Hepatitis B surface antigen (HBsAg) has been detected in breastmilk from HBsAg-positive women. However, studies from Taiwan and England have shown that breastfeeding by HBsAg-positive women does not significantly increase the risk of infection among their infants above that which exists for perinatal infection. Infants born to known HBsAg-positive women should receive Hepatitis B immune globulin (HBIG) and Hepatitis B vaccine, effectively eliminating any theoretical risk of transmission through breastfeeding. Mothers with Hepatitis B should be encouraged to breastfeed.
Hepatitis C Virus (HCV)
Hepatitis C is characterized by mild or asymptomatic infection with insidious onset of jaundice and malaise. In some cases, the course is remittent. An average of 50% of the patients develop chronic liver disease, including cirrhosis. Hepatocellular carcinoma may be associated with Hepatitis C as well as chronic Hepatitis B infections. Hepatitis C virus (HCV) occurs worldwide and has several modes of transmission. It is well recognized that HCV can be transmitted by contact with blood or blood products through transfusions, intravenous drug use, sexual contact and needle-stick exposure.
The risk of perinatal transmission is approximately 4% although reported rates of transmission vary depending on virus genotype, co-infection with HIV and HCV-RNA antigen titers. Overall, the risk of perinatal transmission of HCV appears extremely low if mother is HCV-antibody positive but HCV-PCR (antigen) negative at the time of delivery. Several recent studies demonstrate no increased risk of transmission attributable to breastfeeding. All major health organizations (i.e. World Health Organization, Centers for Disease Control, National Institutes of Health and American Academy of Pediatrics) recommend or support breastfeeding by Hepatitis C carrier mothers. As the risk of vertical transmission of HCV appears to increase with HCV-RNA titer, one approach would be to breastfeed if the mother's HCV PCR is negative or low titer, and recheck the mother's titer periodically. HCV antibodies and HCV-PCR should be followed periodically in the infant during the first 12 to 18 months of life whether or not the infant is breastfed.
Hepatitis D (Delta) Virus (HDV)
Hepatitis Delta virus (HDV) infection causes hepatitis, but only in conjunction with Hepatitis B virus (HBV) infection. Infection in a person with acute or chronic HBV infection can result in acute, possibly fulminant hepatitis, or in chronic hepatitis that may progress to cirrhosis. HDV can cause an infection at the same time as the initial HBV infection (co-infection), or it can infect an individual already chronically infected with HBV (superinfection). Transmission is similar to that of HBV, that is, by parenteral, percutaneous, or mucous membrane inoculation. HDV can be transmitted by blood or blood products, injecting drug use, or sexual contact as long as the patient is concurrently actively infected with HBV (and is therefore HBsAg positive). Transmission from mother to newborn is uncommon and can be prevented by appropriate HBV prophylaxis in the newborn. Intra-familial spread can occur among HBsAg carriers. There is no information available on the transmissibility of HDV through breastmilk, but we must presume it will pass through just as Hepatitis A, Hepatitis B, and Hepatitis C do. Mothers should be encouraged to breastfeed as long as their infants are given HBIG and HB Vaccine.
Hepatitis E Virus (HEV)
Hepatitis E is an acute illness with jaundice, malaise, anorexia, fever, abdominal pain and arthralgia which tends to appear during compromises in good public health such as flooding or other natural disasters. Endemic HEV transmission has not been recognized in Western Europe or in the United States. It is very similar to Hepatitis A disease and appears to be self-limiting. Transmission of HEV is by the fecal-oral route. HEV occurs most frequently in children and young adults, but children are less commonly jaundiced. Liver failure can occur with HEV, particularly during pregnancy. Mortality rates over 30% have been reported in women infected during the third trimester.
There is currently no evidence of perinatal transmission of the virus. There is no current evidence regarding the transmissibility of HEV through breastmilk, or regarding the consequences of its transmission for the infant. At the present time, it appears that it would be especially important to continue breastfeeding during epidemics of HEV in underdeveloped, endemic areas to prevent a greater risk of infant mortality from other infectious diseases.
Hepatitis G Virus (HGV GBV-C)
Although found in human bloodstreams, there is scant evidence that HGV/GBV-C actually causes hepatitis, and no evidence that it causes chronic hepatitis, cirrhosis, or hepatocellular carcinoma. There appears to be a 40-60% vertical perinatal transmission rate, but no clinical illness in the infant. There is no evidence that breastfeeding increases transmission to the infant. Although data is limited, breastfeeding appears safe.
In the years to come, no doubt we will extend the hepatitis alphabet even further. It is highly likely that all will be proved transmissible through breastmilk. However, as noted above, each hepatitis virus carries its own risk of long-term morbidity and mortality. Based on current evidence, it would seem prudent to recommend breastfeeding to mothers infected with Hepatitis A, mothers infected with Hepatitis B and Hepatitis D whose infants have been immunized for Hepatitis B and treated with HBIG, mothers living in areas endemic for Hepatitis E, and mothers infected with Hepatitis G. Unless the mother is actively, heavily viremic, the risk of transmission of Hepatitis C also appears very small, but carries an increased risk of serious and possible fatal sequela to an exposed infant. In all cases, the risks of breastfeeding with maternal hepatitis should be weighed against the known risks of NOT breastfeeding in each individual case and environment.
American Academy of Pediatrics Committee on Infectious Disease. (2000). 2000 Red book: Report of the committee on infectious diseases (23rd ed). Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics Work Group on Breastfeeding. (1997). Breastfeeding and the use of human milk. Pediatrics, 100, 1035-1039.
American Medical Association Advisory group on Prevention, Diagnosis, and Management of Viral Hepatitis. (1995). A guide for primary care physicians. Chicago: American Medical Association, Division of Health Science.
Lawrence, R.A. (1997). A review of the medical benefits and contraindications to breastfeeding in the United States. (Maternal and Child Health Technical Information Bulletin). Arlington, VA: National Center for Education in Maternal and Child Health.