모유수유. WHO의 글.

[윤구현]

모유수유에 대한 질문은 자주 올라오는 것이라 많이들 알고 계실 거라고 생각했었는데요.

제가 여러말을 쓰는 것보다 전문의 선생님들의 글을 올립니다. 김창섭내과 김창섭선생님과 가톨릭대 김종현선생님의 글입니다. 글을 읽어보시면 아시겠지만 김종현선생님은 소아감염이 전공이시고 B형간염의 수직감염을 공부하셨다고 합니다.

그리고 그 아래는 김종현선생님이 저에게 보내주신 WHO의 자료입니다. html로 된 것을 바로 위에도 올렸습니다. 그게 읽기 편합니다. 영어입니다.....


김창섭선생님 ----
아기 엄마가 B형 간염보균자인 경우 모유 수유는 어떻게 하나요?

좋은 일을 앞두고 고민이 많으시겠습니다만,
일단 결론부터 말씀드리면 전에는 권하지 않는 쪽으로 말씀을 드렸었는데, 아래의 테이블안에서 읽으실 수 있는 선배로부터의 편지를 받고 나서는 굳이 말릴 필요가 없다고 생각되는 군요...

과거에 B형간염에 대한 면역글로불린 (immunoglobulin)과 간염백신이 나오기 전 세대는 출생시 감염을 피할 방법이 없었지만,
현재는 산모가 B형 간염바이러스 보유자인 경우에는 산부인과에서 알아서
출생 12시간 이내에 신생아에게 면역글로불린 및 예방백신을 접종해 줍니다.
단지 이 방법을 통해서도 감염을 차단할 수 있는 것은 90%를 상회한다는 것이 문제이겠지요..

대개 출산시에 감염되는 경로는 산도 (여성생식기)를 빠져 나오면서 모체의 체액(분비물) 또는 미세한 상처에서 나오는 혈액 등에서 감염되는 것으로 되어 있습니다.
또한 모유를 먹일 경우 모유를 통해서 간염바이러스가 아기에게 전해질 가능성도 있지요...
하지만 아직 실제로 모유를 통해서 전염된다는 증거는 없습니다.
그렇다고 아무도 안전성을 보장할 수는 없지요...

두 번째로 성질나쁜(?) 아이한테 잘못 걸리면 젖을 빨리다가 유두에 상처가 날 수도 있으며, 그 곳을 통한 감염도 완전히 무시를 할 수는 없지요.. 이빨 없어도 상처날 수 있다고 하더군요..
따라서 모유수유의 경우에는 전염의 위험은 별로 높지 않을 것으로 예상되지만
그 누구도 100% 안전을 보장할 수 있는 것은 아니므로 일단 모유수유는 피하는 것이 좋을 것 같습니다. (이건 예전의 제 생각이었습니다..)

그래도 초유라도 먹이고 싶다면, 짜서 우유병으로 옮겨서 주는 방법도 있겠지만, 제가 점장이가 아니라서.... 자신을 못하겠군요..

99.12.08.
-----
B형 간염을 전공하시는 소아과 선생님의 반론 편지 입니다..
본인의 선배이므로 반말투임을 이해하시기를...
김창섭선생에게
김선생 그동안 안녕하신가?
...중략.....
요새는 무엇을 하면서 살아가냐? 기회 있으면 한번 보고...

홈페이지 내용을 보다가 대부분의 내과, 산부인과 선생님들이 알고 있는 것에 대한 반론을 하려고 한다. 참고해 주었으면 한다.

간염보유자 산모의 모유 수유문제인데 대부분의 내과, 산부인과 의사들이 e항원 양성이면 모유수유를 피하라고 권하는 것으로 알고 있다.
그렇지만 이것은 원칙적으로는 옳지 않다고 생각한다.

왜냐, 물론 모유를 통해서 바이러스가 전파될 수 있기에 위험요인을 제거한다는 면에서는 옳은 방법이다.
그러나 70년대 말, 80년대 초 대만에서 한 연구가 있다.
HBIG + 백신을 올바르게 하면서 모유를 먹인 군과 인공수유(우유)를 한 군과의 예방처치 실패율을 비교했을 때 그 실패율에는 차이가 없었다.
따라서 모유 수유가 실패하는 사람에게의 직접적인 요인이 아니라는 결과를 얻었다.

지금 이같은 연구 결과를 근거로 미국소아과학회에서는 백신과 면역글로불린을 예정대로 맞으면 모유수유를 권장하고 있다.
소아과에서 B형 간염을 전공하는 사람이 적어서 지금까지 소아과 영역에서의 B형 간염에 대한 많은 내용이 일반인들에게 잘 알려지지 않은 것에 대해서 항상 나는 책임을 통감하고 안타깝게 생각해 왔다.

