Travel and Breastfeeding

Introduction

The preparation of a traveler who is breastfeeding differs only slightly from that of other travelers and depends in part on whether the breastfeeding traveler and child will be separated or together during travel. Most travelers should be advised to continue breastfeeding their children throughout travel.

Before departure, travelers might benefit from compiling a list of local breastfeeding resources at their destination, as well as virtual resources to have on hand during travel. Healthcare professionals and travelers can use the Find a Lactation Consultant Tool to find contact information for experts at the traveler's destination. Healthcare professionals and travelers can use La Leche League International's interactive map to find specific location and contact information for breastfeeding support group leaders and groups worldwide. Travelers who will need to store expressed milk while traveling can call ahead to their hotel or other place of lodging to request access to a refrigerator.

Travel with a breastfeeding child

Breastfeeding provides unique benefits to children while traveling. Explain clearly to breastfeeding travelers the value of continuing to breastfeed during travel. The American Academy of Pediatrics and the Dietary Guidelines for Americans recommend exclusive breastfeeding for about the first 6 months of life. Exclusive breastfeeding means feeding only breast milk with no other food or drink. During the first 6 months, breastfeeding children require no water supplementation, even in extreme heat environments. When traveling to areas where contaminants and pathogens in foods or liquids are a concern, exclusive breastfeeding can help minimize risk to the child. Additionally, feeding only at the breast protects children from potential exposure to contaminants on bottles, containers, cups, or utensils. Breastfeeding also protects children from eustachian tube collapse and pain during air travel, especially during ascent and descent, by allowing the tubes to stabilize and gradually equalize internal and external air pressure.

Frequent, unrestricted breastfeeding opportunities ensure that the lactating traveler's milk supply remains sufficient and that the child's nutrition and hydration are ideal. Travelers concerned about breastfeeding away from home might feel more comfortable breastfeeding the child in a fabric carrier or by using a nursing cover. In many countries, breastfeeding in public places is practiced more widely than in the United States. U.S. federal legislation protects mothers' and children's rights to breastfeed anywhere they are otherwise authorized to be while on federal property, including U.S. Customs areas, embassies, and consulates overseas. The Consolidated Appropriations Act, 2021, SEC. 722 states, "Notwithstanding any other provision of law, a woman may breastfeed her child at any location in a federal building or on federal property, if the woman and her child are otherwise authorized to be present at the location."

Special considerations for emergency travel

Natural disasters, such as hurricanes, floods, wildfires, earthquakes, and tornados, can make it difficult for parents or caregivers to feed their infants and young children safely and appropriately. Visit CDC's Infant and Young Child Feeding in Emergencies Toolkit for information and resources when traveling with your breastfed child during an emergency.

Travel without a breastfeeding child

Healthcare professionals and others who provide lactation support should help travelers determine the best course for breastfeeding based on a variety of factors, including the amount of time available to prepare for the trip, options for expressing and storing milk while traveling, the duration of travel, and available resources at the destination. A breastfeeding traveler might decide to express and store a supply of milk to be fed to the child during her absence. Building a supply takes time and patience. It is most successful when begun gradually, many weeks in advance of departure.

Expressing milk while away from the child can help the breastfeeding traveler maintain their milk supply. Expressing milk also can help avoid engorgement, which can increase the risk of developing breast inflammation or a breast infection. Expressing milk by hand is a useful technique to learn prior to traveling because it does not require any equipment or a reliable power source. Hand expression can be helpful when travelers need to express milk while in transit (e.g., on a bus, car, plane, or train). Travelers intending to use breast pumps may need to pack multiple breast pump kits if they anticipate being unable to clean individual pump parts after each use (see the section on Breast Pump Safety later in this chapter). A nursing cover can provide some privacy when expressing milk.

Depending on the length of travel, ability to regularly express milk, and other factors, the breastfeeding traveler's milk supply may decrease. Often, after returning from travel, several days of feeding at the breast will help bring milk supply back to its prior level. Prolonged separation from the nursing child might, however, increase the difficulty and time it takes to transition back to breastfeeding. Travelers who return to a nursing child can continue breastfeeding and, if necessary, supplement with previously expressed milk, pasteurized donor human milk, infant formula, or a combination of these until their milk supply returns to its prior level. A lactation support provider can help address breastfeeding challenges after a traveler reunites with her child.

Medications, vaccines, and other exposures

Healthcare professionals should select medications and vaccines for the nursing traveler that are compatible with breastfeeding. In most circumstances, it is inappropriate to counsel travelers to wean in order to be vaccinated or to withhold vaccination due to breastfeeding status.

