What is anthrax?

Anthrax is a serious disease caused by a bacterial organism known as Bacillus anthracis. This bacterium forms spores, a resistant form that lies dormant until the right conditions exist for them to germinate and produce vegetative cells. The type of illness a person develops depends on how anthrax enters the body. Typically, anthrax gets into the body through the skin, lungs, or gastrointestinal system. All types of anthrax can eventually spread throughout the body and cause death if they are not treated with antibiotics.

How is anthrax spread?

Anthrax is most commonly spread when humans handle products from infected animals, breathe in anthrax spores from infected animal products, or eat undercooked meat from infected animals. Anthrax has also been used as a bioweapon, when in 2001, a powder containing anthrax spores was sent to targeted individuals through the U.S. Postal System.

In very rare cases, person-to-person transmission has been reported for cutaneous anthrax. This is because discharges from skin lesions might be infectious until the patient has been on antimicrobials for a day or so. Therefore, cutaneous anthrax lesions should be kept covered for at least one day after the start of antibiotic therapy.

Is it safe for a mother to continue breastfeeding if she has been exposed to anthrax?

Usually. Clinical management of women who deliver neonates while receiving prophylaxis or treatment for anthrax does not require mother-infant separation. Because there is no evidence for anthrax transmission through human breast milk, anthrax exposure is not considered a contraindication to initiating or continuing breastfeeding or providing expressed human milk. Women with active cutaneous anthrax lesions on the breast should avoid infant contact and not breastfeed from the affected breast until after 48 hours of appropriate antimicrobial drug therapy. B. anthracis has not been isolated from cutaneous lesions 48 hours after the initiation of appropriate antimicrobial drugs; therefore, breastfeeding can resume from the affected breast after these criteria are met.

Some antibiotics are safer than others while breastfeeding. Ciprofloxacin is recommended as the first-line antimicrobial agent of choice for post-exposure prophylaxis (PEP) for asymptomatic lactating women because of the severity of inhalation anthrax. The American Academy of Pediatrics considers ciprofloxacin and tetracyclines (which include doxycycline) to be compatible with breastfeeding because infants absorb only a small amount of these drugs. Physicians may instead prescribe amoxicillin if the strain of anthrax is susceptible to penicillin and no other contraindications to the mother are present. Amoxicillin is among those drugs categorized as safe for use with infants. Health care providers should always weigh the risks and benefits when prescribing medications to breastfeeding mothers.

Learn more about antimicrobial considerations for breastfeeding women and safe prescription medication use while breastfeeding.

Is the Anthrax vaccine safe for breastfeeding mothers and their infants?

Yes. Anthrax vaccines are administered as a component of a PEP regimen, or to persons in occupations placing them at risk for exposure. There is no biologic reason to suggest that breastfeeding women or breastfed infants have an increased risk for adverse events after vaccination with anthrax vaccine absorbed (AVA) or PEP. Therefore, breastfeeding is neither a precaution nor a contraindication to vaccination in a pre- or post–anthrax event setting.

The benefits of breastfeeding outweigh the potential risk of exposure to chemicals through breast milk for most infants. Mothers should try to reduce or eliminate their exposure to environmental chemicals as much as possible while breastfeeding.

Asbestos

Asbestos is a commercial name for minerals used in products such as insulation, fireproofing materials, automotive brakes, textile products, cement, and wallboard materials. Asbestos does not pose health risks unless it is handled or deteriorates and releases microscopic asbestos fibers into the air. The risk of disease depends on many factors including how much asbestos is in the air and how often and for how long exposure occurs. Inhaling asbestos can cause tiny asbestos fibers to irritate lung tissue and cause non-cancer diseases and increase the risk of certain cancers.

Infants are not likely to be exposed to asbestos through breast milk.  Read more about asbestos and your health and protecting your family from exposures to asbestos.

