For Ruth and Susan,

Here are a few points for the patient you described with active herpes on
the breast and a baby with oral lesions.

Here is the blanket statement.  The present of active herpetic lesions on
the breast is a contraindication to breastfeeding.  HSV 1 transmission in
the presence of maternal breast leasions has been described. Nevertheless,
this does not represent a major mode of transmission.

From what you describe, the child has a primary acute herpetic stomatitis.
The differential can include a number of other viral illnesses such as hand,
foot and mouth and erythema multiforme and even drug reactions.  However,
the fact that the mother now has a breast lesion would suggest that it is
indeed a herpetic infection.  She and the toddler should be tested but the
results will take a few days.

What is the point, then, of interrupting breastfeeding until the lesions are
cleared if the child is already infected?   One could argue that this would
serve to limit the spread to the other breast.  It would appear that the
uninfected breast has been bathed in a herpetic soup for a number of days
already and if infection was to occur, it should have already done so.

Would interrupting breastfeeding serve to limit the dissemenation of herpes
into different nerves?  Any two year old with a sore mouth is either going
to drool or have his/her hands in the mouth and thereby apply the virus to
other dermatomes. This probably presents a greater hazzard to the child than
the breastfeeding.

If this were a newborn, this child would require hospitalization and
treatment with IV acyclovir whether it had oral lesions or not.  As a
toddler and having presumably already been infected for numerous days, I do
not know about the relative benefit of this.  In general practice, herpetic
stomatitis is treated supportively with hydration, antipyretics and analgesia.

Does interrupting breastfeeding pose a greater hazzard to the infant by
removing the immunologic benefits of breastmilk?  Perhaps.

How is a mother going to deal with a nursing toddler with a sore mouth?
This child might not be willing to take any other foods or liquids. While
infants with this malady can become dehydrated, this is less likely in a
toddler.  Nevertheless, refusing to allow a child to nurse might turn a
difficult time into a horrible experience.

I have had two cases.  Both mothers were treated with topical acyclovir
applied to the lesions.

One was a nursing 7 month old who had lesions on the face, finger and toe.
His mother had lesions on both breasts and the chest wall.  After speaking
with an infectious diseases expert, we elected to withhold breastfeeding for
five days (when the lesions were well dried up and no new ones were
appearing). He returned to breast without further difficulty. The thinking
was that as long as the mother continued to develop new lesions, these would
act as a viral source for the child and the virus would infect more and more
dermatomes. We also covered up his hands and feet until he too was clear of
new lesions.

The second case was a mother with lesions on one breast and an uninfected
two month old.  We withheld breastfeeding for one week from that side and
fortunately the baby went back to both breasts without further problems. The
mother pumped and dumped.

Both of these mothers were warned that they might have a recurrance, just as
one can have with cold sores.  As far as I know neither has had another
child and neither has had a recurrance.

Summary:  Sorry, no clear answer and not an easy case but remember that a
number of experts recommend cessation of breastfeeding until the active
lesions are quiescent.  You might also speak with an infectious disease
expert.

Shirley Gross


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M. Shirley Gross M.D.,C.M., C.C.F.P., I.B.C.L.C.
Director, Edmonton Breastfeeding Clinic
Edmonton, Alberta, Canada
E mail at  <  [log in to unmask]  >
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