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Most mothers with hepatitis B or hepatitis C can, according to the CDC, breastfeed safely. Is there any evidence that either viral liver infection can ever be transmitted through nursing?

Hepatitis B and C aren't welcome additions to anyone's life. You wouldn't wish them on your worst enemy, and would probably do everything you could to protect your own child from these serious and ultimately potentially fatal viral causes of liver inflammation.

Mothers can pass these blood borne viruses on right as they bring their children into the world, but we also know that minimizing the risk of exposure to infected blood in turn lowers the risk of infection. This is why not sharing unsterilized needles and syringes during IV drug abuse, never receiving a tattoo or piercing from an unregulated studio with substandard hygiene practices, and avoiding unsafe sexual relations are all common-sense preventative measures. 

It's also why people living with someone who has hepatitis B or C — and everyone else, for that matter — will be advised never to share a toothbrush, razor, or any other personal hygiene product that may contain traces of blood. Though it might not be immediately obvious, such scenarios can indeed cause exposure to blood, if both people had even the tiniest open wounds that they may have been completely unaware of.

If you wouldn't share a toothbrush or razor, should you breastfeed if you are living with hepatitis B or C? One study indicated, after all, that 32 percent of nursing mothers will, at some point, suffer from cracked nipples. Could an infant be infected in this way?

Is it safe to breastfeed with hepatitis B?

What kind of person ends up with hepatitis B? Many people will immediately think of IV drug users, folks having unprotected sexual relations, or perhaps healthcare workers exposed to needle-stick injuries. Those are, indeed, all ways in which this potentially-fatal viral liver condition can be spread — but in highly endemic areas, many newly infected patients are babies who acquire hepatitis B from their mothers during birth

Without treatment, an estimated four in 10 babies born to mothers with hepatitis B will develop chronic hep B themselves. Because not every infected person is aware of their status, there isn't a governmental or intergovernmental healthcare organization that doesn't recommend universal screening of pregnant women. Babies born to mothers with hepatitis B should receive hep B immune globulin as well as the first dose of the hep B vaccine in the first 12 hours of life. All other babies should be vaccinated against this viral liver disease within 24 hours. 

Though research has unearthed antigens and even hepatitis B DNA within the breast milk of infected mothers, breast milk itself has never been found to directly transmit the viral infection. There is, on the other hand, a theoretical risk of infection if a mother with hepatitis B breastfeeds with cracked, bleeding nipples and the baby also has some kind of oral laceration. Because preventative treatments in the form of immune globulin and vaccination are highly effective, though, the risk is extremely small for any baby who received proper treatment. 

Should you breastfeed if you have hepatitis B? The US Centers for Disease Control have concluded that it is safe — with the caveat that it may be prudent to be extra cautious if you have cracked nipples, even though there is little evidence that this leads to infection in practice. Hep B positive mothers with bleeding or cracked nipples could formula-feed while pumping and discarding their milk to maintain their supply until they are fully healed. 

Mothers using the antiviral medications lamivudine and tenofovir disoproxil fumarate are also, research has indicated, safely able to nurse their babies. While these medications do reach breast milk, they do so in much lower doses than those babies are exposed to in the womb — and both meds are deemed absolutely safe during pregnancy. 

Is it safe to breastfeed with hepatitis C?

Like hepatitis B, hepatitis C can be acute and short-lived, or become chronic and lead to cirrhosis, liver cancer, and ultimately death unless a patient receives treatment. Unlike hepatitis B, no vaccine is available.

Transmission from mother to baby is less common than with hepatitis C, but it does happen. Despite quite a few studies into the topic, there is, again, very little evidence that breast milk itself poses any risk. Neither the medical literature nor the CDC — which bases its recommendations on the most up-to-date science — suggest that hep C positive mothers need to avoid breastfeeding to reduce the risk that their baby will become infected. The same advice to hold off on nursing if you have cracked or bleeding nipples applies here, too, however. 

One small study published in 1998 came to a different conclusion than most others, however, when it noted that breastfeeding "seems safe" among "asymptomatic mothers" but added that "symptomatic women, especially with high viral loads, should not breastfeed to avoid the risk of viral transmission through breastfeeding". Because no other research has made this particular recommendation since, it's hard to know what to make of it. 

What should you do if you are living with hepatitis B or C?

The decision becomes harder to make when you're personally affected, and your child's health is at stake. We'd advise any mother living with hepatitis B or hepatitis C to discuss all her concerns and questions with her doctor — where possible, while she is still pregnant.

SteadyHealth author Dr Sasa Milosevic noted that there are no documented cases that proved hepatitis B or C were transmitted as a result of breastfeeding — either through breast milk itself or exposure to blood via cracked and bleeding nipples. He adds:

"When you think about it, it would be very hard to determine anyway. Both HBV and HCV can produce acute symptoms three to six months after infection, and in some cases, HCV infection goes without the acute phase. In other words, it is nearly impossible to determine whether a child who goes on to test positive for HCB or HCV was infected during delivery or during breastfeeding."

Should you decide, after careful consultation with your doctor, that you do want to breastfeed and the benefits outweigh the potential risks, you can keep a close eye on your skin. Refrain from nursing when you notice cracked or bleeding nipples, or have an unrelated open wound like a cat scratch in that area. 

Should you decide that the slim theoretical risk of transmission via breastfeeding isn't acceptable to you and you'd feel safer using formula, however, that is a perfectly valid choice to make, too. Too many mothers have been guilted into breastfeeding even if they didn't, for whatever reason, feel comfortable with it. As a mother with hepatitis B or hepatitis C, you certainly sit near the top of the list of people who should never, ever, be bullied into nursing.