Travel & Breastfeeding
The medical preparation of a traveler who is breastfeeding differs only slightly from that of other travelers and depends in part on whether the mother and child will be separated or together during travel. Most mothers should be advised to continue breastfeeding their infants throughout travel. Before departure, mothers may wish to compile a list of local breastfeeding resources at their destination to have on hand. Clinicians and travelers can use the Find a Lactation Consultant Tool (www.ilca.org/why-ibclc/falc) to find contact information for experts at their destination. Map 7-1 shows destinations with English-language breastfeeding support groups facilitated by accredited volunteer mothers. Clinicians and travelers can use La Leche League International’s interactive map (www.llli.org/search/groups) to find specific location and contact information for breastfeeding support group leaders and groups worldwide.
Mothers who plan to use an electric breast pump while traveling may need an electrical current adapter and converter and should have a back-up option available, including information on hand expression techniques (detailed hand expression instructions are available at www.workandpump.com/handexpression.htm).
Traveling with a Breastfeeding Child
Breastfeeding provides unique benefits to mothers and children traveling together. Health care providers should explain clearly to breastfeeding mothers the value of continuing breastfeeding during travel. For the first 6 months of life, exclusive breastfeeding is recommended. This is especially important during travel because exclusive breastfeeding means feeding only breast milk, no other foods or drinks, which potentially protects infants from exposure to contamination and pathogens via foods or liquids. Additionally, feeding only at the breast protects infants from potential exposure to contamination from containers (bottles, cups, utensils).
Breastfeeding infants require no water supplementation, even in extreme heat environments. Breastfeeding protects children from eustachian tube pain and collapse during air travel, especially during ascent and descent, by allowing them to stabilize and gradually equalize internal and external air pressure.
Clinicians should offer information to breastfeeding mothers so that they are better able to continue breastfeeding during travel. Frequent, unrestricted breastfeeding opportunities ensure the mother’s milk supply remains ample and the child’s nutrition and hydration are ideal. Mothers who are concerned about breastfeeding away from home may feel more comfortable breastfeeding the child in a fabric carrier. In many countries around the world, breastfeeding in public places is more widely practiced than in the United States. US federal legislation protects mothers’ and children’s right to breastfeed anywhere they are otherwise authorized to be while on federal property, which includes US Customs areas, embassies, and consulates overseas.
X-rays used in airport screenings have no effect on breastfeeding, breast milk, or the process of lactation. The Food and Drug Administration states that there are no known adverse effects from eating food, drinking beverages, or using medicine screened by x-ray. Airlines typically consider breast pumps as personal items to be carried onboard, similar to laptop computers, handbags, and diaper bags.
Before departure, mothers who will be traveling by air and expect to have expressed milk with them during travel need to carefully plan how they will transport their milk. Airport security regulations for passengers carrying expressed milk vary internationally and are subject to change. In the United States, expressed milk and related infant and child feeding items are exempt from Transportation Security Administration (TSA) regulations limiting quantities of other liquids and gels. The Infant and Child Nourishment Exemption permits passengers to carry with them all expressed milk, ice, gel packs (frozen or unfrozen), and other accessories required to transport expressed milk through airport security checkpoints and onboard flights, regardless of whether the breastfeeding child is also traveling. At the beginning of the screening process, travelers should inform the TSA officer and separate their expressed milk and related accessories from the liquids, gels, and aerosols that are limited to 3.4 oz (100 mL) each. Travelers may find that having on hand the related TSA regulations (available at www.tsa.gov/travel/special-procedures/traveling-children) facilitates the screening process.
Travelers carrying expressed milk in checked luggage should refer to cooler pack storage guidelines in “Proper Handling and Storage of Human Milk” on CDC’s website (www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm) to protect milk during travel. Expressed milk is not considered a biohazard. International Air Transport Authority regulations for shipping category B biological substances (UN 3373) do not apply to expressed milk; it is considered a food for individual use. Travelers shipping frozen milk should follow guidelines for shipping other frozen foods and liquids. Expressed milk does not need to be declared at US Customs upon return to the United States.
Immunizations and Medications
In almost all situations, clinicians can and should select immunizations and medications for the nursing mother that are compatible with breastfeeding. In most circumstances, it is inappropriate to counsel mothers to wean in order to be vaccinated or to withhold vaccination due to breastfeeding status.
Breastfeeding and lactation do not affect maternal or infant dosage guidelines for any immunization or medication; children always require their own immunization or medication, regardless of maternal dose. In the absence of documented risk to the breastfeeding child of a particular maternal medication, the known risks of stopping breastfeeding generally outweigh a theoretical risk of exposure via breastfeeding.
Breastfeeding mothers and children should be vaccinated according to routine, recommended schedules. Administration of most live and inactivated vaccines does not affect breastfeeding, breast milk, or the process of lactation. Only 2 vaccines, vaccinia (smallpox) and yellow fever, require special consideration. Preventive vaccinia (smallpox) vaccine is contraindicated for use in breastfeeding mothers.
