Thank you so very much for your help with the rabies case.  After sending my
plea for help to Lactnet and my private practice LC Group I realized that it
was the wee hours of the morning for most of you so I started enlisting
local opinion and resources.   After many many phone calls, and waiting for
replies, taking up most of the day, this is what transpired:

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?

Once again, I am so grateful for your collective help and your prompt
replies.  The mom has given her permission for me to update you now and
later.  I'll keep you all posted.

Pamela Morrison IBCLC, Zimbabwe
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