Helping a Breastfeeding Mother with Poison Ivy Dermatitis
Prospect, Connecticut, USA
From: LEAVEN, Vol. 37 No. 2, April-May 2001, p. 29-31
When I had my first helping call from a mother with a poison ivy rash on her breasts, I thought it was a rare occurrence. After several calls regarding other mothers in the same difficult situation, and hearing from several Leaders with personal experiences, I wondered if this was more common than one would ever suspect. Poison ivy, poison oak, and poison sumac are the single most common causes of allergic reactions in the United States. Unfortunately, breastfeeding mothers are not immune to them.
Each year 10 to 50 million Americans develop an allergic rash after contact with these plants formerly considered part of the rhus genus, more recently classified in the toxicodendron genus. Part of the cashew or sumac family (Anacadiacae), these plants are widely distributed in Europe, Asia, and North and South America. They grow almost everywhere in the United States except Hawaii, Alaska, and some desert areas in Nevada. Although approximately 85 percent of the population will develop an allergic reaction if exposed, most people need one or more previous exposures to become sensitized. Poison ivy rash is an allergic contact rash, or dermatitis, caused by contact with an oil in the sap of the plants called urushiol. Urushiol is such a potent antigen, it is estimated that 500 people could itch from the amount covering the head of a pin and one-quarter ounce would be enough to cause a reaction in every person on earth.
Since it is preferable to avoid the rash, it is beneficial to know how contact may occur with the oil that causes the reaction. While many mothers may link the rash with recent gardening or other outdoor work, some may be exposed to urushiol that has spread to other items or other people. An exploring toddler (who may or may not subsequently react) could expose his/her mother to the virtually invisible oil during breastfeeding. Exposure to the oil varies because contact with urushiol can occur in three ways: direct, indirect, or through airborne particles (see table).
Understanding Poison ivy Dermatitis
Urushiol begins to penetrate the skin in minutes and is completely absorbed within 10 to 30 minutes. In those with sensitivity, redness and swelling will appear in about 12 to 48 hours followed by blisters, severe itching, oozing, and crusting. Extremely sensitive individuals may react more quickly. Rarely, people react after their first exposure and if this is the case the rash appears after 7 to 10 days. Severe reactions with blisters and extreme swelling on the face (with eyes swelling shut), arms, legs, and genitals require immediate medical attention.
Dispelling common myths regarding poison ivy rash can increase an affected mother's understanding of her condition and can help her make informed decisions regarding breastfeeding. One such myth is that the rash can pass from person to person. Many mothers worry that they might spread the rash to their breastfeeding child. Actually, the oozing blisters are not contagious to others and do not cause further spread even on the affected person's body. The pruritic erythematous and vesicular (itchy, red, and blistered) rash is a reaction to urushiol and only urushiol can be spread by contact. This is reassuring information for mothers. One reason for this common misunderstanding is that the rash seems to spread if it does not appear all at once. This is often the case because the onset of the rash is affected by absorption rates of urushiol, which vary along with skin characteristics (thick vs. thin, intact vs. injured); the amount of urushiol deposited in different areas; repeated exposure to contaminated objects or pets; or oil trapped under the fingernails.
Concerns Regarding Secondary Infection
Since delayed healing warrants consultation with a physician, it is helpful for mothers to know that the rash peaks in five days and takes ten to twenty days to heal from initial onset. Scratching the rash or contact with a nursing child's mouth could potentially result in secondary infection at the site. Signs of secondary infection include blisters oozing for more than two weeks, delayed healing, increased or persistent pain, worsening erosion of tissue, inflammation, pus, fever, or sore or swollen lymph nodes.
Responses vary among health care professionals. In Breastfeeding.. A Guide for the Medical Profession, 5th edition, Ruth Lawrence, MD, states: "The risk involved with continuing to breastfeed if the lesions are on the nipple or areola results from the possibility of secondary infection from infant to mother, which will cause skin breakdown and delayed healing. Treatment with hydrocortisone ointment (1 percent) will hasten healing. Milk should be pumped and may be fed to the infant. Breastfeeding can resume as soon as lesions have healed, usually 4 to 5 days, and the risk of secondary infection is gone."
In an online response to a situation where a mother with poison ivy on her breasts was withholding breastfeeding, Jack Newman, MD, FRCP, Canada, responded: "Put the mother on oral prednisone and get the baby back on the breast." When asked for her opinion regarding whether or not poison ivy on the nipple or areola contraindicated breastfeeding, Christina Smillie, MD, FAAP, IBCLC, responded: "I would say that depending on the individual situation, if the vesicles are right in the area of suckling, the mother might on occasion choose to interrupt breastfeeding temporarily either because of maternal pain, to protect the mother from skin breakdown and secondary infection from the baby, or to speed healing if there is a secondary infection, but that in most cases alternative strategies for management might be devised by the mother and her physician."
The Leader's Role
While Leaders cannot make medical recommendations as to whether or not an affected mother may continue to breastfeed despite a rash affecting her nipples, areolae, or breasts, we can provide her with information. We can also listen and empathize with the discomfort she may be experiencing. Some mothers have reported that the pain and discomfort that they experienced while breastfeeding with a poison ivy rash surpassed that of candidiasis, commonly known as thrush.
