In infants of HCV infected mothers does avoidance of breastfeeding decrease maternal-infant transmission of HCV
Date First Published:
March 15, 2006
Last Updated:
April 13, 2007
Report by:
Kavita Bhola, Sr Registrar (The Canberra Hospital, ACT, Australia)
Search checked by:
William McGuire, The Canberra Hospital, ACT, Australia
Three-Part Question:
In [infants of HCV infected mothers] does [avoidance of breast feeding] decrease [ maternal-infant transmission of HCV]
Clinical Scenario:
You are the neonatal registrar reviewing a newborn infant whose mother is infected with HCV (but not infected with human immunodeficiency virus (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 decision to be based on sound evidence.
Search Strategy:
Medline 1966-2006 and EMBASE 1980- 2006 (using OVID interface).
Cochrane Library (2006, issue 3).
Cochrane Library (2006, issue 3).
Search Details:
Hepatitis C"(MeSH term) AND "breastfeeding"/"breastmilk"(MeSH term) AND "transmission, vertical"(keyword).
Outcome:
We found 44 articles in Medline and EMBASE and none in the Cochrane Library. 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 (Zanetti 1995,Polywka 1999, Kumar 1998, Tajari 2001, Polywka 1997, Zimmerman 1995, Lin 1995, Spencer 1997). Three were large cohort studies undertaken by clinical networks (EPHCVN 2001, Gibb 2000, Resti 1998). These are described in the table.
Eight of the observational studies were small with data reported for less than about 100 mother-infant pairs (Zanetti 1995,Polywka 1999, Kumar 1998, Tajari 2001, Polywka 1997, Zimmerman 1995, Lin 1995, Spencer 1997). Three were large cohort studies undertaken by clinical networks (EPHCVN 2001, Gibb 2000, Resti 1998). These are described in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Mother to child transmission of hepatitis C virus:prospective study of risk factors and timing of infection in children born to women seronegative for HIV-1 Resti M, Azzari C, Mannelli F,Tuscany Study Group on Hepatitis C Virus infection in Children 1998 Italy. | 442 mother-child pairs. Follow up of infants of 275 mothers who were HCV RNA positive (and HIV negative).Breastfeeding status known for all infants: 87 were breast-fed. | Observational - cohort (level 2b) | HCV infection in children diagnosed by PCR and antibody testing on follow up until 24 months. | Proportion of infected children among those who breastfed (7%) was not statistically significantly different to that among the non-breastfed infants (4%). | Drop out- 39 pairs |
| Effects of mode of delivery and infant feeding on the risk of mother-to-child transmission of hepatitis C virus. European Paediatric Hepatitis C Virus Network. 2001 Europe, 7 countries | 971 mother–child pairs. Mothers seropositive for HCV but not for HIV. Breastfeeding status known in 887 pairs. 319 infants were breast fed. | Observational Cohort (level 2b) | HCV infection in children diagnosed by PCR and antibody testing on follow-up until 18 months. | Proportion of infected children among those who breast fed (6.6%) was not statistically significantly different to that among the non-breast fed infants (6.3%). | Maternal viremic load (quantitative PCR) and clinical status (symptomatic liver disease or not) not known. |
| Mother-to-child transmission of hepatitis C virus: evidence for preventable peripartum transmission. Gibb DM, Goodall RL, Dunn DT, et al. 2000 UK and Eire | 441 mother–child pairs (but 22 mothers known to be coinfected with HIV and HIV status not known in 91 mothers). Breast feeding status known in 414 pairs. 59 infants were breast fed. | Observational cohort (level 2b) | HCV infection in children diagnosed by PCR and antibody testing on follow-up until 24 months. | Proportion of infected children among those who breast fed (7.7%) was not statistically significantly different to that among the non-breast fed infants (6.7%). | Maternal viremic load (quantitative PCR) not known in most cases. Unknown HIV status in 20% of mothers |
Author Commentary:
HCV infection is a major worldwide cause of chronic liver disease, including hepatic fibrosis, cirrhosis, and hepatocellular carcinoma (AAP 1998; Poynard 2003). 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% (Schwimmer 2000; Thomas 1998).
HCV is a blood borne virus but has been detected in colostrum and breast milk in low levels (Kumar 1998). We wished to determine whether evidence exists that avoiding breast feeding reduces the risk of mother to infant HCV infection. We did not find any randomised controlled trials of this intervention. We did find several observational studies. Most 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 multi-centre cohort studies in which a total of 1854 mother infant pairs participated.( EPHCVN 2001, Gibb 2000, Resti 1998).
We did not find evidence that avoidance of breast feeding is an effective intervention for preventing mother to infant transmission of HCV. This is consistent with evidence from other cohort studies that indicate that most infants who acquire HCV infection do so in utero or in the peripartum period (Mok 2005; Resti 1998).
