Katherine Shealy

Travel need not be a reason to stop breastfeeding. The medical preparation of a breastfeeding traveler (mother or child) differs only slightly from that of other travelers, and depends in part on whether the mother and child will be separated or together during travel. Most travelers should be advised to continue breastfeeding throughout and after travel.

Prior to departure, health-care providers can help breastfeeding mothers find out about available breastfeeding support at their destination. Mothers may wish to have with them a written list of local breastfeeding resources.

• International Board-Certified Lactation Consultants (IBCLCs)—health professionals in approximately 50 countries who specialize in the clinical management of breastfeeding; see www.ilca.org/falc.html .
• La Leche League Leaders (LLLLs)—trained and accredited volunteer mothers in approximately 60 countries who provide mother-to-mother breastfeeding support and help; see www.llli.org.

Mothers who plan to use a breast pump while traveling should have a back-up option available, including written instructions for hand expression.

Immunizations and Medications

In almost all situations, health-care providers can and should select immunizations and medications that are compatible with breastfeeding. It is inappropriate to counsel mothers to wean to be vaccinated, as well as to withhold vaccination due to breastfeeding status.

• Breastfeeding and lactation do not affect dosage guidelines for any immunization or medication (except certain considerations for yellow fever vaccine, see below); regardless of maternal dose, children always require their own immunization or medication.
• In the absence of documented risk to the breastfeeding child of a particular maternal medication, the known risks of stopping breastfeeding outweigh a theoretical risk of exposure via breastfeeding.

Immunizations

• Breastfeeding mothers and children should be vaccinated according to routine, recommended schedules; only preventive vaccinia (smallpox) vaccine is contraindicated for use in breastfeeding mothers.
• Administration of live and inactivated vaccines does not affect lactation, milk supply, or breast milk safety.

Special Consideration: Yellow Fever Vaccination

• When possible, vaccination of breastfeeding mothers should be avoided, due to the possible risk for the transmission of 17D virus to the breastfeeding child.
• Breastfeeding mothers whose travel to high-risk yellow fever-endemic areas cannot be avoided should be vaccinated (see the Yellow Fever section in Chapter 2).

Medications

• The American Academy of Pediatrics (AAP) 2001 Policy Statement: Transfer of Drugs into Human Milk provides an overview of the compatibility or effects on breastfeeding of approximately 250 drugs.
• Medications and Mothers’ Milk is updated every 2 years and provides a comprehensive review of the compatibility or effects on breastfeeding of approximately 1,000 drugs including generic and trade names, AAP recommendations, risk categories, pharmacologic properties, interactions with other drugs, suitable alternatives, theoretic and relative child dose, pediatric half life, and any other pediatric concerns.

Special Consideration: Antimalarial Medications

• Most experts consider short-term use of doxycycline compatible with breastfeeding.
• Primaquine may be used for breastfeeding mothers and children with normal G6PD levels.
• Breastfeeding mothers should not use atovaquone/proguanil (Malarone) when the breastfeeding infant weighs <5 kg (approximately 11 pounds).

Air Travel

X-rays used in airport screenings have no effect on breastfeeding, breast milk, or the process of lactation. Airlines typically consider breast pumps as personal items to be carried onboard, similar to laptop computers, handbags, and diaper bags.

Prior to departure, mothers who will be traveling by air and expect to have expressed milk with them during travel need to carefully plan how they will transport their milk.

• Airport security regulations for passengers carrying expressed milk vary internationally and are subject to change.
• In the United States, the Transportation Security Administration (TSA) recognizes expressed milk in the category of liquid medications that may be carried on, regardless if the breastfeeding child is traveling, as long as it is declared prior to screening.
  • TSA recommends that travelers carrying expressed milk have with them a printed copy of the TSA website page and URL, www.tsa.gov/travelers/airtravel/children/formula.shtm , to help prevent inadvertent problems at security checkpoints.
• Travelers carrying expressed milk in checked luggage should refer to cooler pack storage guidelines in “Proper Handling and Storage of Human Milk” on CDC’s website at www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm to protect milk during travel.
• Expressed milk is not considered a biohazard to which Universal Precautions apply. International Air Transport Authority (IATA) regulations for shipping Category B Biological Substances (UN 3373) do not apply to expressed milk; it is considered a food for individual use. Travelers shipping frozen milk should follow guidelines for shipping other frozen foods and liquids.
• Expressed milk does not need to be declared at U.S. Customs upon return to the United States.

