The one case I have dealt with was of herpetic areolar lesions exactly
where the infant's mouth was located. For me it was a diagnosis of
exclusion, i.e., it couldn't be anything else I'd ever seen and the history
confirmed the likelihood of herpes. The mother had seen a doctor and asked
whether it could be herpes. He said that he wouldn't get any result from a
culture and so wasn't going to do one, to continue to breastfeed. She came
to me as a case of severe pain during feeding, not as a query re whether to
continue. I simply advised that she continue to breastfeed and in addition
express breastmilk frequently over the lesion to help relieve the infection
and inflammation, and assist healing. Now I'd include use of an appropriate
steri-skin type of occlusive material to cover the lesion at feeds, if I
could find one that worked in the region and the situation.

Pump and dump seems daft to me. The only person capable of providing
antibodies to herpes is the mother via her milk. The child is already
colonised. If you replace the mother's milk with anything else, you are
giving a less protective feed. Cover the lesion seems reasonable if
possible, to reduce total viral load: illness following infection is not
just due to exposure, but exposure to loads a body can't deal with. Reduce
the viral load by using hindmilk on the lesion seems sensible. These are
universally available remedies and therefore worth testing.

I keep seeing US LCs making recommendations to pump and dump when in doubt,
as though this is the more cautious approach. Well maybe if we had
milkbanks with perfectly safe donors to provide breastmilk meanwhile, or if
the mother has heaps of stored breastmilk to use up (although frozen isn't
quite as good as fresh and the difference may matter for sick kids). But in
Australia we tend to breastfeed through many things (some medication
excepted) where Americans pump and dump because nothing else is available
which is any safer, and most alternatives are a lot less safe. I guess it
all depends on what you believe about alternatives...                MM