To Jane in Israel,
I really feel for you and the mom you are helping. I worked with a mom
four years ago who was bitten by a dog, subsequently confirmed to have
rabies. She was nursing a 4 month old baby at the time, and was advised by
almost everyone to wean. She received the rabies vaccine within 4 hours of
being bitten, but the concern was that the baby might be at risk for rabies
through her milk in spite of this. I'm pasting below excerpts from my (very
long) folder on this - from my notes and from several Lactnetters who sent
in advice, opinion, and sought outside opinions for me too.
*********************************************
CASE HISTORY, 4 December, 1998
Mother of 4 1/2 mo old breastfed (with tiny Qx solids) 8.3 kg baby boy was
bitten on Tuesday
afternoon by a dog that has since been confirmed to have rabies. Mother
received rabies vaccine within about 4 hours of the bite, another shot
approx 48 hours after that and is to receive further shots in the next two
weeks. Yesterday (2 days after the bite) she was advised to suspend
breastfeeding because of the risk of infecting the baby. Baby is refusing
formula by bottle.
HELP/OPINIONS FROM COLLEAGUES
From: Cathy Liles
...... but several yeaers ago we had a mother
bitten by a rabid animal. Texas Department of Health Rabies Division
researched this for us and confirmed that rabies is not transmitted
through milk and the antidote is not contraindicated in breastfeeding and
further
is not orally bioavailable if ingested- that is why a series of shots is
given.
Please reassure this mother. Cathy Liles
-------------------
From: "Kathleen L. Hoover"
Cheston Berlin email this message to me.
The rabies virus has been isolated from the saliva of infected persons.
Presumably, it also would be in milk. I am unaware of any reports
measuring viral activity in milk of any species. If the mother is infected, and
the virus is in her saliva, the infant could be infected by exposure through
mucous membranes or cuts/abrasions in the skin. Cheston Berlin
-----------------------
From David Bratt, Trinidad
, the rabies virus is excreted in saliva of people who have rabies. It
takes an average of 30 to 90 days to develop rabies
(that's why dogs are kept in quarantine in the UK for 6 months). Mom was
immunized within hours,no. She will not get rabies. Her baby also will
not get rabies.
-------------------------
From: "Lawrence, Ruth"
Subject: RE: HELP! Rabies and breastfeeding
Date: Mon, 7 Dec 1998 12:49:01 -0500
Your request for information arrived courtesy of Kay Hoover.
There is no known risk to the infant of the rabies vaccine. It is
an inactivated virus preparation that is given IM, implying that it is not
orally available.
With respect to the rabies virus in the breast milk, it would only
occur during viremia. This mother received her first vaccine within 4 hours
so viremia would not occur.
Conclusion: No reason to limit or restrict breastfeeding.
Ruth A. Lawrence, M.D.
Medical Director of the Breastfeeding and
Human Lactation Study Center
University of Rochester Medical Center
Rochester, NY 14642
-----------------------------------
REPORT to colleagues who were helpful
1. My WHO/UNICEF list of Medications for the breastfeeding mother clearly
states that the rabies vaccine is not contraindicated during breastfeeding,
so I was able to reassure my client on that point.
2. After several attempts to feed baby other foods/liquids, with baby
becoming increasingly distressed, mother put baby back to the breast
yesterday morning.
3. Subsequent to resuming breastfeeding, the mother was finally able to
speak to the paediatrician himself (instead of to the nurse). It turns out
that he had advised that risk to the baby of contracting rabies through
mother's milk was unknown, might be one in a million, but in his opinion
there was *some* risk. For that reason *mom* must make the decision about
whether to continue to breastfeed or not.
4. I contacted someone at our Drug & Toxicology Information Service,
Medical School, University of Zimbabwe, who did a Medline search from 1985
to date and found *nothing*. In turn he contacted a veterinarian at the
Vet Labs who described one case report coming from Asia dating back to the
late sixties/early seventies where a breastfed baby acquired rabies from
his mother. No reference was given.
5. I contacted a doctor at our largest Infectious Diseases Hospital in
Harare who was emphatic that there was no risk to the breastfed baby of
acquiring rabies through his mother's milk , their general recommendation
was to *continue* breastfeeding while treating the mother with the rabies
vaccine. His opinion was that the baby himself did not need to receive the
vaccine.
