Clinical Considerations for People Who Are Pregnant or Breastfeeding

Nuclear power plant accidents result in releases of many radioactive materials. Radioactive iodine and cesium would be of primary concern.

The detonation of a nuclear device will result in radiation exposure and the release of many other radionuclides, which would also be of primary concern.

Many radionuclides may be released in the first three days after a radiation/nuclear incident. Medical countermeasures are specific to certain radionuclides. Therefore, the best course of action for the first 1–3 days of any incident is to avoid exposure in the first place and get inside, stay inside, and stay tuned.

Potassium iodide (KI) is used is to prevent latent thyroid cancer. KI is a non-radioactive form of iodine that saturates the thyroid to prevent uptake of the radioactive iodine. The best case is to have this countermeasure distributed prior to a nuclear power plant release of radioactive materials. That way it can be taken when advised by public health or emergency response officials or a healthcare provider.

KI is most useful when taken just prior to or no later than 4 hours after a nuclear power plant release where subsequent internal contamination of radioactive iodine can occur. Efficacy of KI to protect the thyroid decreases sharply after 4 hours.

More information:

• Potassium Iodide (KI) and Radiation Emergencies (YouTube)
• About Potassium Iodide
• How Potassium Iodide (KI) Works (infographic)
• REMM Potassium Iodide (KI)

Yes. Prussian blue is an oral medical countermeasure indicated for use for internal contamination with radioactive cesium and thallium. It can be taken by pregnant people, most adults, and children ages 2 and older.

Persons who are breastfeeding

Persons who are breastfeeding and internally contaminated with cesium or thallium should temporarily suspend breastfeeding/feeding expressed milk because both cesium and thallium are transmitted from parent to infant in breast milk.1 Administer Prussian blue to lactating individuals while the milk is being expressed and discarded. Follow CDC's guidance on breastfeeding during a radiation emergency.

More information:

• Treating Radiation with Prussian Blue
• REMM Prussian Blue
• REAC/TS Prussian Blue (Radiogardase) (YouTube)
  

Each countermeasure is specific to particular radionuclide(s). KI only works for radioactive iodine. Prussian blue only works for radioactive cesium and thallium.

If you are in the affected area, consider temporarily stopping breastfeeding until you are evacuated. Follow CDC's guidance on infant feeding during a radiation emergency. If none of these options are possible, continue to breastfeed. It is important to keep your baby fed and hydrated.

Radionuclides are very small particles that will be part of both dust and plume gases. They can be absorbed by inhaling them, ingesting them, or entering through broken skin such as wounds.

The half-life of a radionuclide is the time it takes for the radionuclide to decay by half of its original amount. The half-lives of additional radionuclides that may be released depend on the type of emergency and vary from very short half-lives (in minutes) to decades.

The guidance regarding breastfeeding remains the same in the immediate response phase of radiation/nuclear emergencies get inside, stay inside, and stay tuned for more information.

In addition, EPA notes that breastfeeding is very important for the well-being of a baby. It provides vital nutrients and a sense of security.

Parents far from the release site

For parents far from the release site, breastfeeding can continue. However, if the person breastfeeding was near the release site and was either injured or is believed to have inhaled significant quantities of radioactive dust or smoke, there is a small possibility that some radioactivity could be passed through breast milk.

Public health and medical officials may advise the parent to temporarily stop breastfeeding and switch to either breast milk that was pumped and stored before the incident or infant formula. This may last until the parent is able to contact their doctor or public health and medical officials for further instructions or advice.

Formula containers and feeding supplies should be cleaned with a damp cloth or clean towel before use.2 The formula or formula powder inside a container is safe to use.

Yes, the "gas/dust" exposure would be the immediate threat for internal contamination for all persons during the first few days after the incident. People in the affected area should take the following steps to reduce risk of exposure and internal contamination:

1. Get inside, stay inside, stay tuned.
2. Wash themselves off (self-decontaminate) gently with soap and warm water to get radioactive material off the body as soon as possible to lower the risk of harm. Put on clean clothes.
3. Then decontaminate babies or children. Make sure to gently wash the child's hands and face (especially around eyes, nose, and mouth) with soap and water or with a clean wet cloth or paper towel.
4. Put clothes and towels in a plastic bag or other sealable container. Store the bag as far away from other people and pets as possible (e.g., closet, attic, basement), to prevent exposure to radiation until local health officials announce how to dispose of it safely.3

CDC's infographics can be helpful to show how to decontaminate, when to take KI or Prussian blue, and other radiation topics.

Drinking water

Only bottled water is certain to be free of contamination until tests can be performed on the drinking water supply. Water, juices or other drinks in sealed containers or in your refrigerator or freezer are safe to drink. If a sealed container was exposed to radioactive dust outside, use a clean towel to wipe off the bottle to remove any radioactive material before opening it. Boiling tap water does not get rid of radioactive material.4

Water for hygiene

Tap or well water can be used for cleaning the body. The risk from having radioactive material on your body is significantly reduced by washing, even if the water itself is contaminated.

