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IFE in cholera

This question was posted the Infant and young child feeding interventions forum area and has 14 replies.

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Astrid Klomp

Independent

Normal user

17 Oct 2022, 09:06

Dear all,

There seems to be a message in several documents that a mother should wash her breasts with soap and water before breastfeeding if she has cholera. This goes against anything I have been tought as an IBCLC (makes it more difficult for the baby to find the breast; barrier to putting the baby to the breast when it needs to; could cause the breasts to dry out and so cracked nipples; soap residues that might be harmful etc) and I don't understand how this could be a source of transmission. Does anybody have any evidence behind this advice, or is this just something that was thought to be good, but actually other evidence could point in the other direction?

Here are the sources where I found this recommendation: https://resourcecentre.savethechildren.net/pdf/b._breastfeeding_mothers_in_cholera_treatment_centres.pdf/ and https://reliefweb.int/sites/reliefweb.int/files/resources/UNICEF-Cholera-Toolkit-2013.pdf (page 208)

I am asking since this message is now being spread in the cholera response in Lebanon, and worried we continue to share something that could be possibly harmful.

Thanks!

Rukhsana

Chair, TAHN Foundation

Normal user

17 Oct 2022, 09:51

Dear Astrid,

Thank you for asking this question. In fact where health staff have not received basic/updated training on breastfeeding, mothers with newborns are often given this advice. As you have rightly pointed out, this advice is quite harmful. I have worked for several years at the International Diarrhoeal Disease Hospital in Bangladesh, and I am sure there is no evidence to support this kind of advice! Mothers admitted with diarrhoea, including suspected or confirmed cholera, are advised to continue breastfeeding their infants ad libitum. General hygienic practices (bathing when possible, and handwashing) should be enough.  

I hope this helps. Thanks again.

Bindi Borg

IYCF researcher and practitioner

Normal user

17 Oct 2022, 10:44

Hi Astrid

Your concerns are very valid and thanks for the clear response Rukhsana.  As I understand the history of this recommendation, breastwashing was in some much earlier, now outdated and refuted advice.  However, where old documents are still about, or as Rukhsana said, when training is not updated, it pops up again.  

Maybe it would be a useful endeavour to track down the original document and have the author/s put out a clear statement that breastwashing is NOT recommended.

Best

bindi

Chantal Autotte Bouchard

Public Health Advisor

Normal user

31 Oct 2022, 07:39

Dear all,

Thanks a lot to have put this in front line.

Any expert on IFE (Mija?) may give their advice on this? I had the confirmation it's  spread out as a good practice in Lebanon but the fact are debating as good or not.

Best

Chantal

André Briend

Frequent user

31 Oct 2022, 07:50

Dear Chantal,

Please refer to the post above by Rukhsana. She is very humble in describing her career but I can tell you she is a leading international expert in IFE with a deep knowledge of cholera. You can really trust her advice.

Kirrily de Polnay

Nutrition department, WHO HQ

Normal user

31 Oct 2022, 08:35

Dear Astrid, 

There is currently no WHO guidance from WHO HQ which recommends washing the breasts before breastfeeding for a woman who has cholera. There is of course a considerable amount of mention (in many pieces of WHO guidance) of the importance of washing hands at all the normal appropriate moments, including before breastfeeding. There is also a lot of mention of the importance of continued breastfeeding for children with all types of diarrhoea including cholera. Hope this helps.

Chantal Autotte Bouchard

Public Health Advisor

Normal user

31 Oct 2022, 13:38

Dear  Adrien, Rukhsana, thanks a lot for both feedback, believe me I do not doubt at all on guidance of Rukhsana or any of us, but as usual concerning EB there is so many tends and believe that sometimes it's hard to convince or influence people in front of us. I have to admit that I do not know Rukhsana and it seem it's an error, but when I am discussing with Lebanon, it seem that it's a believe already spread before cholera outbreak which might influence decision as of now even the official guide I have seen seem not really clear for now on. BEst C.

Mija Ververs

JHU and CDC

Normal user

31 Oct 2022, 14:43

Hi all, I have just been made aware of this extremely useful conversation. So where is the exact disagreement?

1. We all agree that breastfeeding is essential in a cholera setting, whether the mother or infant is positive, or both. Correct?

2. We all agree that handwashing with water and soap is essential too in that scenario.

The question is whether the breast needs to be washed with water and soap - correct? 

What would be against washing the breast with water and soap but not the nipple and areola? (I am not referring here to a newborn, but a child that is already initiated and breastfed). 

IFE Core Group Coordinator

Technical expert

15 Nov 2022, 13:16

Thanks all for your contributions to this important discussion. I am popping into this thread to let you all know that IFE Core Group members engaged with global guidance on cholera and breastfeeding are taking steps to address the concerns that have been raised, and will report back here when progress has been made.

Astrid Klomp

Nutrition and Health Co / Action Against Hunger

Normal user

24 Feb 2023, 07:43

Dear all,

A bit of a late response, but thank you for your great input and also thanks to the IFE Core Group for clarifying this. 

@Mija I agree with your two points, on washin of breasts let me highlight why I find this problematic and very unhelpful.

My first problem with this advice is the lack of evidence around the need for it.

