Nancy E. Wight MD, FAAP, IBCLC

Delineating the risk of transmission of Hepatitis C Virus (HCV) from mother to infant solely attributable to breastfeeding has proven very difficult. The overall risk of infection with respect to perinatal transmission has not been fully elucidated, but studies suggest that in utero, at delivery1,2,3,4,5 and post-natal transmission via close-contact, saliva and breastmilk/breastfeeding2,6,7,8 are all possible, although reported rates of transmission vary.9,10,11,12,13,14,15,16 Available data suggest elevated maternal titers of HCV-RNA,2,17 Hepatitis C genotype 1b+3a1, vaginal delivery5and co-infection with HIV-15,17,18,19 increase the risk of transmission to the infant. Overall, the risk of perinatal transmission of HCV appears very low if mother is HCV-antibody positive and HCV-PCR negative at the time of delivery.1,2,7,11,20

A recent study21 noted that both anti-HCV antibody and HCV-RNA were present in colostral samples in much lower levels than in maternal blood, and that none of 11 breast-fed infants (breast-fed only 3 weeks - 4 months) had evidence of HCV infection up to 1 year age. They concluded that although anti-HCV antibody and HCV-RNA are present in the colostrum of HCV carrier mothers without HIV coinfection, breastfeeding usually does not cause HCV transmission in their infants and thus should not be discouraged.

However, another study7 where mothers breast-fed for considerably longer, noted an exclusively breast-fed infant who had been HCV-RNA negative since birth, turning positive at 10 months, at the same time as his anti-HCV antibody, which had been positive, turned negative. The authors hypothesized that transplacental and breastmilk anti-HCV antibodies play a role in immunological protection against vertical transmission of HCV, and therefore recommended that breastfeeding of HCV-RNA positive milk be stopped when infant serum anti-HCV antibody turns negative.

Perinatal transmission of HCV was not associated with breastfeeding (15% in breast-fed vs. 21% in never-breast-fed infants; P> 0.05) in a longitudinal study of HCV-infected infants of HCV antibody positive, but HIV negative mothers 5. The authors attributed the lack of association to the small number (n=13) of women who chose to breastfeed. Duration of breastfeeding was not mentioned.

Grayson et al22 in a prospective study of 20 mothers who were HCV antibody positive but HIV antibody negative (15/20 used "illicit drugs"), noted 15/19 had detectable serum HCV-RNA at parturition. Of breastmilk collected around the time of delivery, 11/17 had detectable HCV antibody but 0/17 had detectable HCV-RNA. Of this group only 3 mothers did any breastfeeding; 0/3 infants had any detectable HCV antibody at 9 months of age. In a subsequent, retrospective study of 24 children of HCV positive but HIV negative mothers of child-bearing age in their institution since 1989, they identified 18 children born after the time of probable maternal HCV infection of which 14 had been breastfed (length of time not specified). In addition they noted 10 potential blood exposures to cracked, bleeding nipples. None of the children (age 10 months to 17 yrs) had detectable HCV antibody or HCV-RNA. They concluded that breastfeeding was not a major risk factor for maternal-infant transmission of HCV, even in mothers with detectable serum HCV-RNA, although the risk of breastfeeding during acute HCV infection (when viral titers may be very high) remains uncertain.

Duration of breastfeeding as a factor in transmission of HCV was discussed by Mahajan et al23 who concluded "larger studies involving infants who are breastfed for longer periods are needed before pediatricians can safely advocate breast-feeding for HCV-negative infants born to HCV carriers".

Prior to nursing, HCV antibody-positive mothers should be counseled regarding breastfeeding. The known benefits of breastfeeding must be weighed against the probably small, but unknown potential risk of viral transmission with possible later chronic hepatitis, cirrhosis and liver failure in the infant.The World Health Organization and the American Academy of Pediatrics have not, as yet, come out with recommendations for developed nations. The US Centers for Disease Control (CDC) does not recommend that breastfeeding be eliminated or curtailed in mothers positive for anti-HCV.24

As the risk of vertical transmission of HCV appears significant in viremic mothers (HCV-RNA positive) 1,2, we would recommend discouraging breastfeeding for these mothers in developed nations where relatively safe alternatives (artificial milks) are available. In Third World Countries where the morbidity and mortality risks of malnutrition, gastroenteritis and other infectious diseases greatly outweigh the risk of morbidity and mortality of hepatitis C infection transmitted via the breastmilk, breastfeeding, as with HIV virus, should be encouraged.