Traveling Without a Breastfeeding Child

Travel health-care providers should help mothers determine the best course for breastfeeding based on a variety of factors, including the amount of time she has to prepare for her trip, her flexibility of time while traveling, her options for storing expressed milk while traveling, the duration of her travel, and her destination.

• Mothers should continue feeding at the breast until departure. Feeding from a bottle or a cup is more successful when offered by a caregiver other than the mother.
• Mothers may wish to express and store a supply of milk to be fed to the child during their separation.
• Travel health-care providers should encourage mothers to learn and practice expressing milk by hand prior to departure.
  • Hand expression (i.e., without the use of a breast pump) is the most hygienic and most reliable method of milk expression, especially in environments with uncertain electricity and sanitation options. For more detailed instructions for hand expression, see www.workandpump.com/handexpression.htm.
• Electric breast pumps can also be powered by vehicle lighter adapters and battery pack adapters, which are available from retailers who sell breast pump supplies.
• Expressing milk while separated from the breastfeeding child helps a mother maintain her milk supply during the separation, which makes transitioning back to breastfeeding more likely to be successful, even if expressed milk is not kept to be fed to the child.
• A mother who is interested in resuming breastfeeding after travel should always try first with the child rather than deciding independently that it is not possible. Some children, especially older breastfeeding children, resume breastfeeding regardless of the length of time they are separated from their mother, even if she did not express milk.
• If the mother’s milk supply is diminished upon return, she can continue breastfeeding and supplement as needed until her milk supply returns to its prior level.
  • Often a child who is allowed frequent, positive opportunities to breastfeed without time restrictions will bring the milk supply to its prior level.
  • Occasionally a child who is separated from the mother for an extended time has difficulty transitioning back to breastfeeding.

Traveling With a Breastfeeding Child

Breastfeeding provides unique benefits to mothers and children traveling together. Health providers should encourage breastfeeding mothers by explaining clearly the value of continuing breastfeeding during travel.

• Exclusive breastfeeding, which is consuming no foods or liquids other than breast milk and consuming breast milk only while at the breast, protects infants from exposure to contamination and pathogens via foods, liquids, or containers (e.g., bottles, cups, utensils).
• Breastfeeding infants require no water supplementation, even in extreme heat environments and in situations where mothers are dehydrated.
• Breastfeeding during air travel protects children from Eustachian tube pain and collapse. Unlike sucking on a bottle or pacifier, suckling at the breast uniquely generates both positive and negative intraoral pressure, which allows children to stabilize and gradually equalize internal and external air pressure.

Health providers should provide information to breastfeeding mothers to support them to be better able to continue breastfeeding during travel.

• Frequent, unrestricted breastfeeding opportunities ensure that the mother’s milk supply remains ample and that the child’s nutrition and hydration are ideal.

Special Consideration: Travelers’ Diarrhea

• Exclusive breastfeeding provides infants with unique protection from travelers’ diarrhea.
• Breastfeeding is ideal rehydration therapy. Children who are suspected to have travelers’ diarrhea should breastfeed more frequently, reduce consumption of other foods and liquids, and should not be offered other fluids to replace breastfeeding.
• Breastfeeding mothers with travelers’ diarrhea should continue breastfeeding and increase their own fluid intake.
  • The organisms causing travelers’ diarrhea do not pass through breast milk.
  • Breastfeeding mothers should not use bismuth subsalicylate compounds (e.g., Pepto Bismol) due to transfer of salicylate to the child. Compatible alternatives are kaolin-pectin (e.g., Kaopectate) and loperamide (e.g., Imodium). Use of oral rehydration salts (ORS) is fully compatible with breastfeeding.

References

1. Kroger AT, Atkinson WL, Marcuse EK, Pickering LK. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-15):1–48.
2. Cetron MS, Marfin AA, Julian KG, et al. Yellow fever vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2002. MMWR Recomm Rep. 2002; 51(RR-17):1–11.
3. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776–89.
4. Hale TW. Medications and mothers’ milk 2008. 13th ed. Amarillo, TX: Pharmasoft Medical Publishing; 2008.
5. Lawrence RA. Breastfeeding: a guide for the medical profession. 4th ed. New York: Mosby-Yearbook; 1994.
6. CDC. Perspectives in disease prevention and health promotion update: universal precautions for prevention of transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and other bloodborne pathogens in health-care settings. MMWR Morbid Mortal Wkly Rep. 1988;37(24):377–88.