Insect Repellents

When used as directed, EPA-registered insect repellents are proven safe and effective for breastfeeding women. Breastfeeding mothers should keep the repellent away from their nipple area, so their child does not get any in his or her mouth while feeding. Mothers should use insect repellents according to the directions on the label, use them only when needed, and wash repellents off when no longer exposed to insects.

Per- and Polyfluoroalkyl Substances (PFAS)

PFAS are man-made chemicals used in non-stick cookware, water-repellent clothing, stain resistant fabrics, some cosmetics, and products that resist grease, water, and oil. Babies can be exposed to PFAS while breastfeeding. The science on the health risks of PFAS exposure is evolving. However, given the scientific understanding at this time, the benefits of breastfeeding outweigh any potential risks of PFAS exposure through breast milk. Mothers are encouraged to engage in discussions with their healthcare provider when questions or concerns arise.

Pesticides

Pesticides are chemicals used to destroy or control unwanted vegetation (herbicides), insect pests (insecticides), rodent pests (rodenticides), or fungi (fungicides). Pesticides are used in many workplaces, and homes, primarily to get rid of insects found inside the home or outside in unwanted vegetation. Exposure to pesticides can happen by inhaling them, ingesting them by eating foods that were sprayed with pesticides, or absorbing them through the skin.

Some pesticides may pass into breast milk. Studies on the effects of exposure to pesticides through breast milk are lacking, so we do not know what level of exposure to pesticides is safe for breastfeeding. Breastfeeding mothers should try to reduce exposure as much as possible.

Wildfire Smoke Exposure

Mothers may continue to breastfeed after wildfire smoke exposure; however, they should take steps to 1) remove smoke particles from their skin and 2) reduce chemical contaminants brought into a vehicle or the home on clothes, skin, shoes, and hair. As soon as the mother is able, she should remove the contaminated clothing and shoes and either wash the clothes promptly or keep them separated in a closed hamper until ready to wash. She should also promptly take a shower so as not to absorb these chemicals into the bloodstream.

Protecting children from exposure to lead is important for lifelong good health. No safe blood lead level has been identified. Even low levels of lead in blood have been shown to affect IQ, ability to pay attention, and academic achievement. The effects of lead exposure cannot be corrected.

How Might Lead Affect Breastfeeding Mothers and Infants?

Women who have been or are currently exposed to lead can expose their fetus or infant to lead during pregnancy and lactation through blood and breast milk, which can have long-term effects on the neurodevelopment of their child. During pregnancy and lactation, mothers can have lead in their blood or breast milk for two reasons:

1. They have been directly exposed to lead during pregnancy or lactation.
2. Lead that is stored in a woman’s bones and teeth from a prior exposure to lead can be released during pregnancy or lactation.

Can Mothers Breastfeed Their Children If They Have Elevated Blood Lead Levels (BLLs)?

If a pregnant or lactating woman has blood lead levels (BLLs) ≥5 μg/dL, the health care provider should attempt to determine the source(s) of lead exposure, working with the local health department and occupational medicine specialists as needed for environmental assessment and case management.

It is recommended that mothers with BLLs <40 μg/dL should breastfeed, but it is important to note:

• Infant BLLs should be monitored if his or her mother’s BLLs are between 5 and 39 μg/dL. Breastfeeding should continue for all infants with BLLs below 5 μg/dL.
• If infant BLLs are rising or failing to decline by 5 μg/dL or more, the healthcare provider should contact the local health department for environmental sampling. If no external source is identified, and maternal BLLs are ≥20 μg/dL and infant BLLs are ≥5 μg/dL, then breast milk may be the source of lead exposure. Mothers should consider temporarily pumping and discarding their breast milk until maternal BLLs are lower.

Mothers with BLLs ≥40 μg/dL are encouraged to pump and discard their milk until their BLLs drop below 40 µg/dL.

• Testing breast milk for lead is not recommended.

