Can aspiration of breast milk cause death in infants?

Aspiration of Breast Milk as a Cause of Death in Infants

While aspiration of breast milk can potentially cause death in infants, it is a rare occurrence with very low mortality rates in otherwise healthy infants. 1, 2

Risk of Breast Milk Aspiration

• Aspiration occurs when material moves below the true vocal folds and enters the trachea 1
• The most dangerous time for fatal aspiration pneumonia is during the brief period just before and immediately after birth, with neonatal aspiration syndromes reported in 4% of all live births 1
• In newborns and infants, aspiration often presents with subtle signs such as apnea and increased swallowing frequency rather than cough, making detection challenging 1
• Immunohistochemical studies have found that milk aspiration to some degree was detected in more than half of sudden infant death cases and about one-third of in-hospital death cases, though in most cases the amount was very small 2

Severity and Outcomes

• In a study of 80 infants with documented aspiration or penetration risk, 90% did not develop pulmonary illness despite continued intake of breast milk 3
• Only 5 out of 105 infant death cases examined in one study had large amounts of aspirated milk that may have been an important part of the cause of death 2
• Laboratory studies have shown that acidified breast milk instilled into rabbits' lungs can induce acute lung injury, suggesting potential for harm if aspirated 4

Risk Factors and Prevention

• Developmental factors play a role in aspiration risk, as infants have immature protective airway reflexes 1
• During the fetal or newborn periods, water in the larynx does not result in a cough; rather, it results in apnea and increased swallowing frequency 1
• Suck and swallowing dyscoordination or weak swallowing can limit the use of bottle or breast feeding initially in vulnerable infants 1

Clinical Considerations

• Preoperative fasting guidelines recommend that breast milk may be ingested up to 4 hours before elective procedures requiring anesthesia, compared to 6 hours for infant formula, reflecting the different aspiration risks 1
• These guidelines are based on the principle of minimizing the risk of pulmonary aspiration of gastric contents while preventing unnecessarily long fasting intervals 1
• Pulmonary aspiration associated with anesthesia is rare and has nearly no mortality in pediatric anesthesia 1

Management of Aspiration

• In rare cases of secondary surfactant deficiency due to blood aspiration, surfactant replacement therapy has been shown to be effective 5
• For infants with chronic lung disease or those at risk of aspiration, continuous naso- or orogastric tube feedings may be necessary initially 1
• As respiratory status improves, bolus feedings may be initiated, though additional supplemental oxygen may be required 1
• Concomitant stimulation of oral-motor skills should occur in all tube-fed patients to prepare them for eventual feeding by mouth when there is no longer a risk of oral-pharyngeal aspiration 1

Important Caveats

• Immunohistochemical staining with antibodies against components of human milk can be useful to demonstrate human milk aspiration post-mortem 6
• Slight milk aspiration is not rare in infant death cases, but is usually not the cause of death 2
• The presence of aspirated milk in some cases may be a result of occasional gastroesophageal reflux or cardiopulmonary resuscitation rather than the primary cause of death 2