After a radiation release, it is better for all populations, including parents or guardians with infants to get inside, stay inside, and stay tuned for up to three days. Radiation from radionuclides like radioactive iodine and cesium will disperse based on weather patterns. Recommendations will be situation-dependent, which is why people should "stay tuned" for more information about the specific situation.

If a breastfeeding person is outside of the immediate affected area, they may continue to breastfeed because they are not affected by the radiation release. Officials should be able to determine the affected area.

Lactation suppressant drugs are not recommended. If immediate temporary cessation of breastfeeding were advised, breastfeeding people would need to express or pump their milk as much as the baby would normally consume to keep up their milk supply and discard it. No action could lead to a breast infection and a reduction in milk supply. The goal is to return to breastfeeding once the situation is safe.

When the risk of exposure to radioactive iodine is temporary

If KI is available, people who are at risk for becoming internally contaminated can continue to breastfeed on the first day of exposure if appropriate doses are administered to the breastfeeding parent and to the infant within 4 hours of the release. One dose of KI offers protection for 24 hours.

If KI is not available, the person breastfeeding, and the infant should be prioritized to receive other protective measures like evacuation. In this case, breastfeeding should be temporarily stopped (if possible) and resumed when advised by local health officials or after evacuation and self-decontamination.

People who are breastfeeding should take only 1 dose of KI if they have been internally contaminated with (or are likely to be internally contaminated with) radioactive iodine.‍

When the risk of exposure to radioactive iodine is prolonged (>24 hours) and more than 1 dose of KI is indicated for the mother and the infant

Breastfeeding must be temporarily suspended unless there is no other food source for the infant. This is due to the risks associated with KI therapy in infants and neonates.‍ People who are breastfeeding must be supported to express their milk to maintain their milk supply until the infant can resume breastfeeding. Milk expressed during this time should be discarded.

Safe human milk (that was pumped and stored before the exposure) or ready-to-feed infant formula, to avoid use of potentially contaminated tap water, should be provided as a temporary solution. Breastfeeding can resume once public health officials indicate that it is safe or after evacuation and self-decontamination.

If the parent's internal contamination with radioactive iodine is high or if repeat doses of KI to the infant are necessary (because of lack of availability of noncontaminated food sources, resulting in continued breastfeeding), the infant should be evaluated for secondary hypothyroidism that could have resulted from the repeat dosing of KI. If the parent must continue breastfeeding, they should wash the nipple and breast thoroughly with soap and warm water. Gently wipe around and away from the infant's mouth before breastfeeding. This is a proactive protective measure in case the mother becomes externally contaminated during evacuation. FDA guidance indicates that if the mother continues to breastfeed, the infant should be monitored.

Second dose of KI for neonates

Second doses of KI are not recommended for neonates. Second doses are not recommended for lactating people except for extreme exposure incidents.

Many of the decisions regarding a radiation/nuclear incident are scenario dependent. This is especially true in the middle to late response phases. Since we are focusing on the early phase (1-3 days) the best steps are to:

• Get inside
• Stay inside
• Stay tuned
• Self-decontaminate

If you are in the affected area, consider temporarily stopping breastfeeding until you are evacuated. Follow CDC's guidance on infant feeding during a radiation emergency. If none of these options are possible, continue to breastfeed.

There is really no way for the person to know if they have inhaled particles or gas because the particles can be small micron-sized and may not even be visible. If someone who is breastfeeding is in the affected area, they should consider temporarily stopping breastfeeding until they are evacuated. Follow CDC's guidance on infant feeding during a radiation emergency. If none of these options are possible, continue to breastfeed. It is important to keep the baby fed and hydrated.

People should "stay tuned" for more information about the specific situation as recommendations will be situation dependent and will likely change over time. During the event, authorities will use distance and/or other location-specific guidance with their recommendations. The farther away a person is from the release, the less likely they will be internally contaminated with radioactive iodine because it dilutes and decays as it travels farther away.

While radioactive particulates can be large and clearly visible as dust, they can also be very small and invisible. As far as protective actions to take against exposure from radioactive iodine, there is no real distinction between dust and gases.

Incidents such as Hiroshima, Three Mile Island, Sellafield, Chernobyl, and Fukushima were very different in nature and associated with different circumstances. In the immediate aftermath of any radiation emergency, you should get inside, stay inside, and stay tuned for more information. Recommendations will be situation dependent and will likely change over time, which is why people should “stay tuned” for more information about the specific situation.

If a breastfeeding person is in the affected area, they should consider temporarily stopping breastfeeding until they are evacuated. Breastfeeding can resume when advised by local health officials or after evacuation and self-decontamination. Follow CDC's guidance on infant feeding during a radiation emergency. If none of these options are possible, parents should continue to breastfeed. It is important to keep the baby fed and hydrated.

It is best to use previously frozen or refrigerated breast milk to feed the baby in a radiation emergency.

