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Recommendations for Breastfeeding During Maternal Infections

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0021-7557/04/80-05-Supl/S181 Jornal de Pediatria Copyright © 2004 by Sociedade Brasileira de Pediatria ARTIGO DE REVISÃO Recomendações quanto à amamentação na vigência de infecção materna Recommendations for breastfeeding during maternal infections Joel A. Lamounier1, Zeina S. Moulin2, César C. Xavier3 Resumo Abstract Objetivo: Revisão da literatura com o enfoque de amamentação e Objective: To make a literature review on breastfeeding and doenças infecciosas maternas, no intuito de contribuir com conheci- maternal infectious diseases in order to contribute with knowledge and mentos para decisões a serem tomadas pelo profissional de saúde. information that can aid the pediatrician to decide upon allowing Fontes de dados: Informações foram obtidas em consultas que infected mothers to breastfeed their babies or not. incluíram livros-texto, normas técnicas, artigos selecionados por meio Sources of data: Lilacs and MEDLINE databases were searched for de busca na base de dados Lilacs e MEDLINE, além de referências books, technical rules and articles on the issue of breastfeeding and específicas. infected mothers. Síntese dos dados: Nutrizes com doenças infecciosas podem Summary of the findings: Infected lactating mothers can transmitir agentes patogênicos pelo leite materno para a criança. transmit pathogenic agents to their infants. Although breastfeeding Embora a amamentação confira proteção à criança, ela pode também protects the child it can also be a dangerous source of infection. ser uma importante fonte de infecção. Doenças maternas causadas por Maternal diseases caused by bacteria, virus, fungi and parasites may vírus, fungos e agentes parasitários podem, em alguns casos, ser sometimes be transmitted via human milk. The literature points out transmitidas via leite humano. Para mães com infecções pelo vírus da that mothers infected with HIV and T-lymphotropic human viruses imunodeficiência humana e vírus T-linfotrópicos humanos tipo I, a (type I) should not breastfeed. With other diseases a careful approach recomendação é não amamentar. Nas demais doenças, é necessária should be made, but, in general, breastfeeding is maintained. uma avaliação cuidadosa, mas, em geral, na maioria dos casos, o Conclusion: The mother who is exposed to infectious diseases aleitamento materno é mantido. may transmit pathogenic agents through the human milk, attention Conclusões: Algumas doenças, principalmente as causadas por should also be made to milk from milk banks. The healthcare provider vírus, podem ser transmitidas durante a amamentação. O profissional must take his/her decision upon suspending breastfeeding - or not, de saúde, ao identificar uma nutriz com infecção viral ativa ou outra what can be distressful, once he/she has a fundamental role in doença infecciosa, necessita tomar a decisão de suspender ou não a promoting and stimulating breastfeeding. amamentação, o que pode ser um fato angustiante pelo seu papel fundamental na promoção e estímulo ao aleitamento materno. J Pediatr (Rio J). 2004;80(5 Supl):S181-S188: Leite humano e J Pediatr (Rio J). 2004;80(5 Supl):S181-S188: Human milk and infecção, doenças infecciosas da mãe, aleitamento materno e infection, mothers infectious illnesses, maternal breast-feeding and doenças. infection. Introdução O leite humano, além de seus componentes nutritivos, membranas e moléculas que atuam na proteção do recém- contém, em sua composição, uma complexidade de células, nascido. Na mulher em lactação, o sistema denominado enteromamário ou broncomamário atua quando os patóge- 1. Doutor em Saúde Pública, Universidade da Califórnia, Los Angeles, nos (bactérias) entram em contato com as mucosas do EUA. Professor titular, Departamento de Pediatria, Faculdade de Medi- intestino ou aparelho respiratório e são fagocitados pelos cina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, macrófagos. Com isso, desencadeia-se uma ação estimu- MG. Professor orientador do Programa de Pós-graduação em Saúde da Criança e do Adolescente da UFMG. lante nos linfócitos T, promovendo diferenciação dos linfó- 2. Mestre em Pediatria pela UFMG. Professora de Pediatria, Faculdade de citos B produtores de imunoglobulinas A (IgA). Os linfócitos Medicina, UFMG, Belo Horizonte, MG. migram para a glândula mamária e, com a mediação de 3. Doutor em Pediatria, Faculdade de Medicina da USP, Ribeirão Preto. Professor de Pediatria, Faculdade de Medicina, UFMG. Professor orien- citocinas, tornam-se células plasmáticas que produzem tador do Programa de Pós-graduação em Saúde da Criança e do uma glicoproteína que é acoplada à IgA, convertendo-se em Adolescente da UFMG. imunoglobulina A secretória (IgAs). Esta é uma função Como citar este artigo: Lamounier JA, Moulin ZS, Xavier CC. Recomen- dações quanto à amamentação na vigência de infecção materna. J importante e específica de proteção do recém-nascido Pediatr (Rio J). 