Re: “Academy of Breastfeeding Medicine's 2017 Position Statement on Informal Breast Milk Sharing for the Term Healthy Infant” by Sriraman NK,et al. ( Breastfeed Med 2018;13(1):2–4)

To the Editor:

I agree with a recent statement by the Academy of Breastfeeding Medicine regarding the potential benefits of informal breast milk sharing for infants and families. ¹ Conversely, I do not fully agree about the need to discard breast milk donated by hepatitis B-infected mothers. Based on the mechanisms of mother-to-child transmission of hepatitis B virus (HBV), several strategies have been invited for the prevention of HBV perinatal infection. Full adherence to the prophylaxis recommendations is a more important point than whether the hepatitis B-infected mother breastfeeds or not in reducing the mother-to-child transmission. The message from the World Health Organization (WHO) is that the risk of transmission associated with breast milk is negligible, and that hepatitis B vaccination will virtually eliminate any risk of transmission through breastfeeding or breast milk feeding. ² Even more, WHO guidelines state that protection against mother-to-child transmission of HBV achieved by routine practices consisting in universal immediate vaccination against HBV may not be improved by the addition of passive prophylaxis.

Let us remember that evidence against breastfeeding as a mechanism for vertical transmission of HBV dates from 1975. ³ Before the availability of HBV vaccine, 147 babies born to hepatitis B-infected mothers were followed up for 11 months; the frequency of acquisition of hepatitis B surface antigen (HBsAg) and anti-HBs was almost identical among breastfed and formula-fed infants (53% versus 49%). These results have been replicated before and after implementation of universal HBV vaccination. No significant difference in the acquisition rate of HBV antigens between breastfed and formula-fed infants was reported again in the prevaccination era. ⁴ Recent research from the vaccination era shows comparable rates of HBV transmission in breastfed and formula-fed children (0% versus 3%). ⁵ Although recent systematic reviews conclude that breastfeeding is not a risk factor for mother-to-child transmission of HBV,^6,7 we know that many hepatitis B-infected mothers tend to formula feed their infants to prevent mother-to-child transmission of HBV, ⁸ and it has been suggested that maternal HBV infection is one of the factors for the persistently low breastfeeding rate in some areas of the world. ⁹

To summarize, current schedules of neonatal HBV vaccination support inclusion of HBV-infected mothers in informal breast milk sharing practices.