not infected. This report addresses 3 challenges in mpox management and control: diagnosis in the absence of rash, exposures in healthcare settings, and management of lactating patients.
Sara Lovett, Jayne Griffith, Nick Lehnertz, Teresa Fox, Greg Siwek, Aaron M T Barnes, Aaron D Kofman, Kaitlin Hufstetler, Alexander L Greninger, Michael B Townsend, William C Carson, Ruth Lynfield, Shama Cash-Goldwasser, Ocular Mpox in a Breastfeeding Healthcare Provider, Open Forum Infectious Diseases, Volume 11, Issue 6, June 2024,
ofae290, https://doi.org/10.1093/ofid/ofae290
"Validating Tools to Detect and Inactivate Monkeypox Virus in Human Milk"
Daungsupawong H, Wiwanitkit V. Re: "Validating Tools to Detect and Inactivate Monkeypox Virus in Human Milk" by Clark et al. Breastfeed Med. 2023 Dec;18(12):960. doi: 10.1089/bfm.2023.0224. Epub 2023 Nov 29. PMID: 38016148.
(I don’t have access to this paper)
This case report describes a neonate from an infected, originally breastfeeding woman.
Castejon-Ramirez S, Pennington J, Beene H, Hysmith N, Ost S. A Case of Neonatal Monkeypox Treated With Oral Tecovirimat. Pediatrics. 2024 Jan 1;153(1):e2023061198. doi: 10.1542/peds.2023-061198. PMID: 38148743.
Note that recommendations regarding continuation or halting breastfeeding in these publications should be interpreted with the geolocation and specific context in mind.
Mija
Answered:
3 months agoDear Mija and Chantal,
Thank you for this discussion. I found the article difficult to read, but the advice from WHO much clearer. We also need to remember what we have learnt and mistakes we have made in the past when providing advice on breastfeeding and possible mother-to-child transmissions of diseases. I think the basics are important to remember:
- the risk of non-breastfeeding often far outweighs the very minimal possible risk of a disease
- mother's will not want to do harm by breastfeeding if we create any form of doubt that their breastmilk or lesions might be harmful
- the infant has most probably already been exposed and been in close proximity to the virus if somebody has been infected in the household ones we assess the situation
- we know that breastmilk most often contain the antibodies of diseases in the mother's environment (like with COVID-19)
- even if the virus is in breastmilk it still needs to pass the child's gastro-intestinal system and might just be broken down there, especially if the child is exclusively breastfed
I hope we can continue to ensure we provide advice from research on breastfeeding that is already available, and even though there might be remaining questions I hope we can put them into the context of what we already know.
Answered:
3 months agoDear Astrid
You make good points. The WHO guidance is clear that it is important to take a precautionary approach, balancing the risk of not breastfeeding against the risk of disease. These are lessons from the HIV and COVID-19 epidemics, and they are especially important in low resource settings.
Answered:
3 months agoDear all,
Posting for reference two resource hubs which have additional useful information:
Mpox Resource Hub | Nutrition Response | Global Nutrition Cluster
Best,
Answered:
3 months agoMpox and breastmilk: for once, can we act in time? - The Lancet
For those interested, we wrote this letter as a call for action to align recommendations but also to address the very important question of whether breast milk actually carries a viable mpox virus.
Mpox and breastmilk: for once, can we act in time? - The Lancet
or
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01881-6/fulltext
Regards, Mija
Answered:
3 months agoDear all,
Just to share that UNICEF released an internal technical note on nutrition and Mpox case management which aims to provide guidance on the Nutrition-Mpox response for UNICEF and partner staff.
https://www.nutritioncluster.net/resources/unicef-internal-technical-note-nutrition-and-mpox-case-management
For more resources on mpox and nutrition, please check out:
Mpox Resource Hub | Nutrition Response | Global Nutrition Cluster
Thank you!
Answered:
3 months agoDear all,
For those interested, here are 2 new resources on mpox and IYCF-E:
- Template joint statement on IYCF-E in the context of mpox (in English) | Modèle Déclaration Conjointe sur l'Alimentation des Nourrissons et des Jeunes Enfants dans le Contexte de Mpox (en français): this template joint statement is to be used by countries who wish to adapt it in order to help secure immediate, coordinated, multi-sectoral action on infant and young child feeding (IYCF) in line with IYCF guidance in the context of the mpox response.
- Frequently Asked Questions (FAQs): breastfeeding in the context of mpox – information for health workers (version 1): These FAQs are intended to provide answers to health workers and the public – including mothers who are breastfeeding or expressing milk – on breastfeeding during the current mpox outbreak. A decision tree shows how health workers in maternity services, paediatric units, nutritional units and community settings may implement these recommendations as part of their daily work with mothers and families.
Thank you!
Dima
Answered:
2 months ago"Do breastfeeding mothers in DR Congo have access to the mpox vaccine?" - The Lancet Global Health
For those interested to follow the conversation on mpox vaccine and breastfeeding, please see this correspondence published just yesterday. It calls for the consideration of breastfeeding women for mpox vaccines and provision of clear recommendations.
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(24)00423-6/fulltext
Best regards,
Dima
Answered:
2 months agoA new release of by:
République Démocratique du Congo, Ministère de la Santé Publique, Hygiène et Prevention - Programme National de Nutrition -PRONANUT
Guide de prise en charge nutritionnelle et du soutien alimentaire dans le contexte de la maladie à virus M-Pox en République Démocratique du Congo
Oct 2024
It's worth reading for everyone working on MPOX, especially in DRC. Unfortunately, I don't have the website link, but you surely can obtain it via the Nutrition Clustre in DRC:
The document also addresses issues around breastfeeding, breastmilk and mpox.
Answered:
1 month agoDear All,
The Frequently Asked Questons (FAQs) on Breastfeeding in the context of mpox - information for health workers are now available in French.
"QUESTIONS FRÉQUENTES : L’allaitement dans le contexte du Mpox – informations pour les professionnels de santé"
These FAQs are intended to provide answers to health workers and the public – including mothers who are breastfeeding or expressing milk – on breastfeeding during the current mpox outbreak. A decision tree shows how health workers in maternity services, paediatric units, nutritional units and community settings may implement these recommendations as part of their daily work with mothers and families.
Thank you!
Dima
Answered:
1 month agoUpdate:
The UNICEF internal technical note on nutrition and mpox case management is now available in French at this link:
"Note technique interne de l'UNICEF: recommandations provisoires sur la nutrition et la gestion des cas de mpox".
Thank you.
Dima
Answered:
22 days ago