Breastfeeding and lactation do not affect maternal or child dosage guidelines for any medication or vaccine; children always require their own medications and vaccines, regardless of maternal dose. In the absence of documented risk to the breastfeeding child associated with a particular maternal medication, the known risks of stopping breastfeeding generally outweigh a theoretical risk for exposure via breastfeeding.

Drugs and chemicals

Few medications are contraindicated in women who are breastfeeding or are associated with adverse effects on their children. The National Library of Medicine's Drugs and Lactation Database (LactMed) is an online resource for clinical information about drugs and chemicals to which breastfeeding travelers could be exposed. LactMed provides information about the levels of substances in breast milk and infant blood, potential effects on breastfeeding children and on lactation itself, and alternative drugs to consider.

MotherToBaby is a service of the nonprofit Organization of Teratology Information Specialists and provides evidence-based information on the benefit or risk of medications and other exposures during pregnancy and lactation. MotherToBaby provides a free information and risk assessment service to mothers, healthcare professionals, and the public via text, chat, phone, or email, in English and Spanish.

Malaria prophylaxis medication

Because chloroquine and mefloquine can be safely prescribed to infants, both are considered compatible with breastfeeding. Most experts consider short-term use of doxycycline compatible with breastfeeding. Primaquine and tafenoquine can be used for breastfeeding women if both the breastfeeding woman and the infant are tested using a quantitative glucose-6-phosphate dehydrogenase (G6PD) assay prior to treatment and have normal G6PD activity. Data are not yet available on the safety of atovaquone-proguanil prophylaxis in infants weighing <5 kg (11 lb), so it is not recommended to prevent malaria in women who are breastfeeding infants weighing <5 kg (<11 lb; see Malaria chapter).

The quantity of antimalarial drugs transferred to breast milk is not enough to provide protection against malaria for the infant. Breastfeeding infants need their own antimalarial drug. More information about malaria and breastfeeding is available at Malaria and Breastfeeding.

Travelers' diarrhea treatment

Exclusive breastfeeding helps protect children against travelers' diarrhea (TD). Breastfeeding is ideal rehydration therapy. Children suspected of having TD should breastfeed more frequently and, in order to reduce the chances of reinfection, should not be offered other fluids or foods that replace breastfeeding. Breastfeeding travelers with TD should continue breastfeeding if possible and increase their own fluid intake. Evidence is lacking that any TD pathogen can pass into breast milk.

Breastfeeding travelers should check the labels of over-the-counter antidiarrheal medications to avoid using bismuth subsalicylate compounds (e.g., Pepto-Bismol), which can lead to the transfer of salicylate to the child via breast milk. Loperamide is the preferred antidiarrheal medication to use while breastfeeding. Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) and macrolides (e.g., azithromycin), commonly used to treat travelers' diarrhea, are excreted in breast milk. Consult with the breastfed child's primary healthcare professional before deciding which antibiotics to prescribe for breastfeeding travelers. Most experts consider the short-term use of azithromycin compatible with breastfeeding. Use of oral rehydration salts is fully compatible with breastfeeding (see Travelers' Diarrhea and Post-Travel Diarrhea chapters).

Vaccinations

Most vaccines do not affect breastfeeding, breast milk, or the process of lactation; immunize breastfeeding travelers according to routine, recommended vaccine schedules. Two vaccines, mpox/smallpox (ACAM2000) and yellow fever, require special consideration.

Mpox/smallpox (ACAM2000)

ACAM2000 is a replicating viral vaccine and is contraindicated in breastfeeding women because of the risk for contact transmission to the breastfed child. When pre- or post-exposure prophylaxis by vaccination is needed, JYNNEOS, a live, non-replicating viral vaccine, can be used for women who are breastfeeding. The risks and benefits of JYNNEOS should be discussed with the patient using shared decision-making.

Yellow fever vaccine

Breastfeeding is a precaution against administering yellow fever vaccine. Three cases of yellow fever vaccine–associated neurologic disease (encephalitis) have been reported in infants exclusively breastfed by women who received yellow fever vaccine. All 3 infants were aged <1 month at the time of exposure.

Until specific research data are available, avoid vaccinating breastfeeding travelers against yellow fever. When a breastfeeding woman must travel to a yellow fever endemic area, however, vaccination should be recommended. Although limited data are available, some experts advise that breastfeeding travelers who receive yellow fever vaccine should temporarily suspend breastfeeding, pump, and discard milk for at least 2 weeks after vaccination before resuming breastfeeding (see Yellow Fever chapter). Refer travelers to a lactation support provider for information on how to maintain milk production and how to feed the child while not breastfeeding; options include using previously expressed milk, pasteurized donor human milk, infant formula, or a combination of these.