내가 우리 김선생에게 확실하게 얘기할 수 있는 것은 내 전공이 소아감염이고 그 중 B형 간염의 수직감염에 대해서 5년 이상 공부해왔고 계속 follow up을 해왔기 때문에 얘기할 수 있는 것이다.
아마도 수직감염쪽은 자신있게 얘기할 수 있지..
하지만 김선생도 알다싶이 의학이라는 것이 고정된 것이 아니라서 현재 옪았던 것이 후일 잘못된 지침이라고 증명이 될 때도 있으니까 어느 누구도 확신할 수는 없지만 현재 권장되는 stategy가 모유수유를 권하는 것이니까 이에 따라야 하지 않을까 싶네.

물론 현재 산과 교과서와 일부 감염 교과서(즉 author에 따라서)에는 모유수유를 피하는 것이 좋겠다고 조심스럽게 쓰여있는 것도 있기는 하다네.
그렇지만 그렇게 써 있는 책의 author는 B형 간염에 대한 책임있는 의사는 아닌 것이 사실이야.

그럼 좋은 새해를 맞이하기를 바라면서 ...... 선배 종현이가.

추신)

내년에 아마도 CDC hepatitis branch로 유학갈 것 같애. 기회있으면 한번 만나지..

===== 김 종 현 (Peter/Jong Hyun Kim),M.D. 가톨릭대학교 의과대학 소아과학 조교수. Assistant Professor. Division of Infectious Diseases, Department of Pediatrics, St. Vincent's Hopital, College of Medicine, The Catholic University of Korea

E-mail:jonghyunped@yahoo.co.kr

2000.12.25.









Hepatitis B and breastfeeding

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A statement prepared jointly by the Global Programme for Vaccines and Immunization (GPV) and the Divisions of Child Health and Development (CHD), and Reproductive Health (Technical Support ) (RHT) World Health Organization
Introduction
The question of whether breastfeeding plays a significant role in the transmission of hepatitis B has been asked for many years. It is important given the critical role of breastfeeding and the fact that about 5% of mothers worldwide are chronic hepatitis B virus (HBV) carriers. Examination of relevant studies indicates that there is no evidence that breastfeeding poses any additional risk to infants of HBV carrier mothers. The use of hepatitis B vaccine in infant immunization programmes, recommended by WHO and now implemented in 80 countries, is a further development that will eventually eliminate risk of transmission. This document discusses the issues relevant to breastfeeding and HBV transmission, and provides guidance from a WHO perspective.
Hepatitis B virus infection
HBV infection is of major public health importance world-wide. It can cause asymptomatic infection, clinical acute hepatitis, fulminant hepatitis, or persistent infection which is known as the chronic carrier state. Globally, there are over 350 million chronic carriers of HBV who are at high risk of developing severe sequelae including chronic active hepatitis, cirrhosis, and primary hepatocellular carcinoma, complications which kill more than 1 million persons per year. It has been estimated that as many as 25-35% of individuals who become chronic carriers will eventually die from these complications (1).
Transmission of HBV
The pattern of transmission of HBV varies with carrier preval‎ence. In areas where persistent infection is highly endemic (including East and Southeast Asia and Sub-Saharan Africa), transmission is mainly either perinatal, from a carrier mother to her newborn, or through close contact between children. (horizontal transmission). In Asia approximately 40% of HBV carrier women of childbearing age are also positive for the hepatitis "e" antigen (HBeAg) and these mothers have a 70% to 90% chance of infecting their newborn perinatally. Perinatal transmission of HBV occurs mainly during or soon after delivery, through contact of the infant with maternal blood and other body fluids. In Asia, perinatal transmission accounts for approximately 25% to 30% of the carrier pool. Outside Asia, approximately 10% of HBV carrier women of childbearing age have HBeAg, and perinatal transmission is a much less important contributor to the carrier pool. In areas of low endemicity (including Western Europe and North America), perinatal transmission is less common and transmission occurs mainly through blood and by sexual contact between adults (2). However, most industrialized countries screen every pregnant women for HBsAg, and treat infants of carrier mothers with specific hyperimmune globulin, (Hepatitis B Immune Globulin, or HBIG) and hepatitis B (HB) vaccine, (3).
Risk of transmission by breastfeeding
Breastfeeding has been suggested as an additional mechanism by which infants may acquire HBV infection, because small amounts of Hepatitis B surface antigen (HBsAg) have been detected in some samples of breastmilk. However, there is no evidence that breastfeeding increases the risk of mother to child transmission. A follow up study of 147 infants born to mothers known to be carriers of HBV in Taiwan (4) found similar rates of HBV infection in 92 children who were breastfed compared to 55 who were bottle fed. A study in Britain, involving 126 subjects, also showed no additional risk for breastfed versus non breastfed infants of carrier mothers (5). This study included the measurement of HBeAg status of the mothers, but found no association between maternal e-antigen status and transmission rates. These findings suggest strongly that any risk of transmission associated with breastmilk is negligible compared to the high risk of exposure to maternal blood and body fluids at birth. Experts on hepatitis, however, do have concerns that breast pathology such as cracked or bleeding nipples or lesions with serous exudates could expose the infant to infectious doses of HBV.
Prevention of perinatal and horizontal HBV transmission
Active immunization with HB vaccine is effective for the prevention of both perinatal and horizontal transmission of HBV (6-7). Immunization can prevent development of the persistent carrier state in 70-90% of infants of carrier mothers, and in up to 95% of infants who are infected horizontally. Administration of HBIG within 24 hours of birth together with the first dose of vaccine increases the protection up to 85-90% in infants of HBV carrier mothers (1). However, neither screening of pregnant women for HBV infection nor use of HBIG are feasible in most developing countries. Routine immunization of infants with HB vaccine is therefore recommended, the first dose to be given within 48 hours of birth where feasible, and subsequent doses with routine childhood immunizations. Delivery of HB vaccine at birth is possible with clinic or hospital deliveries but is more difficult following home deliveries where contact with the immunization system does not take place for several weeks or months. A dose of HB vaccine around the time of birth is more important in Asia where perinatal transmission is commoner. Infants who have received their first dose of vaccine can safely breastfeed (8).
In areas where infants are not routinely immunized against HBV, the issue of wet-nurses and the use of donated breastmilk must be considered. Most non-carrier mothers in endemic areas have previously been infected with HBV and have recovered, and have passively transferred anti-HBs antibody through the placenta to the infant, protecting them against HBV infection for approximately 6 months. In many industrial countries, wet-nurses and donor mothers are screened for HBsAg, and if positive their milk is not used for infants other than their own. However, this strategy is less feasible in developing countries where HBV testing may be unavailable. Infants immunized with HB vaccine have no risk of HBV infection through wet nurses or donated breastmilk.

