Elsevier

Vaccine

Volume 32, Issue 16, 1 April 2014, Pages 1786-1792
Vaccine

Review
Breastfeeding after maternal immunisation during pregnancy: Providing immunological protection to the newborn: A review

https://doi.org/10.1016/j.vaccine.2014.01.083Get rights and content

Highlights

  • Maternal vaccination during pregnancy has a beneficial effect on the amount of sIgA in breast milk.

  • Breastfeeding after maternal vaccination results in a lower incidence of some infectious diseases in young infants.

  • The lack of a validated standardised assay for sIgA makes the research on immunoglobulin analyses in breast milk hard to interpret.

Abstract

Vaccination during pregnancy results in an augmentation of disease specific maternal antibodies. Immunoglobulin G (IgG) is mainly transferred through the placenta during the third trimester of pregnancy, while secretory Immunoglobulin A (sIgA) is passed through breast milk. At birth, newborns are partially protected against infectious diseases by these antibodies.

This review aims to provide an overview of the effect of vaccination during pregnancy on the immunological protection of the newborn by the presence of disease specific sIgA antibodies in breast milk and their possible protective function against disease.

Our search produced 11 relevant papers; 1 on pertussis, 7 on pneumococcus, 2 on influenza and 1 on meningococcus.

All of the studies in this review that measured disease specific antibodies in breast milk (n = 8 papers), stressed the beneficial effect of maternal vaccination during pregnancy on the amount of disease specific sIgA in breast milk. Only a few studies demonstrated a potential protective effect, particularly with influenza vaccines. In an era where maternal vaccination is increasingly considered as a valuable strategy to protect both the mother and infant, further research is needed to assess the effect on breast milk sIgA and to understand the potentially beneficial effects to the infant.

Introduction

In industrialised countries, the use of vaccines in pregnant women has been controversial. Live attenuated vaccines are contraindicated in pregnant women because of the possible transplacental transmission of the attenuated virus to the foetus. However, this recommendation is based on a theoretical risk rather than on evidence [1]. In contrast, vaccination with killed or inactivated vaccines has not been shown to cause any risk to the foetus when administered during pregnancy [2], [3], [4], [5]. Some of these vaccines are even recommended during pregnancy [5]. This strategy has the potential to protect the pregnant woman and foetus from serious illness during pregnancy (e.g., from influenza). In addition, it provides better protection to the infants after birth and during the first months of life when they are too young to be vaccinated for certain diseases (e.g., from tetanus, influenza and pertussis) [5]. The Centers for Disease Control and Prevention (CDC) have published a summary of vaccines that may be given during pregnancy, i.e., vaccines against typhoid fever infection, Japanese encephalitis, tick-borne encephalitis, pneumococci (both conjugate and polysaccharide), hepatitis A, hepatitis B, meningococci (both conjugate and polysaccharide), cholera, inactivated polio, rabies, inactivated influenza, pertussis, tetanus and diphtheria [6].

As a rule, breastfeeding is not a contraindication to maternal vaccination nor is vaccination a contraindication to breastfeeding. The only exception is the yellow fever vaccination, as reports have demonstrated that the live attenuated virus may be transmitted through breast milk [7]. Vaccination with the yellow fever vaccine should therefore be avoided during breastfeeding.

According to the World Health Organization (WHO), colostrum is the perfect food for the newborn and should be given within the first hours of life. Furthermore, breast milk provides essential nourishment to the newborn and assures healthy growth and development. Breast milk is also known to have a protective effect against sudden infant death syndrome, infant mortality, allergic disease, necrotising enterocolitis, gastrointestinal tract infections and respiratory tract infections [8]. The WHO recommends exclusive breastfeeding up to the age of 6 months, followed by a combination of breast milk and supplementary food up to 2 years of age or older [9].

In general, the transfer of maternal antibodies from the mother to child via placental transport [10], [11] has been well documented. The placental transport of Immunoglobulin G (IgG) depends on the placental function and on the concentration of maternal antibodies in the pregnant woman [11], [12]. The concentration of IgG in women at childbearing age is defined by the previous exposure to the antigen through either disease and/or vaccination. Increased levels of maternal IgG antibodies have been described after vaccination during pregnancy [13], [14], [15]. In contrast, little is known about the effect of vaccination during pregnancy on the transfer of vaccine-induced secretory Immunoglobulin A (sIgA) maternal antibodies via breastfeeding, which is the principal immunoglobulin in breast milk [16]. SIgA protects infants by binding and opsonising pathogenic microorganisms, thus inhibiting the colonisation and invasion of the mucosal membranes of the child [17]. Via this mechanism, sIgA functions as a first-line barrier protecting the epithelium from pathogens and toxins. Other factors that are responsible for the protective effect of breast milk are lactoferrin, oligosaccharides, interleukin-10, epidermal growth factor and other anti-inflammatory factors [17], [18].

