Breastmilk is the ideal in infant nutrition, and breastfeeding the optimal delivery system.  The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life and continued breastfeeding with the addition of appropriate complementary foods for at least one year, and thereafter for as long as mother and baby desire.  The benefits of breastfeeding in terms of nutrition, increased resistance to diseases, allergy protection and psychosocial development, make it the most important, cost effective substance we have in medicine today. 
Unfortunately, breastfeeding has been implicated as a possible mode of transmission of various forms of hepatitis from mothers to their infants.  Acute viral hepatitis is a frequent cause of liver disease in the United States and results in significant illness and sometimes death. The range of viruses of concern is expanding significantly and has become a true alphabet soup, with Hepatitis A, B, C, D, E, and now Hepatitis G as well.  Fortunately, transmission of most forms of hepatitis via breastfeeding is rare.

Hepatitis A Virus (HAV)

Hepatitis A virus occurs worldwide and is transmitted predominantly by the stool-hand- mouth route, through person-to-person contact or by contaminated food or water.  Hepatitis A is characterized by an acute feverish illness with jaundice (yellow color to the skin and eyes), loss of appetite, nausea and malaise (general discomfort and tiredness).  Newborns are rarely infected, and in infants and preschool-aged children, most infections either have no symptoms or cause mild, non-specific symptoms without jaundice.  Severe, fatal Hepatitis A is rare, and chronic infection does not occur. 

Hepatitis A, even during the acute infectious period, is not a contraindication to breastfeeding. Perinatal (mother-to-child around the time of delivery) transmission of Hepatitis A is rare, and there is no evidence for transmission through breastmilk. Some experts have advised giving the infant immune globulin if the mother has the onset of symptoms in the period from two weeks before to one week after delivery.  Even without immune globulin, severe disease has not been reported in infants. Careful hand washing should still be emphasized to the mother.

Hepatitis B Virus (HBV)

Hepatitis B virus is transmitted by sexual contact, perinatally, and rarely congenitally (mother-to-child during pregnancy). A major route of transmission from an infected mother to her baby is via contact with blood at the time of birth.  Household contacts of Hepatitis B virus carriers are also at high risk of acquiring infection.  Hepatitis B virus (HBV) causes a wide spectrum of infections, ranging from a blood infection without symptoms, sub-acute illness with nonspecific symptoms (loss of appetite, nausea, malaise) and clinical hepatitis with jaundice, to severe, fatal hepatitis.  Infection without symptoms is most common in young children. 
Chronic HBV virus infection occurs in as many as 90% of infants who become infected around the time of birth, and in 6-10% of older children, adolescents and adults who become infected in infancy and childhood.  Chronically infected persons are at increased risk for developing chronic liver disease (cirrhosis, chronic active hepatitis, chronic persistent hepatitis) or liver cancer in later life.

Hepatitis B antibodies have been detected in breastmilk from women who test positive for Hepatitis B.  However, studies from Taiwan and England have shown that breastfeeding by Hepatitis B positive women does not significantly increase the risk of infection among their infants. Infants born to known Hepatitis B positive women should receive Hepatitis B immune globulin (HBIG) and Hepatitis B vaccine (HBV), effectively eliminating any theoretical risk of transmission through breastfeeding.  Mothers with Hepatitis B should be encouraged to breastfeed.

Hepatitis C Virus (HCV)

Hepatitis C is characterized by mild or asymptomatic infection with slow onset of jaundice and malaise.  In some cases, the symptoms come and go.  An average of 50% of the patients develop chronic liver disease, including cirrhosis.  Liver cancer may be associated with Hepatitis C as well as chronic Hepatitis B infections.  Hepatitis C virus (HCV) occurs worldwide and can be transmitted by contact with blood or blood products through transfusions, injecting  drug use, sexual contact or needle-stick exposure. 
The risk of perinatal transmission is approximately 4 % although reported rates of transmission vary depending on a variety of factors. Overall, the risk of perinatal transmission of HCV appears extremely low.  Several recent studies demonstrate no increased risk of transmission caused by breastfeeding.  All major health organizations: the World Health Organization, the Centers for Disease Control, the National Institutes of Health and the American Academy of Pediatrics recommend or support breastfeeding by Hepatitis C carrier mothers. The baby should be checked periodically for HCV antibodies during the first 12 to 18 months of life whether or not the infant is breastfed.

Conclusion

Due to space constraints, we limited our information to Hepatitis A, B and C.  However, each hepatitis virus carries its own risk of illness.  The risks of breastfeeding with maternal hepatitis should be weighed against the known risks of NOT breastfeeding in each individual case and environment.

For more information about breastfeeding and hepatitis or breastfeeding in general, go to www.breastfeeding.org.

  CSSD Division of Neonatology