What Are Some Kinds of Lead Hazards Breastfeeding Women Might Be Exposed To? How Can They Protect Themselves and Their Infants?

Breastfeeding women should be aware of or avoid the following:

• Lead-based paint (typically found in homes built before 1978). Stay away from repair, repainting, renovation, and remodeling work. Test paint before starting home improvements that disturb paint. If hiring someone else to perform work, make sure they follow lead paint repair rules from the Environmental Protection Agency (EPA).
• Pica. Never eat or mouth clay, soil, pottery, or paint chips because they may be contaminated with lead.
• Tainted food. Use caution when eating candies, spices, food additives, and other foods from abroad, especially if they appear to be noncommercial products of unknown safety. Limit eating game meat—such as deer—that have been hunted with lead ammunition.
• Tainted foodware. Avoid using imported lead-glazed ceramic pottery and pewter or brass containers or utensils to cook, serve, or store food. Avoid using leaded crystal to serve or store beverages. Do not use dishes that are chipped or cracked.
• Tainted medicine or personal care products. Avoid imported medicines and herbal remedies (azarcon, Ayurvedics); cosmetics and ceremonial powders (tiro, kohl, kajal, surma); and personal care products (litargirio) that may contain lead.
• Water with lead levels exceeding 15 parts per billion (ppb). If water lead levels exceed EPA’s action level of 15 ppb, use bottled water or water from a filtration system certified by an independent testing organization to reduce or eliminate lead for cooking and drinking.
• Some occupations or hobbies that may involve lead exposure. These include construction or home renovation/repair in pre-1978 homes; firing ranges and military or police work; battery or electronics manufacturing or recycling; soldering or casting metal; oil field work; mining; and aviation gas used in small planes. If a household member works with lead, take precautions to avoid taking home lead dust in cars or on clothing, skin, hair, and shoes.
• Prior exposure. Prior significant exposure such as childhood environmental exposure or previous occupational exposure could lead to large stores of lead in bone which can become mobilized during pregnancy.
• Recent immigration. Recent immigration to the United States from countries where relatively high lead exposure is endemic, such as countries where leaded gasoline is still used or where use of consumer products containing lead is widespread.

Breastfeeding mothers should minimize exposure to mercury in their diets, at home, and at work.

Mercury is a naturally-occurring element in the environment and is also released into the environment through human activities such as burning coal and oil. Mercury collects in streams, lakes, and oceans, where fish and other animals are exposed. Small amounts of mercury are also used in making common household items like fluorescent bulbs and some thermometers. People who work in recycling plants, who manufacture items with mercury, and who handle dental amalgam might have some mercury exposure on the job.

How might mercury affect breastfeeding mothers and babies?

Mercury can pass from a mother to her baby through the placenta during pregnancy and, in smaller amounts, through breast milk after birth. Exposure to mercury can affect the infant’s brain and nervous system development during pregnancy and after birth.

How much and what types of fish are recommended for breastfeeding women to consume?

Although mercury naturally occurs throughout the environment, the mother’s diet is the primary source of mercury exposure for most breastfed infants before they are introduced to complementary foods. Most fish contain some level of mercury. When a mother eats fish, the mercury in the fish can be passed into her breast milk. However, the benefits of breastfeeding may be greater than the possible adverse effects of exposure to mercury through breast milk.

Although fish remains an excellent source of protein and essential vitamins and minerals for breastfeeding women, some care must be taken in how much and what kind to eat. The U.S. Food and Drug Administration (FDA) and the U.S. Environmental Protection Agency (EPA) have issued fish consumption guidance for pregnant and breastfeeding women and young children:

• Eat a variety of fish.
• If you eat fish caught by family or friends, check for fish advisories. If there is no advisory, eat only one serving and no other fish that week.
• Try to avoid eating the “Choices to Avoid” fish or feeding them to children.