6. The mother sought the advice of her GP who was also emphatic that there
was no risk to the baby, that the virus travelled through the nerves, and
would not be found in the blood, nor the breastmilk. Mom also contacted a
popular pharmacist who obtained the opinion of another couple of GPs who
said much the same thing. The other paediatrician whom I asked for a
second opinion was reluctant to give one until he had had a chance to hear
the reasoning of the first paediatrician whose judgement he obviously holds
in high regard (as do I!)
7. Baby is being christened today, and mom wants him to be "happy", so he
is still breastfeeding, for now at least. She has also received lots of
other opinions from "South Africa and overseas", all conflicting I gather,
and we will discuss these later this evening. She describes how she feels
that she might be putting him at risk for contracting rabies each time she
breastfeeds him, and is still undecided about whether to wean or not in the
next few days.
The large majority of the replies I have received from Lactnet and members
of my private practice group confirm that breastfeeding is safe while
continuing with the rabies vaccine, and state that the breastfed baby is
not at risk for contracting rabies through the mother's milk. One person
writes, "The way rabies works is that when the rabid animal bites, the
virus travels up the nerves from the bite to the brain. It does not travel
through the bloodstream. Then when it reaches the brain it travels down
nerves to get into the saliva. So if the virus is not multiplying in the
blood, probably not transferred into the milk." However, one or two
people express concerns, for example, "The rabies virus has been isolated
from the saliva of infected persons. Presumably, it also would be in milk.
I am unaware of any reports measuring viral activity in milk of any
species. If the mother is infected, and the virus is in her saliva, the
infant could be infected by exposure through mucous membranes or
cuts/abrasions in the skin."
Thus it is clear that opinion is divided. Several thoughts occur to
me. There seems to be a distinct lack of researched fact regarding the
risk of transmission of rabies via breastfeeding. However, the fact that
the vaccine is not contraindicated during breastfeeding would pre-suppose
that mothers in this unfortunate situation are not always advised to
wean. Furthermore, if the vaccine is effective enough to prevent disease
in the mother, then presumably it would be effective in preventing
infection of her milk. Additionally, in the case I am working with the
baby has already *had* four days of breastfeeding. Logic would dictate
that weaning *now* would be like shutting the gate after the horse has
bolted, unless of course, viral replication could be expected to
accelerate, with viral shedding in the breastmilk, from the time of
exposure until the body mounts an effective immune response as a result of
repeated doses of vaccine. Several sources, including the paediatrician,
have specifically said that the baby does not need to receive the vaccine
but if there were any risk, why not give the baby the vaccine too?
---------------------------------------
UPDATE, 9th December, 1998
Thought you would all like to know that Mom is *still* breastfeeding, and
she's going to carry on!
-------------------------------------------
UPDATE 4th January, 1998
Mom seen again. Baby big, fat, thriving, still breastfed, refuses bottle,
but takes water/juice in cup, "so good" and sleeps through the night.
Rabies vaccine was given - immediately after exposure, and at
3 days
7 days
14 days
28 days (just
had) and to be given at
60 days
90 days
Dr ........(vet) was extremely helpful to her, said he KNOWS about rabies,
and his opinion is virus would not have entered milk, goes to nerves and
she would have been protected from the very first shot.
Last month has been very worrying - she has had nightmares. Made up her
mind not to worry about it now.
Has just taken baby for his 6 mo check-up with Dr ....... (paediatrician)
who said he found out more about it, glad she is still breastfeeding. His
caution had been that although the risk is infinitessimal, rabies is fatal
- hence his advice to stop.
I asked if she will follow up with me in March or thereabouts.
Gave verbal permission for me to write this up as case history, if wished,
in the future.
*****************************************
FINAL UPDATE - from memory - without looking up file .... Hazy recollection
that this mom contacted me by phone once more. She had continued
breastfeeding for several months more, still fine, and breastfed baby was
fine. She had received an incredible amount of advice from within and
outside Zimbabwe, with friends and relations contacting all sorts of
apparent experts all over the world. The main lesson I learned is that
amazingly little seems to be known about breastfeeding and rabies, but that
the knee-jerk reaction outside the lactation community is very negative.
I would like to thank all the many many posts I received from so many
Lactnetters when I was working in this very difficult situation to attempt
to help this mother - too many to copy them all - but so helpful and
supportive and containing a wealth of information. This mother went
through a really terrible time emotionally with great courage and common
sense. I admired her tremendously. Jane, I hope this helps. Please let
us know how this turns out.
***********************************************
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Pamela Morrison IBCLC, Zimbabwe
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