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Chickenpox - Management
How should I manage a woman with chickenpox who is breastfeeding?

  • Offer symptomatic treatment.
  • Consider prescribing aciclovir for an immunocompetent adult with chickenpox who presents within 24 hours of rash onset, particularly for people with severe chickenpox or those at risk of complications.
  • Seek urgent specialist advice regarding whether the mother should continue to breastfeed if she has chickenpox.
  • Give advice about contact with other people and when to seek medical advice.
  • Admit to hospital if serious complications (e.g. pneumonia, encephalitis) are suspected.
  • Notify the relevant authorities if in Scotland or Northern Ireland (chickenpox is not a notifiable disease in England or Wales).
Basis for recommendation
  • CKS found no specific guidelines on the management of breastfeeding women with chickenpox. Therefore, CKS suggest symptomatic management as for healthy adults, in line with current knowledge about the use of analgesics/antipyretics and calamine in breastfeeding women.
  • Adults are more likely to develop complications of chickenpox than children. There is an indication that smokers and people with severe lung or cardiovascular disease, or those with a chronic skin disorder, are particularly at risk from complicated chickenpox [Wilkins et al, 1998; BNF 54, 2007].
    • Recommendations vary between UK organizations regarding the use of aciclovir in immunocompetent adults with chickenpox [Ogilvie, 1998; Wilkins et al, 1998; HPA, 2006; BNF 54, 2007].
    • A review by BMJ Clinical Evidence [Swingler, 2007] identified an RCT (n = 148) that found aciclovir given within 24 hours of rash onset reduced the number of lesions and time to full crusting of lesions compared with placebo (no significant difference in time to crusting of lesions if aciclovir was given 24–72 hours after rash onset). Two other RCTs identified did not find a significant difference in time to no new lesions with aciclovir given more than 24 hours after rash onset compared with placebo.
    • CKS could find no recent trials looking specifically at the effect of aciclovir on preventing complications of chickenpox in an adult population.
  • CKS advise seeking specialist advice regarding whether a mother with chickenpox should breastfeed in view of the potential complications for the baby and differing recommendations between separate organizations:
    • Recommendations on breastfeeding from the Health Protection Agency guidance on the management of rash illness and exposure to rash illness in pregnancy state that: if the mother has chickenpox, she should be allowed to breastfeed. If lesions are close to the nipple, milk should be expressed from the affected side until lesions have crusted. This milk can be fed to the baby if he or she is covered by varicella-zoster immunoglobulin and/or aciclovir. These treatments should be initiated by a specialist [HPA, 2007a].
    • The American Academy of Family Physicians recommends: babies born to mothers who develop chickenpox within 5 days antepartum or within 2 days postpartum are at risk for more serious chickenpox infections. It is recommended that baby and mother be separated until the mother is no longer infectious, but expressed breast milk may be supplied, as long as the milk does not come into contact with active lesions [Lawrence and Lawrence, 1999].
  • The recommendation on reporting cases of chickenpox is from the Department of Health and the Health Protection Agency [DH, 2006; HPA, 2006].

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