Special Consideration: Yellow Fever Vaccination
Breastfeeding is a precaution for yellow fever vaccine administration. Three cases of yellow fever vaccine–associated neurologic disease (YEL-AND) have been reported in exclusively breastfed infants whose mothers were vaccinated with yellow fever vaccine. All 3 infants were diagnosed with encephalitis and aged <1 month at the time of exposure. Further research is needed to document the risk of potential vaccine exposure through breastfeeding. Data about possible excretion of vaccine virus and duration of excretion in breast milk are insufficient to make a recommendation about temporary suspension of breastfeeding, pumping, and discarding pumped milk. Until more information is available, yellow fever vaccine should be avoided in breastfeeding women. However, when nursing mothers must travel to a yellow fever–endemic area, these women should be vaccinated (see Chapter 3, Yellow Fever, for more information).
According to the American Academy of Pediatrics (AAP) 2013 Clinical Report: The Transfer of Drugs and Therapeutics into Human Breast Milk, many mothers are inappropriately advised to discontinue breastfeeding or avoid taking essential medications because of fears of adverse effects on their infants. The AAP’s Tips for Giving Accurate Information to Mothers (www2.aap.org/breastfeeding/files/pdf/Lactmed.pdf) advises that this is usually unnecessary because only a small proportion of medications are contraindicated in breastfeeding mothers or associated with adverse effects on their infants. The National Institutes for Health’s database of information on drugs and lactation (LactMed) is an online database of clinical information about drugs and breastfeeding (http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm). It provides information about maternal levels of drugs in breast milk, infant levels in blood, potential effects in breastfeeding infants and on lactation itself, the AAP category indicating the level of compatibility of the drug with breastfeeding, and alternate drugs to consider. The pharmaceutical reference guide, Medications and Mothers’ Milk, is updated every 2 years and provides a comprehensive review of the compatibility or effects on breastfeeding of approximately 1,000 drugs, including concerns such as risk categories, pharmacologic properties, interactions with other drugs, and suitable alternatives.
Special Consideration: Antimalarial Medications
Since chloroquine and mefloquine may be safely prescribed to infants, both are considered compatible with breastfeeding. Most experts consider short-term use of doxycycline compatible with breastfeeding. Primaquine may be used for breastfeeding mothers and children with normal G6PD levels. The mother and infant should be tested for G6PD deficiency before primaquine is given to the breastfeeding mother. Because data are not yet available on the safety of atovaquone-proguanil prophylaxis in infants weighing <11 lb (5 kg), CDC does not recommend it to prevent malaria in women who are breastfeeding infants weighing <11 lb (5 kg).
Special Consideration: Travelers’ Diarrhea
Exclusive breastfeeding protects infants against travelers’ diarrhea. Breastfeeding is ideal rehydration therapy. Children who are suspected of having travelers’ diarrhea should breastfeed more frequently. Children in this situation should not be offered other fluids or foods that replace breastfeeding. Breastfeeding mothers with travelers’ diarrhea should continue breastfeeding and increase their own fluid intake. The organisms that cause travelers’ diarrhea do not pass through breast milk. Breastfeeding mothers should carefully check the labels of over-the-counter antidiarrheal medications to avoid using bismuth subsalicylate compounds, which can lead to the transfer of salicylate to the child via breast milk. Fluoroquinolones and macrolides, which are commonly used to treat travelers’ diarrhea, are excreted in breast milk. The decision about the use of antibiotics such as fluoroquinolones and macrolides in nursing mothers should be made in consultation with the child’s primary health care provider. Most experts consider the use of short-term azithromycin compatible with breastfeeding. Use of oral rehydration salts by breastfeeding mothers and their children is fully compatible with breastfeeding.
Special Consideration: Zika Virus
CDC encourages mothers with Zika virus infection and living in or traveling to areas with ongoing Zika virus transmission to breastfeed their infants. Current evidence suggests that the benefits of breastfeeding outweigh the theoretical risks of Zika virus transmission through breast milk. Updated information is available at www.cdc.gov/zika/hc-providers/infants-children.html.
Traveling without a Breastfeeding Child
Before departure, a breastfeeding mother traveling without her breastfeeding infant or child may wish to express and store a supply of milk to be fed to the infant or child during her absence. Building a supply to be fed in her absence takes time and patience and is most successful when begun gradually, many weeks in advance of the mother’s departure.
A mother’s milk supply can diminish if she does not express milk while away from her nursing child, but this does not need to be a reason to stop breastfeeding. Clinicians should help mothers determine the best course for breastfeeding based on a variety of factors, including the amount of time she has to prepare for her trip, her flexibility of time while traveling, her options for expressing and storing milk while traveling, the duration of her travel, and her destination. A mother who returns to her nursing infant or child can continue breastfeeding and, if necessary, supplement as needed until her milk supply returns to its prior level. Often, after a mother returns from travel, her nursing infant or child will help bring her milk supply to its prior level. However, nursing infants or children who are separated from their mother for an extended time may have difficulty transitioning back to breastfeeding.
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Katherine R. Shealy