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Breastfeeding a child on treatment for childhood cancer

It is generally accepted that breastfeeding is the preferred form of nutrition during the first six months of life. Both the World Health Organization and the American Academy of Pediatrics recommend to continue exclusively breastfeeding children about six months. As mutually desired by mother and infant, breastfeeding can be continued after introduction of complementary foods. Many literature data are available regarding the risk for the child during maternal cancer and chemotherapy treatment because of toxicities in the breast milk. After a PubMed search was performed, no data were found for the opposite situation, i.e. the maternal risk for a healthy mother, breastfeeding her (neutropenic) child treated for cancer. In addition, a lack of guidelines from organizations confirms this lacuna. Our research question was guided by the concern of a mother breastfeeding her three-month young child during treatment for acute lymphoblastic leukemia. Regarding the anatomy of infant sucking and breastfeeding, it is known that milk is maintained under positive pressure in the breast which, via the duct system, is projected from the lacteal sinuses and propelled toward the back of the mouth of the child. A theoretical risk of entry of chemotherapy in the converse direction (i.e. into the breast of the mother) is negligible. Although no data were found on chemotherapy concentrations in the oral cavity of a child during breastfeeding, we consider that damage of the maternal breast skin by chemotherapy concentrations present in the child’s mouth can be ignored. Higher concentrations would primarily result in damaging the child’s oral mucosa and emergence of mouth sores, leading to inappropriate sucking and failure of adequate breastfeeding. Although local breast infections, mastitis or breast abscesses are no contraindications for continuing breastfeeding in immunocompetent children, one should consider to interrupt or withhold breastfeeding temporary in (profound) neutropenic children. Antimicrobial agents directed against the most common organisms (penicillin-resistant Staphylococcus aureus, Escherichia coli, . . .) and compatible with breastfeeding should be considered for the mother. Finally, major attention should be paid to hand hygiene by the mother and hospital staff. In case breast pumps are used, which is a possible source of contamination, they need to be washed thoroughly. Apart from standard protective measures for personnel protective equipment and handling patient’s vomiting, excreta and fluids (drained from body cavities contaminated with chemotherapeutics), we do not encourage mothers to perform additional measures but recommend to handle standard operating procedures for chemotherapeutics (Table 1). These can be performed in addition to recommendations provided by breastfeeding counselors. The added-value effect of breastfeeding on the prevention of infectious diseases and their positive influence on the immune system are well known. Apart from medical and neurodevelopmental advantages, there are the psychological effects such as comfort and connectedness in a stressful situation, which cannot be ignored. When professionally assisted, mothers are able to cope with the situation as proven by witnesses on internet forums. Although our recommendations reflect expert opinion rather than evidence-based information on this issue, we strongly encourage mothers of children with cancer to continue breastfeeding their child during its chemotherapeutic treatment.