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Chapter 7 International Travel with Infants & Children

Travel & Breastfeeding

Katherine R. Shealy

The medical preparation of a traveler who is breastfeeding 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 mothers should be advised to continue breastfeeding their infants throughout travel. Before departure, mothers may wish to carry with them a list of local breastfeeding resources at their destination. Clinicians may be able to help breastfeeding mothers find out about available breastfeeding support experts at their destination through sources that include the following:

  • International board-certified lactation consultants (IBCLCs)—health professionals in approximately 96 countries who specialize in the clinical management of breastfeeding (http://iblce.org). The Find a Lactation Consultant (FALC) tool can help clinicians and mothers identify in advance local IBCLCs worldwide (www.ilca.org/i4a/pages/index.cfm?pageid=3432).
  • La Leche League leaders—accredited volunteer mothers in approximately 65 countries who provide mother-to-mother breastfeeding support and help (www.llli.org). La Leche League’s interactive map lists location and contact information for La Leche League leaders and groups worldwide (www.llli.org/search/groups).

Mothers who plan to use a breast pump while traveling may need an electrical current adapter and converter and should have a back-up option available, including written instructions for hand expression (for more detailed instructions about hand expression, see www.workandpump.com/handexpression.htm).

TRAVELING WITH A BREASTFEEDING CHILD

Breastfeeding provides unique benefits to mothers and children traveling together. Health care providers should explain clearly to breastfeeding mothers the value of continuing breastfeeding during travel. For the first 6 months of life, exclusive breastfeeding is recommended. This is especially important during travel because exclusive breastfeeding means feeding only breast milk, no other foods or drinks, which protects infants from exposure to contamination and pathogens via foods or liquids. Additionally, feeding only at the breast protects infants from exposure to contamination from containers (bottles, cups, utensils).

Breastfeeding infants require no water supplementation, even in extreme heat environments. Breastfeeding protects children from eustachian tube pain and collapse during air travel, especially during ascent and descent, by allowing them to stabilize and gradually equalize internal and external air pressure, which cannot be replicated by sucking on a bottle or pacifier.

Clinicians should offer information to breastfeeding mothers so that they are better able to continue breastfeeding during travel. Frequent, unrestricted breastfeeding opportunities ensure the mother’s milk supply remains ample and the child’s nutrition and hydration are ideal. Safe use of a fabric infant carrier helps maintain breastfeeding by increasing breastfeeding opportunities and skin-to-skin contact with the child, while also protecting the child from environmental hazards and easing the burden of carrying a heavy child. Mothers who are concerned about breastfeeding away from home may feel more comfortable breastfeeding the child in a fabric carrier. In many countries around the world, breastfeeding in public places is more widely practiced than in the United States. US federal legislation protects mothers’ and children’s right to breastfeed anywhere they are otherwise authorized to be while on federal property, which includes US Customs areas, embassies, and consulates overseas.

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.

Before 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 of whether the breastfeeding child is also traveling, as long as it is declared before screening. TSA recommends that travelers carrying expressed milk have with them a printed copy of the TSA website page (www.tsa.gov/traveling-formula-breast-milk-and-juice) to help prevent 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 (www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm) to protect milk during travel. Expressed milk is not considered a biohazard. International Air Transport Authority 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 US Customs upon return to the United States.

IMMUNIZATIONS AND MEDICATIONS

In almost all situations, clinicians can and should select immunizations and medications for the nursing mother that are compatible with breastfeeding. In most circumstances, it is inappropriate to counsel mothers to wean in order to be vaccinated or to withhold vaccination due to breastfeeding status.

Breastfeeding and lactation do not affect maternal or infant dosage guidelines for any immunization or medication; children always require their own immunization or medication, regardless of maternal dose. In the absence of documented risk to the breastfeeding child of a particular maternal medication, the known risks of stopping breastfeeding generally outweigh a theoretical risk of exposure via breastfeeding.

Immunizations

Breastfeeding mothers and children should be vaccinated according to routine, recommended schedules. Administration of most live and inactivated vaccines does not affect breastfeeding, breast milk, or the process of lactation. Only 2 vaccines, vaccinia (smallpox) and yellow fever, require special consideration. Preventive vaccinia (smallpox) vaccine is contraindicated for use in breastfeeding mothers.

Special Consideration: Yellow Fever Vaccination

Breastfeeding is a precaution for yellow fever vaccine administration. Three cases of yellow fever vaccine–associated neurologic disease (YEL-AND) have been reported in exclusively breastfed infants whose mothers were vaccinated with yellow fever vaccine. All 3 infants were diagnosed with encephalitis and aged <1 month at the time of exposure. Further research is needed to document the risk of potential vaccine exposure through breastfeeding. Data about possible excretion of vaccine virus and duration of excretion in breast milk are insufficient to make a recommendation about temporary suspension of breastfeeding, pumping, and discarding pumped milk. Until more information is available, yellow fever vaccine should be avoided in breastfeeding women. However, when nursing mothers must travel to a yellow fever–endemic area, these women should be vaccinated.

