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K Bhola, W McGuire, Department of Paediatrics and Child Health, Australian National University Medical School, Canberra, Australia; firstname.lastname@example.org
You are the doctor or midwife reviewing a newborn infant whose mother is infected with hepatitis C virus (HCV; but not infected with human immunodeficiency viris (HIV)). She wishes to breast feed but is concerned about whether this would affect the risk of her infant acquiring HCV infection. You would like your advice to be based on the best evidence available.
In newborn infants of mothers with [HCV] infection [patients], does avoidance of breastfeeding [intervention] reduce mother‐to‐infant transmission of HCV [outcome]?
Medline 1966–2006 and EMBASE 1980–2006 (using OVID interface).
The Cochrane Library [2006, issue 3].
Search terms: hepatitis “C” (MeSH term) AND “breastfeeding”/“breastmilk”(MeSH term) AND “transmission, vertical” (keyword).
We found 44 articles in Medline and EMBASE and none in The Cochrane Library. Altogether, 33 articles were irrelevant. All of the relevant articles were observational studies (cohort studies or case‐series). We did not find any systematic reviews or randomised controlled trials.
Eight of the observational studies were small with data reported for less than about 100 mother–infant pairs.1–8 Three were large cohort multicentre studies undertaken by clinical networks.9–11 Table 22 describes the large cohort studies.
HCV infection is a major worldwide cause of chronic liver disease, including hepatic fibrosis, cirrhosis and hepatocellular carcinoma.12 13 Mother–to–infant transmission is now the principal route of infection in childhood. The rate of mother to infant transmission of HCV is about 6%.14 15
HCV is a bloodborne virus but has been detected in colostrum and breast milk in low levels.3 We wished to determine whether any evidence exists showing that avoiding breast feeding reduces the risk of mothe–to–infant HCV infection. We did not find any randomised controlled trials of this intervention. We did find several observational studies. Most of them were small single‐centre studies (less than about 100 mother–infant pairs) and therefore underpowered to assess whether the transmission was affected. We found three larger multicentre cohort studies in which a total of 1854 mother–infant pairs participated.9–11 None of these studies found a relevant difference in the rate of transmission between infants fed with breast milk and those fed with formula. This is consistent with evidence from other cohort studies which indicate that most infants who acquire HCV infection do so in utero or in the peripartum period.11 16
The studies were all undertaken in European countries during the past 10 years. They were generally of good methodolgical quality with valid definitions of inclusion criteria and outcomes and near‐complete cohort follow‐up. Only one of the studies specifically examined the effect of breast feeding avoidance in mothers with HCV viraemia. Because transmission from a mother with no RNA detectable at delivery is extremely rare,17 this may have been a confounding variable in the other studies where the HCV viral status was not assessed. We specifically aimed at evaluating the evidence in women who were not coinfected with HIV. This was possible for two studies but not for the third where 5% of participants were HIV positive. A subgroup analysis of mothers who were not infected with HIV was not possible. HIV coinfection is a contraindication to breast feeding in high‐income countries.