Zika virus and other arboviruses

Women with Zika virus infection and those living in or traveling to areas with ongoing Zika virus transmission are encouraged to breastfeed their children (see Zika chapter). Evidence suggests that the benefits of breastfeeding outweigh the risks of Zika virus transmission through breast milk. Similar to the approach for those infected with Zika virus, breastfeeding travelers infected with chikungunya virus, dengue virus, tick-borne encephalitis virus, West Nile virus, or yellow fever virus are encouraged to continue breastfeeding.

More information about breastfeeding and certain maternal and infant illnesses and conditions is available at Illnesses or Conditions and Breastfeeding and Contraindications to Breastfeeding.

Air travel

Air travel should not be a barrier to breastfeeding or expressing breast milk (see Air Travel chapter). Being prepared and aware of available resources can help ease anxiety about traveling by air with breast milk, breast pump equipment, or a breastfeeding child.

Breast pump equipment and breast milk

People who will be traveling by air and expect to have expressed milk with them during travel need to plan how they will transport the expressed milk. Airport security regulations for passengers carrying expressed milk vary internationally and are subject to change.

In the United States, expressed milk and related infant and child feeding items are exempt from Transportation Security Administration (TSA) regulations limiting quantities of other liquids and gels. Travelers can carry with them expressed milk, ice packs, gel packs (frozen or unfrozen), pumps and pump kits, and other accessories required to transport expressed milk through airport security checkpoints and onboard flights, regardless of whether the breastfeeding child is also traveling. Travelers should inform TSA officers that they are carrying breastfeeding equipment and separate the expressed milk and related accessories from the liquids, gels, and aerosols that are limited to 100 mL (3.4 oz) each, as subject to TSA's Liquids Rule.

Breast pumps are medical devices regulated by the U.S. Food and Drug Administration, and most airlines allow passengers to carry breast pumps on board in addition to other permitted carry-on items. Travelers can check the airline's policies related to breastfeeding and breastfeeding equipment prior to travel.

X-rays used in airport screenings have no effect on breastfeeding, expressed milk, or the process of lactation. No adverse effects are known from eating food, drinking beverages, or using medicine screened by x-ray. Travelers who do not want expressed milk to be opened or irradiated in scanners should inform a TSA officer; they might conduct different or additional screening procedures, such as Advanced Imaging Technology screening and additional/enhanced screening of other carry-on property. Travelers should plan for extra time at the airport to get through the airport security checkpoints when traveling with expressed milk and related supplies. Travelers might find that providing TSA officers with the related TSA regulations for expressed milk can help facilitate the screening process.

Travelers carrying expressed milk in checked luggage should refer to cooler pack storage guidelines on the CDC website, Breast Milk Storage and Preparation. Expressed milk is considered a food for individual use and is not considered a biohazard. International Air Transport Authority regulations for shipping category B biological substances (UN 3373) do not apply to expressed milk.

Lactation spaces

All small, medium, and large hub airports in the United States are required by the Friendly Airports for Mothers Improvement Act to provide a clean, private, non-bathroom lactation space in each terminal for breastfeeding or expressing milk. Travelers can check the airport's website to locate these spaces.

Packing and shipping breast milk

Travelers shipping frozen milk should follow guidelines for shipping other frozen foods and liquids. Travelers planning to ship frozen milk might need to bring supplies (e.g., milk storage bags or resealable bags; paper lunch bags or newspaper for wrapping frozen milk; coolers; labels, packing tape, and shipping boxes; tongs or gloves for handling dry ice). Some shipping carriers provide temperature-controlled options that can be used for transporting expressed milk. Some employers will cover the cost of shipping expressed milk home for employees who are traveling for work. Travelers should make sure in advance that transporting expressed milk will meet customs regulations because these can vary by country. Expressed milk does not need to be declared at U.S. Customs upon return to the United States.

Breast pump safety

Travelers who plan to use an electric breast pump while traveling might need an electrical current adapter and converter. They should also have a back-up option available, such as a manual pump or information on hand expression techniques.

Travelers using a breast pump should follow proper cleaning guidance for breast pumps and infant feeding items (e.g., bottles and the nipples, rings, and caps that go with them) to minimize potential contamination. Travelers also could consider packing a cleaning kit for breast pump parts, including a cleaning brush, dish soap, and portable drying rack or mesh bag to hang items to air dry.

Travelers should wash hands thoroughly with soap and water before pumping and handling expressed milk; if safe water is not immediately available, travelers can use an alcohol-based hand sanitizer containing ≥60% alcohol. If travelers are unable to clean pump parts between uses, they can bring extra sets of pump parts (e.g., connectors, flanges, membranes, valves) to use until they are able to clean used parts thoroughly. Cup feeding can also be used to feed infants when they are unable to feed directly at the breast or when infant feeding items cannot be cleaned properly.

Acknowledgements

The following author contributed to the previous version of this chapter: Katherine R. Shealy.