2004;80(5 Supl):S181-S188. conferida pelo leite humano1-5. S181 S182 Jornal de Pediatria - Vol. 80, Nº5(supl), 2004 Infecções maternas na lactação Lamounier JA, et alii O aleitamento materno, pelas inúmeras vantagens pos protetores capazes de neutralizar o agente infeccioso. que traz tanto para a mãe como para o recém-nascido, é Portanto, de modo geral, não há contra-indicação formal reconhecido como a melhor forma de alimentação da para amamentação na maioria dos casos de doenças virais, criança. Entretanto, doenças envolvendo tanto a mãe exceto para o grupo dos retrovírus. quanto o recém-nascido podem constituir obstáculos para A transmissão de retrovírus RNA, incluindo HIV-111,12, a amamentação. Nessas circunstâncias, é importante que HTLV I e HTLV II13, já foi demonstrada. O vírus HIV-2 o profissional tenha habilidade, conhecimento técnico e também poder ser transmitido da mãe para o filho, mas o atitude acolhedora para avaliar adequadamente a viabi- papel do aleitamento na transmissão via leite humano ainda lidade do aleitamento. A nutriz, ao apresentar sintomas não está bem estabelecido. O vírus Epstein-Barr e herpes de uma doença, geralmente já expôs seu filho ao agente vírus 6 podem ser encontrados no leite humano, mas, até 6- patogênico, e a orientação geral é manter o aleitamento o momento, são raros os relatos de crianças amamentadas 9 . Se a mãe suspende a amamentação quando surgem os infectadas por esses vírus. Até certo ponto, é surpreendente sintomas da doença, a proteção ao lactente fica diminu- que o leite materno não seja mais infectante, especialmente ída, aumentando a chance da criança adoecer, pois ela com o volume consumido diariamente pelo lactente em deixará de receber anticorpos específicos e demais fato- aleitamento materno exclusivo. Portanto, isso leva a supor res de proteção do leite humano. que devam existir mais fatores de proteção no leite humano Não há indicação de suspender a amamentação, mesmo além dos já conhecidos. que temporariamente, nas mães com infecção urinária, Uma síntese das infecções virais mais importantes infecção bacteriana de parede abdominal, episiorrafia, com possibilidade de transmissão do vírus via leite mater- mastite ou outra em que as condições físicas e o estado no para o recém-nascido, bem como das respectivas geral da nutriz não estejam muito comprometidos. condutas em relação ao aleitamento materno, está ilus- Embora o leite humano contenha anticorpos, células trada na Tabela 1. mononucleares e outros fatores de proteção, em algumas doenças maternas ele pode funcionar como possível fonte 6,7 de infecção para a criança . As células mononucleares do Tabela 1 - Infecções maternas virais e conduta na amamentação leite humano, mesmo promovendo proteção, podem trans- Tipo de vírus Recomendação ferir partículas infecciosas da mãe para o lactente. Assim, o profissional de saúde, ao identificar uma nutriz com Citomegalovírus Amamentar infecção viral ativa ou outra doença infecciosa, pode ficar Hepatite A* Amamentar angustiado frente ao dilema na tomada de decisão de Hepatite B Amamentar suspender ou não a amamentação, já que seu papel é o de Hepatite C* Amamentar promover e estimular o aleitamento materno. Rubéola Amamentar Algumas doenças não-infecciosas podem impedir o Caxumba Amamentar aleitamento materno temporária ou definitivamente de- Herpes simples Amamentar, exceto se as lesões vido à condições físicas da mãe, tais como doenças forem na mama cardíacas, renais e hepáticas graves, psicose e depressão Varicela Amamentar, exceto se a infecção pós-parto grave10. for adquirida entre 5 dias antes e 3 dias após o parto Nesta revisão, são feitas considerações sobre o mane- Sarampo Suspender amamentação jo em relação à amamentação na presença de doenças temporariamente maternas comuns causadas por bactérias, vírus, parasi- HTLV I Não amamentar tas e fungos. HIV Não amamentar * Ver comentários no texto. Infecções por vírus Em várias doenças virais maternas, tais como hepatite, herpes vírus, sarampo, caxumba e rubéola, dentre outras, Infecção pelo HIV pode haver excreção de vírus no leite humano. Porém, O HIV é excretado livre ou no interior de células no leite exceto para as infecções causadas pelos retrovírus vírus de mulheres infectadas, que podem apresentar ou não da imunodeficiência humana (HIV-1), vírus T-linfotrópicos sintomas da doença. Cerca de 65% da transmissão vertical humanos tipo I (HTLV I) e vírus T-linfotrópicos humanos do HIV ocorre durante o trabalho de parto e no parto tipo II (HTLV II) , a transmissão por essa via tem pouco propriamente dito; os 35% restantes ocorrem intra-útero, valor epidemiológico. Na maioria das doenças viróticas
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