What Do You Mean, I Shouldn’t Breastfeed?

You’ve heard the mantra from health care professionals:  “Breast is best.”  While there are very good reasons for this advice, there is a subset of Moms who, for one reason or another, have been told that they simply can’t breastfeed.  And there are others in the “gray zone”:  they may hear conflicting bits of advice to only breastfeed, only bottle feed, or anything in between.  Let’s take a little time to talk about who absolutely should stay away from giving their little one breast milk; who may need to mostly or completely give formula; who can breastfeed with a little tweaking; and possibly even a few other variations on the feeding theme.

Who Really, Truly Shouldn’t Breastfeed?

There are very few situations where a mother who wants to nurse shouldn’t give it a go.  They can be divided into the following categories:

  • Certain medical conditions in Moms, most of which are infectious. The best known of these is probably the human immunodeficiency virus (HIV), which is transmitted in breast milk.
  • Certain medications that a mother might be taking. While there isn’t an all-inclusive list here, it’s actually a relatively small number of medications that will totally nix nursing.  Some examples are radioactive substances, cancer chemotherapeutic agents, some migraine medications, amphetamines (which are often used for attention deficit disorder), and statins (used to lower high cholesterol).  As a rule, most illegal drugs are not compatible with breastfeeding.
  • A very few conditions present in infants. The biggest prohibition is on breastfeeding an infant with galactosemia.  This is a rare condition where an infant can’t process a sugar known as galactose (which is actually part of lactose, the familiar milk sugar).  The newborn screen—that drop of blood that’s collected from all babies before anyone will send you home—will test for galactosemia.  Prenatal testing is available for the disease, which is especially important if a family member has it.

Let’s talk about the alternatives to breastfeeding.  If it’s Mom’s medical condition (including medications) that forbids nursing, any standard infant formula is usually a good choice.  Although companies tout this or that additive as making formula “close to breast milk,” there is not enough evidence to support one formula over another based on most additives.  The only exception is iron, which is incredibly important for growth and development.  (Read a little more about myth vs. reality regarding iron in formula here.)

If the breastfeeding ban is because of an infant issue, often some or all standard infant formulas can’t be given either.  Many babies in this situation will see a specialist (often in the field of genetics) who can give advice on the correct formula.  In any case your newborn’s provider (or your provider, since some conditions can be diagnosed prenatally) will help guide you in formula selection.

That “Gray Zone” Thing

There are several conditions where babies may be able to take breast milk, but may not be able to fully breastfeed.  There are many variations in Mom’s and the baby’s situation.  In addition, providers differ in their approach, and sometimes new research changes things.  Because of this, your provider will be the best source on what to do in your own unique case.  (Ever notice that manuals debug every problem except “your problem”?  That’s one reason that babies don’t come with instructions.)  Following are several examples as to how the nursing process may need to be tweaked a little:

  • Phenylketonuria (PKU): another metabolic disease diagnosed with the newborn screen.  Nowadays it’s thought that some breastfeeding is OK, but too much risks an overload of the amino acid phenylalanine.  Fine-tuning this is usually done with the help of specialists in genetics and nutrition.
  • Some medications and infections may mean no nursing temporarily, but Mom may be able to pump and initiate or resume nursing when these are out of her system. One of the more common infections where this comes up is herpes simplex virus infection on the breast.  (In this case, sometimes Mom can use the other breast if it’s not affected and the infection can be covered.)
  • Some infections, including untreated tuberculosis and chicken pox, mean no putting of the baby to the breast, but milk can be pumped and given that way.
  • Where some medications are concerned, timing is everything. (Alcohol—assuming your provider OKs small amounts after the baby is born—is in this category.)  In many cases this involves nursing before taking the next dose.  Providers have databases on what we know about medications at their disposal.

Finally, there are mother-baby pairs who have “none of the above,” but for whatever reason, the little one is just simply not getting enough, or, in some cases, any milk by breast.  Working with a lactation specialist is always a good idea; depending on individual situations, pumping and giving by bottle (or sometimes by tube, to encourage eventual successful nursing) are options.  And there is the evolving field of donor milk.

We’re fortunate in the U.S. to have nutritional alternatives when breastfeeding is not possible.  (For example, in some developing countries, HIV-positive women are encouraged to breastfeed because there is no better option.)  We’re also finding ways to include breast milk in an infant’s diet in ways that didn’t seem possible.  The field is constantly evolving, which leads to another oft-quoted mantra:  talk to your provider!  And realize that if you can’t breastfeed, or can only partially do so, your baby can still have a great start in life.

Stan Sack
Dr. Stan Sack has 29 years’ experience as a primary care pediatrician in Massachusetts and Florida. A medical writer since 2015, he enjoys blogging on topics that are on parents’ minds but are covered less often in books and on websites. He lives in the Florida Keys with his family and enjoys healthy cooking, fitness activities and singing in his spare time.

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