Medications

According to the American Academy of Pediatrics (AAP) 2013 Clinical Report: The Transfer of Drugs and Therapeutics into Human Breast Milk, many mothers are inappropriately advised to discontinue breastfeeding or avoid taking essential medications because of fears of adverse effects on their infants. The AAP advises that this cautious approach may be unnecessary in many cases because only a small proportion of medications are contraindicated in breastfeeding mothers or associated with adverse effects on their infants. The National Institutes for Health’s database of information on drugs and lactation (LactMed) is an online database of clinical information about drugs and breastfeeding (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT). It provides information about maternal levels of drugs in breast milk, infant levels in blood, potential effects in breastfeeding infants and on lactation itself, the AAP category indicating the level of compatibility of the drug with breastfeeding, and alternate drugs to consider. The pharmaceutical reference guide, 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 concerns such as risk categories, pharmacologic properties, interactions with other drugs, and suitable alternatives.

Special Consideration: Antimalarial Medications

Since chloroquine and mefloquine may be safely prescribed to infants, both are considered safe to prescribe to mothers who are breastfeeding. Most experts consider short-term use of doxycycline compatible with breastfeeding. Primaquine may be used for breastfeeding mothers and children with normal glucose-6-phosphate dehydrogenase (G6PD) levels. The mother and infant should be tested for G6PD deficiency before primaquine is given to the breastfeeding mother. Because data are not yet available on the safety of atovaquone-proguanil prophylaxis in infants weighing <11 lb (5 kg), CDC does not recommend it to prevent malaria in women breastfeeding infants who weigh <5 kg.

Special Consideration: Travelers’ Diarrhea

Exclusive breastfeeding protects infants against travelers’ diarrhea. Breastfeeding is ideal rehydration therapy. Children who are suspected of having travelers’ diarrhea should breastfeed more frequently. Children in this situation should not be offered other fluids or foods that replace breastfeeding. Breastfeeding mothers with travelers’ diarrhea should continue breastfeeding and increase their own fluid intake. The organisms that cause travelers’ diarrhea do not pass through breast milk. Breastfeeding mothers should carefully check the labels of over-the-counter antidiarrheal medications to avoid using bismuth subsalicylate compounds, which can lead to the transfer of salicylate to the child via breast milk. Fluoroquinolones and macrolides, which are commonly used to treat travelers’ diarrhea, are excreted in breast milk. The decision about the use of antibiotics such as fluoroquinolones and macrolides in nursing mothers should be made in consultation with the child’s primary health care provider. Most experts consider the use of short-term azithromycin compatible with breastfeeding. Use of oral rehydration salts by breastfeeding mothers and their children is fully compatible with breastfeeding.

TRAVELING WITHOUT A BREASTFEEDING CHILD

A breastfeeding mother traveling without her breastfeeding infant or child may wish to express and store a supply of milk to be fed to the infant or child during her absence. Building a supply to be fed in her absence takes time and patience and is most successful when begun gradually, many weeks in advance of the mother’s departure.

A mother’s milk supply can diminish if she does not express milk while away from her nursing child, but this does not need to be a reason to stop breastfeeding. Clinicians 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 expressing and storing milk while traveling, the duration of her travel, and her destination. A mother who returns to her nursing infant or child can continue breastfeeding and, if necessary, supplement as needed until her milk supply returns to its prior level. Often, after a mother returns from travel, her nursing infant or child will help bring her milk supply to its prior level. However, nursing infants or children who are separated from their mother for an extended time may have difficulty transitioning back to breastfeeding.

BIBLIOGRAPHY

  1. Academy of Breastfeeding Medicine (ABM) Protocol Committee. ABM clinical protocol #8: human milk storage information for home use for full-term infants. Breastfeed Med. 2010 Jun;5(3):127–30.
  2. CDC. Transmission of yellow fever vaccine virus through breast-feeding—Brazil, 2009. MMWR Morb Mortal Wkly Rep. 2010 Feb 12;59(5):130–2.
  3. 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 Morb Mortal Wkly Rep. 1988 Jun 24;37(24):377–82, 387–88.
  4. Hale TW, Rowe HE. Medications and Mothers’ Milk 2014: A Manual of Lactational Pharmacology. 16th ed. Plane, TX: Hale Pub; 2014.
  5. Kuhn S, Twele-Montecinos L, MacDonald J, Webster P, Law B. Case report: probable transmission of vaccine strain of yellow fever virus to an infant via breast milk. CMAJ. 2011 Mar 8;183(4):e243–5.
  6. Sachdev HP, Krishna J, Puri RK, Satyanarayana L, Kumar S. Water supplementation in exclusively breastfed infants during summer in the tropics. Lancet. 1991 Apr 20;337(8747):929–33.
  7. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012 Mar;129(3):e827–41.
  8. Staples JE, Gershman M, Fischer M. Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 Jul 30;59(RR-7):1–27.
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