There is no scientific evidence to indicate whether breast milk contaminated with radionuclides becomes safe after some time. Discard milk that is expressed/pumped while temporarily stopping breastfeeding. Milk that is expressed/pumped during a radiation emergency (when in the affected area) should NOT be frozen or stored for later use.

Well, tap, and ground water

Well and tap water may be used for cleaning individuals and food and infant feeding items such as bottles and nipples, as well as pump parts.4 Any radioactive material that gets into surface or ground water sources will be diluted to low levels by the water and will be safe to use for washing skin, hair, and clothing.

If the breastfeeding person was inside and clothed, they do not need to wash their breasts prior to breastfeeding. However, washing your body or decontaminating is recommended for the population in the affected area in any radiation emergency.

You may also need to decontaminate others.

Table 4 (below) describes dosing in detail.5 An oral liquid solution of KI is available and would be given to infants with a dropper.

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Table 4. Adolescents approaching adult size (more than or equal to 150 lb) should receive the full dosage of 130 mg.

Tritium is present naturally in the environment and is identical to the tritium produced from nuclear power plants.6 Tritium is distributed by the hydrological or water cycle. The process tends to dilute the tritium and thus lessens the concentration in water sources in the immediate aftermath of the release.

Guidance

The general guidance to get inside, stay inside, and stay tuned should be sufficient to protect the population from inhalation of various radionuclides. Bottled water, if available, is recommended to prepare formula. If bottled water is not available and tritium has been released from the power plant, regular tap water can be used to mix formula. If a nuclear power plant releases tritiated water, it is unlikely that the tritium would be concentrated enough in the water to be harmful.

Example from the U.S. Nuclear Regulatory Commission

Yes, all sealed/closed packaged foods are safe for consumption in the aftermath of a radiological/nuclear event. People should:

• Wipe off food containers with a damp cloth or clean towel before opening them.
• Wipe off counters, plates, pots, and utensils with a damp cloth or clean towel before using them.
• Put the used cloth or towel in a plastic bag or other sealable container and place the bag in an out-of-the-way place, away from other people and pets.
• Do not pick or eat food from their garden until emergency officials determine it is safe to do so.4

Food in a pantry or drawer away from radioactive material is safe to eat.4 Unspoiled food in your refrigerator or freezer is also safe to eat. Food stored inside cabinets, drawers, refrigerators, or freezers will not get contaminated with radioactive gases or dust particles.

Use infant formula if you do NOT have breast milk that was pumped and stored before the emergency. Wash your hands with soap and water before feeding.

Use a clean cloth or towel to wipe down all feeding supplies (including bottles and containers of infant formula) that are brought into the house. Put the used cloth or towel in a plastic bag or other sealable container. Store the bag as far away from other people and pets as possible (e.g., closet, attic, basement). This will prevent exposure to radiation until local health officials tell you how to dispose of it safely.

After each use, carefully clean all infant feeding supplies, such as bottles and nipples, with soap and water.

Ready-to-feed infant formula

Use ready-to-feed infant formula, if possible. Ready-to-feed infant formula is a sterile liquid formula that does not need to be mixed with water.

Powdered infant formula

Use powdered infant formula if you do not have ready-to-feed infant formula. Prepare powdered infant formula with bottled water if possible or tap water if local officials say it is safe to use.

Temporary stops in breastfeeding

Hand express or pump your breast milk regularly and discard it to maintain your milk supply and prevent a breast infection. Carefully clean your pump kit parts after each use with water.

If needed, connect with lactation support providers in your community who can help you manage your milk supply and create a temporary feeding plan for your child.

When to resume breastfeeding

Breastfeeding can resume when advised by local health officials or after evacuation and self-decontamination. For additional questions or concerns, contact your baby's doctor.

If you do not have access to alternative sources of food

If you do NOT have any other safe food source (no previously expressed breast milk, ready-to-feed infant formula, powdered infant formula, or safe water to mix with powdered infant formula):

• Continue breastfeeding. It is important to make sure you and your baby are hydrated and fed.
• Wash your hands, nipples, and breasts thoroughly with soap and warm water before nursing or expressing milk.3

Yes, such risk exists, but people can still use tap or well water for cleaning themselves. Any radioactive material that gets into surface water or ground water sources will be diluted to very low levels by the water and will be safe to use for washing skin, hair, and clothing. Water in other containers in your home, such as a toilet tank or hot water heater will also be free of radioactive material and can be used for cleaning.

Boiling tap water does not get rid of radioactive material.

People can drink water, juices, or other drinks in sealed containers. Drinks in the refrigerator or freezer are also safe to drink. The package protects the liquid inside from radioactive material.

If there's concern the container or package may have radioactive material on the outside, use a damp cloth or clean towel to wipe it off before opening it. Put the used cloth or towel in a plastic bag or other sealable container. Place the bag in an out-of-the-way place, away from other people and pets (e.g., closet, attic, basement).4