As the risk of HCV transmission in women who are assessed at the time of delivery to be HCV antibody positive, but HCV-RNA negative, appears to be close to zero, we would encourage breastfeeding in this population. However, since there is a 50% chance of reactivation of the virus (that is, converting to HCV-RNA positive status), in women who are HCV antibody positive, the mother's HCV-RNA status should be rechecked periodically during gestation, and always at delivery. Additional HCV-RNA testing is recommended during the breastfeeding period. The optimal timing and frequency of repeat testing during gestation and lactation is not known. HCV antibodies and HCV-PCR should also be followed periodically in the infant during the first 12 to 18 months of life.

References:

  1. Zuccotti GV, Ribero ML, et al. Effect of Hepatitis C genotype on mother-to-infant transmission of virus. J Pediatr 1995; 127: 278-80.
  2. Ohto H, Terazawa S, et al. Transmission of Hepatitis C Viral from Mothers to Infants. N Engl J Med 1994; 330: 744-50.
  3. Kurauchi O, Furui T, Et al. Studies on transmission of hepatitis C virus from mother-to-child in the perinatal period. Arch Gynecol Obstet 1993; 253: 121-126.
  4. Nagata I, Shiraki K, et al. Mother-to-infant transmission of hepatitis C virus. J Pediatr 1992; 120: 432-4.
  5. Paccagnini S, Principi N et al. Perinatal transmission and manifestation of hepatits C virus infection in a high risk population. Pediatr Infect Dis J 2995; 14:195-9.
  6. Ohto H, Okamoto H, Mishiro S. Reply to Letters to Editor. N Engl J Med 1994; 331: 400.
  7. Uehara s, Abe Y, et al. The Incidence of Vertical Transmission of Hepatitis C Virus. Tohoku J Exp Med 1993; 171: 195-202.
  8. Oqasawara S, Kage M, et al. Hepatitis C virus RNA in saliva and breastmilk of hepatitis C carrier mothers, Letter to the Editor. Lancet 1993; 341: 561.
  9. Alter MT. Transmission of hepatitis C virus -route, dose and titer. N Engl J Med 1994; 330: 784-6.
  10. Kudesia G, Ball G, Irving WL. Vertical transmission of hepatitis C, Letter to the Editor. Lancet 1995; 345:1122.
  11. Maggione G, Bentura A, Et al. Vertical transmission of hepatitis C, Letter to the Editor. Lancet 1995; 345:1122.
  12. Giacchino R, Picciotto A, et al. Vertical transmission of hepatitis C, Letter to the Editor. Lancet 1995; 345: 1122-23.
  13. Roudot-Thoraval F, Pawlotsky JM et al. Lack of mother-to-infant transmission of hepatitis C virus in human-immunodeficiency virus-seronegative women: a prospective study with hepatits C virus RNA testing. Hepatology 1993; 17:772-7.
  14. Chen DS, Lin HH et al. Mother to child transmission of hepatitis C virus. J Infect Dis 1991; 164:428-9.
  15. Degos F, Thiers V et al. Neonatal transmission of HCV from mother with chronic hepatits. Lancet 1991; 338:758.
  16. Reinus JF, Leiken EL et al. Failure to detect vertical transmission of hepatitis C virus. Ann Intern Med 1992; 117: 881-6.
  17. Novati R, Thiers V et al. Mother to child transmission of hepatitis C virus detected ny nested polymerase chain reaction. J Infect Dis 1992; 165:720-3.
  18. Giovannini M, Tagger A et al. Maternal-infant transmission of hepatitis C virus and HIV infections: a possible interaction. Lancet 1990; 335:1166.
  19. Zanetti AR, Tanzi E, et al. Mother-to-infant transmission of Hepatitis C virus. Lancet 1995; 345: 289-91.
  20. Resti M, Azzari C, et al. Mother-to-infant transmission of hepatitis C virus. Acta Paediatr 1995; 84: 251-5.
  21. Lin H, Kao J, et al. Absence of infection in breast-fed infants born to hepatitis C virus-infected mothers. J Pediatr 1995; 126: 589-91.
  22. Grayson M L, Braniff KM et al. Breastfeeding and the risk of vertical transmission of  hepatitis C virus. Med J Austr 1995; 163:107.
  23. Mahajan L, Wyllie R et al. Mother-to-infant transmission of Hepatitis C virus and breastfeeding. J Pediatr 1995; 127(4):670-1.
  24. Centers for Disease Control, Public Health Service Inter-Agency Guidelines for Screening Donors of Blood, Plasma, Organs, Tissues, and Semen for Evidence of Hepatitis B and Hepatitis C, Morbidity and Mortality Weekly Report, Recommendations and Reports, Vol 40, No.RR-4, April 19, 1991.

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