Caesarean section or non-breastfeeding for prevention of MTCT-beware of sending the wrong message.

Pan and colleagues(1) used a prospective cohort and meta-analysis to investigate the role of caesarean section (CS) and non-breastfeeding on mother-to-child transmission (MTCT) of hepatitis B virus (HBV) in the setting of high maternal viral load and absence of anti-viral therapy. The prospective cohort of 857 newborns found no significant benefit, yet the authors suggested "a tendency to reduce risk of infection". As the largest study to address this question and with adequate power to detect a meaningful benefit if present, this conclusion seems misplaced. The subsequent meta-analysis concluded there was benefit of CS and non-breastfeeding. However, the effect was modest; 23 women would need to undergo CS and 65 avoid breastfeeding to prevent one MTCT. Our concern is that the "costs" in terms of morbidity from CS and loss of infant benefits of breastfeeding are not emphasized.