The studies were all undertaken in European countries within 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. Since transmission from a mother with no RNA detectable at delivery is extremely rare (Dore 1997), this may have been a confounding variable in the other studies where the HCV viral status was not assessed.
We specifically aimed to evaluate the evidence in women who were not co-infected with HIV. This was possible for two studies but not for the third where a 5% of participants were HIV positive. A subgroup anlysis was not possible. HIV co-infection is a contra-indication ot breast-feeding in high-income countries.
HCV is a blood borne virus but has been detected in colostrum and breast milk in low levels (Kumar 1998). We wished to determine whether evidence exists that avoiding breast feeding reduces the risk of mother to infant HCV infection. We did not find any randomised controlled trials of this intervention. We did find several observational studies. Most 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 multi-centre cohort studies in which a total of 1854 mother infant pairs participated.( EPHCVN 2001, Gibb 2000, Resti 1998).
We did not find evidence that avoidance of breast feeding is an effective intervention for preventing mother to infant transmission of HCV. This is consistent with evidence from other cohort studies that indicate that most infants who acquire HCV infection do so in utero or in the peripartum period (Mok 2005; Resti 1998).
The studies were all undertaken in European countries within 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. Since transmission from a mother with no RNA detectable at delivery is extremely rare (Dore 1997), this may have been a confounding variable in the other studies where the HCV viral status was not assessed.
We specifically aimed to evaluate the evidence in women who were not co-infected with HIV. This was possible for two studies but not for the third where a 5% of participants were HIV positive. A subgroup anlysis was not possible. HIV co-infection is a contra-indication ot breast-feeding in high-income countries.
Bottom Line:
Approximately 6% of babies born to hepatitis C (HCV) infected mothers will develop HCV infection (grade A).
Avoidance of breast feeding is not an effective intervention for preventing mother-to-infant transmission of HCV (grade B).
Avoidance of breast feeding is not an effective intervention for preventing mother-to-infant transmission of HCV (grade B).
References:
- Resti M, Azzari C, Mannelli F,Tuscany Study Group on Hepatitis C Virus infection in Children. Mother to child transmission of hepatitis C virus:prospective study of risk factors and timing of infection in children born to women seronegative for HIV-1
- Zanetti AR,Tanzi E, Paccagnini S, Principi N, Pizzocolo G, Lombardy Study Group on Vertical HCV Transmission.. Mother-to-infant transmission of hepatitis C virus.
- Polywka S, Schroter M, Feucht H, Zollner B, Laufs R. Low risk of vertical transmission of Hepatitis C virus by breast milk.
- Kumar R, Shahul S.. Role of breast-feeding in transmission of Hepatitis C virus to infants of HCV-infected mothers.
- Tajari H, Miyoshi Y, Funada S, Etani Y, Abe J, et al.. Prospective study of mother-to-infant transmission of hepatitis C virus.
- Polywka S, Feucht H, Zollner B, Laufs R.. Hepatitis C virus infection in pregnancy and their risk of mother-to-child transmission
- Zimmermann R, Perucchini, Fauchere JC, Jemelka HJ, Geyer M.. Hepatitis C in breast milk.
- Lin HH, Kao JH, Hsu HY.. Absence of infection in breast-fed infants born to hepatitis C virus-infected mothers.
- Spencer JD, Latt N, Beeby PJ, Collins E, Saunders JB.. Transmission of hepatitis C virus to infants of human immunodeficiency virus-negative intravenous drug-using mothers:rate of infection and assessment of risk factors for transmission.
- Poynard T, Yuen MF, Ratziv V, Lai CL.. Viral Hepatitis C.
- Schwimmer JB, Balistreri WF.. Transmission, natural history, and treatment of hepatitis C virus infection in the pediatric population.
- Thomas SL, Newell ML, Peckham CS, Ades AE, Hall AJ.. A review of hepatitis C virus (HCV) vertical transmission: risks of transmission to infants born to mothers with and without HCV viraemia or human immunodeficiency virus infection.
- Dal Molin G, D'Agaro P, Ansaldi F, Ciana G, Fertz C, Alberico S, et al.. Mother-to-infant transmission of hepatitis C virus: rate of infection and assessment of viral load and IgM anti-HCV as risk factors.
- Dore GJ, Kaldor JM, McCaughan GW.. Systematic review of role of polymerase chain reaction in defining infectiousness among people infected with hepatitis C virus.
- Mok J, Pembrey L, Tovo PA, Newell ML, European Paediatric Hepatitis C Virus Network.. When does mother to child transmission of hepatitis C virus occur?
- European Paediatric Hepatitis C Virus Network.. Effects of mode of delivery and infant feeding on the risk of mother-to-child transmission of hepatitis C virus.
- Gibb DM, Goodall RL, Dunn DT, et al.. Mother-to-child transmission of hepatitis C virus: evidence for preventable peripartum transmission.