For adults:

• 1 serving = 4 ounces of fish, measured before cooking. Eat 2 to 3 servings (between 8 and 12 ounces) of fish a week from the “Best Choices” list OR 1 serving (4 ounces) from the “Good Choices” list on this chart.

How can breastfeeding mothers and their families protect themselves from mercury at home?

Handling an intact lightbulb or thermometer that contains mercury does not cause mercury exposure. If a mercury-containing lightbulb or thermometer breaks, however, it can spill mercury onto surfaces and release mercury vapors into the air. If this happens, families should be advised to follow the EPA instructions on safe clean-up of a broken mercury-containing lightbulb or broken mercury thermometer.

How can breastfeeding mothers reduce their exposure to mercury at work?

Women who are concerned about mercury exposure at work should be advised to talk to their supervisor or safety officer to discuss ways to avoid or reduce exposure to mercury. Information on how to reduce mercury exposure in different jobs is available from the National Institute for Occupational Safety and Health (NIOSH), the Occupational Safety and Health Administration (OSHA).

Most mothers who work around chemicals can safely breastfeed their babies. The benefits of breastfeeding outweigh the potential risk of exposure to common toxicants through breast milk for most infants. Mothers should try to reduce or eliminate their exposure to occupational toxicants as much as possible while breastfeeding. Employers should provide mothers with information about and training on their potential occupational exposures.

These are some examples of occupational exposures that breastfeeding mothers may be exposed to at work. Employers should work with mothers to reduce possible exposure to occupational toxicants as much as possible.

Working with Chemotherapy Drugs

Many chemotherapy drugs used to treat cancer are cytotoxic at very low doses. Some antineoplastic (chemotherapy) drugs are carcinogens with no known safe level of exposure, so it’s best to reduce or eliminate exposure as much as possible. Employers should provide all workers, including breastfeeding mothers, with information about the chemicals they work with and training on safe work practices.

Working in Dry Cleaning Facilities

Perchloroethylene (PCE) is the most used solvent in dry cleaning facilities. PCE is also known as PERC, perchlor, and tetrachloroethene. Studies show that PCE can enter breast milk. Greater amounts can be found in the breast milk of women exposed to higher amounts of PCE over longer periods of time. Few studies have looked at the effects of PCE on nursing infants, however there are reports on neurological responses and perc exposure in children.

Working with Ionizing Radiation

Working near diagnostic X-ray sources does not affect breast milk. Receiving an X-ray also does not affect breast milk.

However, workers who handle radioactive materials, such as radioisotopes in health care and laboratories, or radioactive waste, need to take precautions to reduce exposure. Additional information can be found on NIOSH’s topic page on ionizing radiation.

Workers can also speak with their workplace radiation safety officer, or the state’s department of radiation protection, if they have concerns.

Working in Laboratories

Laboratory work, in either clinical or research laboratories, can involve potential exposure to a wide range of chemicals and agents such as solvents, formaldehyde, ionizing radiation, and infectious agents. Because some chemicals used in laboratories can enter breast milk, breastfeeding mothers who work with chemicals should talk to their health care provider and employer about how to reduce exposure as much as possible.

Lab workers should:

1. Follow recommended best practices when handling infectious materials and chemicals,
2. Make sure they are using appropriate biological and chemical safety cabinets correctly, and
3. Check the Safety Data Sheets (SDS) for chemicals they handle to make sure they are wearing appropriate personal protective equipment (PPE).

Not all gloves or other types of PPE provide adequate protection for all chemicals, thus it is important to match the type of PPE to the type of chemical. If appropriate, local exhaust ventilation, such as fume hoods, exhaust ducts, and exhaust fans should be in place.

Working in Nail, Hair, and Beauty Salons

Nail, hair, and beauty salon employees are potentially exposed to many different chemicals including acrylates (epoxies or resins), solvents, formaldehyde, and biocides as dusts or vapors. Some chemicals commonly used in salons can enter breast milk or be carried home on skin, clothes, and shoes. There are ways to reduce or eliminate exposure to these chemicals at work. Learn more about working in nail, hair, and beauty salons and how to prevent take-home exposures.