Sharing general comfort measures for sore nipples can help the mother who chooses to continue to breastfeed. it may be helpful to use feeding positions where the force exerted on the injured area(s) of the breast is minimized. The child's lower jaw, followed by the upper jaw, exerts the most pressure on the breast. The sides of the child's mouth point in the direction where the least pressure is exerted on the breast. A Leader can help the mother find positions which utilize this information to her advantage. An overly hungry child or postponed nursings may result in a tense and vigorous nurser who can stress already traumatized breast tissue. Beginning nursings on the least sore side or favoring the least sore breast, including the possibility of gentle pumping or hand-expression on the most sore breast, are other possible suggestions.
When the mother chooses to wean temporarily because of pain or reasons relating to secondary infection, she can be supported with information about manual milk expression, breast pump techniques, milk storage, and alternative feeding methods.
When a mother reports that she has a rash or blisters on her breast a Leader cannot assume anything or diagnose her condition. It is appropriate to encourage a mother who has a rash, scaling, crusting, sores, or fluid-filled sacs, such as blisters, to see a doctor. A medical professional can evaluate her condition and determine whether it is caused by dermatitis, eczema, impetigo, scabies, herpes, or another infection or skin condition. These conditions may require treatment and some of them may temporarily contraindicate breastfeeding. Eczema on one nipple that doesn't respond to treatment may be a symptom of a more serious condition, Paget's disease of the nipple, a rare form of breast cancer.
Leaders can encourage a mother to share their breastfeeding status with their health care provider and offer to coach her in a positive, constructive dialogue with that provider. For many Leaders, our ability to enhance communication using Human Relationship Enrichment (HRE) techniques enables us to share the skills we've learned with mothers. For mothers who are dissatisfied with their health care provider's recommendations for treatment, statements like these could be helpful: "I would like to explore treatment alternatives with you that are compatible with breastfeeding," or "Although I respect your concerns regarding secondary infection, I would really like to explore alternatives to weaning. How might any potential for secondary infection be minimized and monitored.?" Sometimes it is appropriate to remind a mother that she can seek a second opinion.
Treatment of any nipple that is infected or eroded may include the use of medications such as topical and/or oral antibiotics and topical and/or oral steroids. Leaders can look up these medications and moist wound healing recommendations in LLL resources. They may want to contact the Professional Liaison Department for more information as necessary. Mothers are encouraged to share these references with their health care providers.
A Leader's support and resources can help a mother preserve the breastfeeding relationship despite poison ivy dermatitis. This is true regardless of whether a helping call is from a mother who wishes to continue to breastfeed but is concerned about transmitting poison ivy to her baby/child; from a mother who is concerned about the safety of medications while breastfeeding; from a mother who has made an informed decision to temporarily wean; or from a mother who has been told that she should not breastfeed, or must wear long sleeves and gloves whenever handling the baby.
Poison Ivy Treatments
It is beyond the scope of this article, and beyond our role as Leaders, to recommend specific treatments for poison ivy rash wherever it may be on a mother's body. However, we can tell the mother that there are usually treatments available that are compatible with breastfeeding. A mother should consult her health care provider regarding treatment options - prescription or otherwise.
If any home-remedy-type comfort measures are mentioned, it is the mother's responsibility to consult her health care provider. A remedy that works well for one mother with poison ivy may not be helpful, to another. Leaders should not assume that "natural" or "herbal" remedies are inherently safe and compatible with breastfeeding. Refer the mother to her physician, to a certified herbalist, or a professional familiar with herbs. Leaders may also call their local Professional Liaison Leader for information on a specific herb or medication in response to a mother's inquiry.
Many reputable resources are available on the Internet and elsewhere that offer information about poison ivy in general, alternatives for treating the rash, measures for preventing exposure or for preventing outbreaks despite exposure, and plant identification. We may assist mothers needing additional information and yet stay within the boundaries of our role as Leaders by referring them to other sources when appropriate.
American Academy of Dermatology website, Poison Plants: lvy-Sumac-Oak http://www.aad.org/public/Publications/pamphlets/Poison_IvyOakSumac.htm*
Hale, T. Medications and Mother's Milk 2000, 9th edition. Amarillo, Texas: Pharmasoft Medical Publishing, 2000.
Lawrence, R. Breastfeeding: A Guide for the Medical Profession, 5th edition. St. Louis, Missouri: Mosby, 1999; 548.
LLLI. THE WOMANLY ART OF BREASTFEEDING. Schaumburg, Illinois: La Leche League International, 1997.
Mohrbacher, N. and Stock, J. BREASTFEEDING ANSWER BOOK, Revised edition. Schaumburg, Illinois: La Leche League International, 1997.
Newman, Jack, MD, FRCPC, Lactnet email list archives, poison ivy post, 5/3/98. Used with permission.
Poison Ivy, Oak, & Sumac Information Center http://poisonivy.aesir.com/faq.html
Riordan J. and Auerbach, K. Breastfeeding and Human Lactation, 2nd edition. Sudbury, MA: Jones and Bartlett, 1999; 318.
Smillie, Christina, MD, FAAP, IBCLC, personal communication, September 2000.
US Food and Drug Administration website, FDA Consumer magazine (September 1996), "Outsmarting Poison Ivy and Its Cousins" by Isadora B. Steblinhttp://www.fda.gov/fdac/features/796_ivy.html*
Wilson-Clay, B. and Hoover K. The Breastfeeding Atlas. Austin: Texas: LactNews Press, 1999; 18-19.
* Link corrected for website.