As an IBCLC with experience in many different settings, and from research (especially our experience of how breastfeeding and HIV was delt with) that if we put up barriers, women will choose not to breastfeed since they do not want to pass on anything to their infants. 

If a mother is sick with cholera and she is told she should wash her breasts before each breastfeed, this is a major barrier, especially if she in in-patient care (where this is mainly recommended - although in Lebanon it is a general recommendation to those with Cholera). 

My issue is also that we see the breasts as a possible route of transmission, where is the evidence for this? Even with the hand washing, this is mainly important if the mother has cracked nipples that she can introduce something to the breast, not necessarily to the infant. If a mother that is sick with cholera vomits all over herself, she will most likely want to take a bath, so it naturally takes care of this.

One last point, if there is an insitance on this practice, imo that recommendation should be towards the carer of this patient, (ie the nurse) that she ensures that the mother can stay in bed and this can still be done and that material (a cloth, soap, water, a basin etc.) so that it can be done at the bed.

Mija Ververs

JHU and CDC

Normal user

24 Feb 2023, 12:40

Thanks Astrid. I'd like to bring under your attention some confusion in guidance/statements that are currently circulating on cholera and breastfeeding and use of disinfectant.

In the Joint statement from the Whole of Syria on infant feeding it is stated

‘Breastmilk feeding should continue by ensuring the areola, breast, and the mother’s hands are cleaned with soap/water or disinfectant. Rubbing some breastmilk on the nipple will remove the taste of soap from the breast.'

Source:  https://reliefweb.int/report/syrian-arab-republic/whole-syria-joint-statement-protecting-maternal-infant-and-young-child-nutrition-during-earthquake-response-syria-12th-february-2023

However, in the Interim Technical Note Treatment of cholera in pregnant women 21 November 2022 (Global Task Force on Cholera Control) it is stated

'Care for a neonate in a Cholera Treatment Centre If a baby is born in the Cholera Treatment Centre (CTC) and at any time the neonate comes into contact with faeces, wash with soap and water. Do not use a chlorine solution or other antiseptic solution. Mothers should be encouraged to breast feed. The mother should be encouraged to wash her hands with soap and water before putting the neonate to breast'.

Source: https://www.gtfcc.org/wp-content/uploads/2020/11/gtfcc-interim-technical-note-treatment-of-cholera-in-pregnant-woment-1.pdf

Maybe something to address by the designated agencies? Just flagging.

Jodine Chase

Normal user

27 Feb 2023, 18:01

Hello, all, I promised an update when new guidance has been released per above, and I'm pleased to let all know that the Global Task Force on Cholera Control (GTFCC) website is now up-to-date with an Interim Technical Note for Treatment of cholera in pregnant women, dated  21 November 2022  with details as follows:

...
Care for a neonate in a Cholera Treatment Centre

If a baby is born in the Cholera Treatment Centre (CTC) and at any time the neonate comes into contact with faeces, wash with soap and water. Do not use a chlorine solution or other antiseptic solution. Mothers should be encouraged to breast feed. The mother should be encouraged to wash her hands with soap and water before putting the neonate to breast. Administration of antibiotic prophylaxis to the neonate for prevention of cholera is not necessary. Note: If there is a reason to believe that the mother’s breast has been in contact with stool or vomit, consider asking the mother to clean her breast with soap and water and expressing some small amount of breast milk on her nipple and areola before putting the neonate to feed. Do not use chlorine or other antiseptic solutions. There is insufficient available evidence to make a strong recommendation, however breastfeeding should always be encouraged. Institution of any barriers to breastfeeding should be evidence based and, on a case-by-case basis.
...

The document can be found here  https://www.gtfcc.org/wp-content/uploads/2020/11/gtfcc-interim-technical-note-treatment-of-cholera-in-pregnant-woment-1.pdf

It is my understanding that an updated Joint Statement from the Whole of Syria will reflect this guidance.

Warmly,

-- Jodine Chase

IFE Core Group Facilitator

Jodine Chase

Normal user

27 Feb 2023, 18:38

I have a further request, does anyone have examples of a good key messages document for breastfeeding and cholera? 

Maryse Arendt

Lactation consultant IBCLC , BLL Luxembourg

Normal user

27 Feb 2023, 18:59

This guidance seems to cover only infants born in chilera treatment centers, what about breastfed infants of mothers who are ill with cholera. Will the babies be admitted with them to the treatment center? 

Chantal Autotte Bouchard

Public Health Advisor

Normal user

8 Mar 2023, 05:23

Dear all,


Thanks a lot Jodine for the sharing document. As mention by Maryse and request by you we miss some good recommandations/practices around how to promote and ensure adequate continious breasfeeding for child already breasfeed avoiding any risk and burden on the mother.

I have seen / heard some recommadation sometimes who make me feel a bit doubting like by example:  suggest to the mother to wrap the baby in clean and  washed (chlorine)  clothes / cloth before every breasfeed.... If I do understand the point, I think in situation like Syria right now it's a really complicated things and as it mention above put a risk on mother who would ensure to avoid spreading cholera would prefer to not breasfeed....

HOpe we will have the chance to see more good recommadation sharing in near future.

Best

C.

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