Working in Veterinary and Animal Care Services

Veterinary workers may be exposed to several potentially hazardous chemicals and agents such as antineoplastic drugs, antiviral drugs, anesthetic gases, disinfectants, and pesticides, such as those used for flea and mite treatments. Zoonotic infections, or infections acquired from animals should be evaluated individually to determine breastfeeding safety. There are ways to reduce or eliminate exposure to these chemicals and other hazards at work. Learn more about veterinary safety and health and workplace controls.

Using Personal Protective Equipment to Reduce Hazardous Chemical Exposures at Work

A workplace-specific hazard assessment should be conducted to determine potential workplace exposures and which types of controls are needed to reduce those exposures. Controlling exposures to occupational hazards is the fundamental method of protecting workers. However personal protective equipment (PPE) is one method of workplace control. PPE is equipment that is worn to reduce exposure to hazardous chemicals and other workplace hazards. Gloves, protective clothing, goggles, and respirators are types of PPE. The type of PPE needed is determined by the specific chemicals and other hazards in a mother’s workplace. PPE must also be worn and maintained correctly, or else it might provide little or no protection. PPE may reduce exposure to chemicals but does not eliminate it completely. Breastfeeding mothers should talk to their employer about the types of PPE recommended for their work.

Breastfeeding is the best source of nutrition for most infants.

The broad and compelling advantages of breastfeeding for infants and mothers have been documented with extensive research. Breastfeeding is beneficial for the health of infants and mothers.  Some of the many benefits for infants include a reduced risk of ear and respiratory infections, asthma, obesity, and sudden infant death syndrome (SIDS).

Breastfeeding can also help lower a mother’s risk of high blood pressure, type 2 diabetes, and ovarian and breast cancer. The American Academy of Pediatrics (AAP) and the Dietary Guidelines for Americans, 2020-2025, both recommend exclusive breastfeeding for about 6 months, and continuation of breastfeeding, with the introduction of complementary foods, for 1 year or longer as mutually desired by mother and infant.

Do PFAS enter breast milk?

Multiple factors play a role in the personal decision to breastfeed an infant. The potential for exposing an infant to environmental chemicals, including per- and polyfluoroalkyl substances (PFAS), through breast milk is one of the many factors that mothers and their families may consider. PFAS are widely dispersed and ubiquitous in the environment, and most people in the United States and other industrialized countries have measurable amounts of PFAS in their blood. Research studies have shown that PFAS can be found in human breast milk and excreted through lactation. The mechanism by which PFAS enter breast milk is not yet fully understood. The level of exposure to an infant depends on a number of circumstances, some of which include the level of PFAS in the mother, the amount of PFAS that transfers to her breast milk, and the duration of breastfeeding.

Should I have breast milk tested for PFAS?

Significant developments in laboratory analytical methods now allow for the detection and measurement of small amounts of PFAS in human breast milk. However, measuring PFAS in breast milk is not a routine test performed by most commercial laboratories. The composition of breast milk is complex, and factors that influence the concentration of PFAS in breast milk are not completely understood. Some studies show that levels of PFAS may vary depending on the time of breast milk collection during a single feed or throughout the course of lactation. Methods of breast milk sample collection, storage, and shipping must be performed in a way that minimizes or eliminates the possibility of contamination. Testing requires a standard, validated method for detection, extraction, and analysis, as well as quality control methods for human milk. PFAS levels measured in breast milk are most helpful when performed as part of a carefully designed research study.

To date, there have not been large-scale biomonitoring studies for PFAS in breast milk to establish reference values for comparison that are representative of the population of breastfeeding women in the United States. Reference values allow physicians and scientists to determine whether a person or group has an unusually high exposure. Further, there is no established PFAS level for breast milk at which a health risk for an infant (or mother) is expected.  Without this information, it is difficult to interpret test results.