In this paper, we review the literature on the possible immunological protection provided through breastfeeding in women who were vaccinated during pregnancy. Animal studies were not selected because we cannot extrapolate the results to humans. The immune system and the role of breastfeeding in animals are entirely different from humans. In mice, for example, maternal antibodies are mainly transmitted to the offspring through breastfeeding and less often through placental transfer, as confirmed by foster feeding studies. These breast milk derived maternal antibodies of these animals provide a longer lasting protection in comparison to the antibodies transferred via the placenta [19].

The current recommendations for vaccination during pregnancy are based on evidence that vaccination during pregnancy or shortly before pregnancy has a positive effect on the amount of IgG antibodies transported through the placenta [13]. The question remains whether this vaccination also has a positive effect on the amount of maternal sIgA antibodies found in breast milk and if these breast milk antibodies will provide actual protection against infectious diseases.

Section snippets

Systematic literature review

A review of the literature on transfer of maternal antibodies through breastfeeding from mothers vaccinated during pregnancy was performed according to the MOOSE criteria (Meta-Analysis of Observational Studies in Epidemiology) [20]. A Medline search was conducted using the National Library of Medicine's PubMed online search engine with a combination of the following Medical Subject Headings (MESH) terms: Vacc*, Lact*, Breast milk, Breastfeeding, Colostrum, Preg*, Pertussis, Pneumo*, Influenza,

Results of the search

The overall search produced a total of 208 papers, of which 70 papers were repeatedly selected. A searching of the bibliographies revealed 5 further publications. On the basis of the inclusion/exclusion criteria, 22 abstracts were selected and the full papers were obtained and read. A second selection was made using the same inclusion/exclusion criteria on the full text of the papers. Only 10 publications and 1 presentation were selected for the present review (Table 1).

A summary of the

Discussion

Based on this review, we conclude that very little data are available on the effect of vaccination during pregnancy on the composition of breast milk and, in particular, on the presence of disease specific sIgA antibodies.

The concept of providing protection to children through breast milk is not new. Considering the US article on pertussis [22], it is obvious that there is a long history of research on the possible protective effects of breast milk. However, most research does not focus on the

References (36)

  • P.L. Moro et al.

    Safety of influenza A (H1N1) 2009 live attenuated monovalent vaccine in pregnant women

    Obstetrics and Gynecology

    (2013)
  • Y. Zheteyeva et al.

    Safety of meningococcal polysaccharide-protein conjugate vaccine in pregnancy: a review of the Vaccine Adverse Event Reporting System

    American Journal of Obstetrics and Gynecology

    (2013)
  • C.M. Healy

    Vaccines in pregnant women and research initiatives

    Clinical Obstetrics and Gynecology

    (2012)
  • U.S. Department of Health and Human Services

    Guidelines for vaccinating pregnant women

    (2013)
  • CDC

    Transmission of yellow fever vaccine virus through breast-feeding—Brazil, 2009

    MMWR Morbidity and Mortality Weekly Report

    (2010)
  • American Academy of Pediatrics

    Breastfeeding and the use of human milk

    Pediatrics

    (2012)
  • WHO. Exclusive breastfeeding for six months best for babies everywhere. Geneva. 2011....
  • A. Malek et al.

    Maternal-fetal transport of immunoglobulin G and its subclasses during the third trimester of human pregnancy

    American Journal of Reproductive Immunology (New York, NY: 1989)

    (1994)
  • Cited by (74)

    • Maternal vaccination as an additional approach to improve the protection of the nursling: Anti-infective properties of breast milk

      2022, Clinics
      Citation Excerpt :

      In addition, studies assessing the digestibility of IgG in ileal aspirates and stools from infants, children, and adults have demonstrated that orally-administered IgG, from human or bovine serum as well as from bovine colostrum and milk, but not from human milk, survived gastric exposure and resisted to proteolysis in the stomach and intestinal tract, but the recovered IgG concentrations varied from study to study.108 While the placental transfer of IgG antibodies after vaccination during pregnancy is well documented, few studies exist on the induction of vaccine-specific antibodies, particularly IgA antibodies, in breast milk.109 It is noteworthy that transplacentally acquired systemic IgG has a short half-life,3,110,111 while IgA acquired by breastfeeding will be present in the infant's mucosa throughout the breastfeeding period.

    View all citing articles on Scopus
    View full text