Recommendations
WHO recommends that all infants receive hepatitis B vaccine as part of routine childhood immunization. Where feasible, the first dose should be given within 48 hours of birth or as soon as possible thereafter. This will substantially reduce perinatal transmission, and virtually eliminate any risk of transmission through breastfeeding or breastmilk feeding. Immunization of infants will also prevent infection from all other modes of HBV transmission.
WHO and UNICEF recommend that all infants be exclusively breastfed for at least 4 and if possible 6 months, and that they continue to breastfeed up to two years of age or beyond with the addition of adequate complementary foods from about 6 months of age. There is a considerable risk of morbidity and mortality among infants who are not breastfed. There is no evidence that breastfeeding from an HBV infected mother poses an additional risk of HBV infection to her infant, even without immunization. Thus, even where HBV infection is highly endemic and immunization against HBV is not available, breastfeeding remains the recommended method of infant feeding.

References
Global control of Hepatitis B through vaccination: Role of Hepatitis B vaccine in the Expanded Programme on Immunization, Maynard JE, Kane MA and Hadler SC, Rev Inf Dis 1989;11 (suppl 3):574-578
Protocol for assessing preval‎ence of Hepatitis B infection in antenatal patients, World Health Organization, WHO/EPI/GEN/90.6
Protection against viral hepatitis, Recommendations of Immunization Practices Advisory Committee (ACIP), MMWR 1990;39(no S-2)
Evidence against breastfeeding as a mechanism for vertical transmission of Hepatitis B, Beasley PR, Shiao I-S, Stevens CE, Meng H-C, Lancet 1975;ii:740-41
Vertical transmission of hepatitis B surface antigen in carrier mothers in two west London hospitals, Woo D, Davies PA, Harvey DR, Hurley R, Waterson AP, Arch Child Dis, 1979;54:670-75
Prevention of perinatally transmitted Hepatitis B virus infections with Hepatitis B Immune globulin and Hepatitis B vaccine, Beasley RP, Hwang LY, Lee GCY, et al. Lancet 1983;ii:1099-102
Prevention of the HBsAg carrier state in newborn infants of mothers who are chronic carriers of HBsAg and HBeAg by administration of Hepatits B vaccine and hepatitis B immunoglobulin, Wong VCW, IP HMH, Reesink HW, et al. Lancet 1984;1:921-6
Breastfeeding babies of HBsAg-positive mothers, Tseng AKY, Lam CWK, Tam J. Lancet 1988; ii:1032
For further information, contact:

The Director, Division of Child Health and Development
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 791-2632, Fax: +41 22 791-4853,
E-mail:tullochj@who.ch
World Wide Web: http://cdrwww.who.ch