Some additional limitations with interpreting test results include

• Even with the ability to confirm the presence of PFAS in breast milk, it may be difficult to estimate how much PFAS an infant is absorbing (bioavailability).
• PFAS levels in breast milk cannot determine if exposure is associated with past or present illness and cannot predict future (short or long term) illness or adverse health effects in the infant or the mother.
• Infants can also be exposed to PFAS during pregnancy and from other sources in their environment, making it extremely difficult to determine if or how much of an infant’s body burden of PFAS is contributed from breast milk.

Should I continue to breastfeed?

For the general population, ingestion of PFAS is considered the major human exposure pathway. For populations with PFAS in their drinking water supplies, drinking water exposure is an important contributor to PFAS exposure. For infants, breast milk can be a source of PFAS exposure. Even though PFAS have been detected in breast milk, studies have not shown a causal relationship with a specific health effect in infants or children. In addition, an infant could be exposed to other environmental chemicals, besides PFAS, through breast milk, making it difficult to associate any potential health affect to one chemical or class of chemicals.

With numerous protective health benefits, breast milk continues to be the ideal nutrition for infants, and in nearly every circumstance, the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend that nursing mothers continue to breastfeed their babies despite the potential presence of environmental contaminants.⁷

There are circumstances in which an infant may not be able to breastfeed. In this case, if powdered or concentrated liquid formulas are used, they should be mixed with water from a safe source. In addition, it’s important for everyone, including nursing mothers and women of reproductive age, to take steps to reduce or eliminate sources of PFAS exposure (e.g., certain foods and food packaging, contaminated drinking water, and stain-repellant and water-repellant materials).

The science on the health risks of PFAS exposure is evolving. However, given the scientific understanding at this time, the benefits of breastfeeding outweigh any potential risks of PFAS exposure through breast milk. In addition to regular prenatal care, nursing mothers should continue to receive recommended routine post-natal care and are encouraged to engage in discussions with their healthcare provider when questions or concerns arise. Infants and children should also receive regular well-child checkups, recommended vaccinations, and health screening tests appropriate for age.

Consultation with a specialist in occupational and environmental medicine, or others with expertise and experience treating patients exposed to PFAS, may help guide primary healthcare providers with development of a periodic monitoring plan, as appropriate.

A woman’s decision to breastfeed is a personal choice, often made in consultation with her healthcare provider.  It is a choice made after the consideration of many different factors specific to the mother and child. ATSDR has developed information on PFAS to guide clinicians and aid in this decision-making process.

What is tear gas?

Tear gas is a riot control agent that is used to disperse crowds and control riots, and sometimes as personal protection (for example, pepper spray). Several different chemical compounds can be used in  tear gas. These chemicals cause temporary irritation to the eyes, mouth, throat, lungs, and skin. These effects usually last 15–30 minutes after the person has left the area of exposure and cleaned off.

Is it safe for a mother to continue breastfeeding if she has been exposed to tear gas?

After being exposed to tear gas, it is important to protect your own health as well as to avoid exposing infants and young children to the chemicals.  If you are exposed to tear gas, (1) quickly remove your clothing and place them into a plastic bag that can be sealed, (2) wash your body thoroughly with lots of soap and water (rinse your eyes with just water and dispose of contact lenses), (3) dispose of your clothing, and (4) seek medical care as quickly as possible. For more information about how to thoroughly clean your body and dispose of clothing after a chemical release exposure, see “Chemical Agents: Facts About Personal Cleaning and Disposal of Contaminated Clothing.”

It is not known if agents used in tear gas can be found in breast milk. Mothers exposed to riot control agents are advised to thoroughly decontaminate (remove clothes and wash their bodies well) before breastfeeding or expressing milk/pumping. “Pumping and dumping” breast milk is currently not thought to be necessary after exposure to riot control agents.