October 21, 2020
By Sara Peterson

Editor’s Note: “Breastfeeding has become a well-documented protective factor for breast cancer.”[i] This was one of the conclusions in a 2017 article published by Anstey et al in the American Journal of Preventive Medicine titled, “Breastfeeding and Breast Cancer Risk Reduction: Implications for Black Mothers.” A 2014 article by Babita et al concludes by stating, “Breastfeeding has a significant role in reducing breast cancer, and so information, education, and communication activities for the promotion of breastfeeding and creating awareness about this fatal disease are the need of the hour.”[ii] Research conducted in different countries studying a variety of cultures reports similar conclusions.

During National Breast Cancer Awareness Month, we celebrate the role of breastfeeding in breast cancer reduction as well as its many other benefits for mother and child. To raise awareness about breastfeeding, we will publish two timely reviews on the importance of assessing the evidence about risks and benefits of breastfeeding during pandemics.

This is a review of an article[iii] published this summer in the International Breastfeeding Journal. Sara Peterson, a fourth-year medical student, wrote this as part of a two-week online fertility awareness electivetaught by FACTS executive director, Dr. Marguerite Duane, at Georgetown University School of Medicine. To learn more and enroll in one of the FACTS electives, you may visit our website.

Breastfeeding in the Midst of a Pandemic

For the majority of people in the United States, the new requirements of increased social distancing and hygiene practices have become an adaptable part of our daily routines. But for a very important subset of patients, these guidelines lead to a major question: “What will happen to me and my baby if I have the virus?”

As hospitals across the country continue to adapt to meet the challenges of the novel coronavirus (COVID-19) pandemic, a special challenge has emerged for medical professionals managing expecting mothers and their newborns. What do we suggest for COVID-19 positive mothers caring for their newborns? Can we ask new moms to stay two arm lengths away from their infants? Should COVID-19 positive moms be required to hold and kiss their babies through layers of disposable gloves and masks? And is it ethical or even beneficial to separate a mother and child in the early hours of life?

These are the types of questions Dr. Karleen Gribble and colleagues sought to address in the article titled, “Mistakes from the HIV pandemic should inform the COVID-19 response for maternal and newborn care.” Ultimately, Dr. Gribble and her colleagues posit that lessons learned from the early years of the HIV pandemic should influence decisions surrounding maternal and newborn care for the COVID-19 positive mother. Recommendations and management decisions should be driven predominantly by science and evidence, not fear.

Learning from the HIV Pandemic

Arising in the late 1980’s as a global concern, the HIV pandemic bears some similarities to the COVID-19 crisis today. Thus, it is wise to reflect on lessons learned from the HIV pandemic as it relates to policy-making, particularly regarding the potential for maternal-newborn vertical transmission.

As with COVID-19, the early response to the HIV pandemic focused on preventing viral transmission, and for HIV positive mothers, this meant a swift (but not necessarily science-based) recommendation to not breastfeed their newborns. This recommendation remained in place in many developing countries for nearly seven years before research concluded only 14% of breastfed infants risked contracting HIV after 24 full months of breastfeeding, and only 4% over a 6-month period of breastfeeding. Moreover, exclusive breastfeeding in the first 6 months of life proved to minimize that risk and ultimately improve survival of infants with HIV positive mothers.

Although meant to protect children, policies and guidelines that suggested a stop on breastfeeding for HIV positive mothers had negative consequences in terms of infant survival. It is worth noting that, unlike HIV, there is no evidence that COVID-19 can be transmitted via breastmilk, and the disease state of COVID-19 in infants is predominantly very mild, often manifesting only as a fever with cough, if symptomatic at all.* Therefore, as this study concludes, limiting breastfeeding in the setting of a known COVID-19 infection bears little benefit but could mimic the harmful impact on infant mortality seen during the early rise of HIV.

Breastfeeding Benefits Mother and Child

Preserving infant and maternal survival is paramount during a pandemic, and breastfeeding has a proven track record of doing just that. According to at least one study cited by Dr. Gribble and her colleagues, a majority of hospital admissions for diarrhea-related illnesses and respiratory infections like pneumonia can be tied to a lack of breastfeeding. Because of its critical importance to the developing neonatal immune system, breastfeeding is encouraged through practices such as immediate skin-to-skin contact between mother and child, and same-room accommodations for mother and newborn while in the hospital.

While breastfeeding helps prevent diarrheal illness and infections in newborns, evidence links reduced breastfeeding practices to maternal death due to breast cancer, ovarian cancer, and type 2 diabetes. As a vital component of health for both mother and child, breastfeeding in the setting of infections like HIV or COVID-19 is an important consideration that must be evaluated through a risk-benefit analysis.

World Health Organization Guidelines

So, what are the guidelines for breastfeeding in known or presumptive COVID-19 positive mothers? Since March of 2020, the World Health Organization (WHO) has had consistent recommendations with very few, if any, limitations to be placed on maternal-newborn contact. Specifically, WHO supports many of the established recommendations that drive maternal-newborn care in non-pandemic settings: immediate skin-to-skin contact, early and exclusive breastfeeding, and close maternal-newborn contact with same-room accommodations.*

Protecting Mother and Child

According to the authors, the risk of mother-to-child transmission of the COVID-19 virus needs to be carefully weighed against the many known benefits of the mother-child bond formed during the early hours, days, and weeks of an infant’s life. In light of substantial evidence supporting the benefits of both maternal-newborn contact and breastfeeding, it is critical to consider how interrupting these practices can do more harm than good, as seen more than thirty years ago at the onset of the HIV pandemic.

For patients who wish to utilize fertility awareness-based methods (FABMs), guidelines for continued maternal-newborn contact such as those set by WHO can support a mother who chooses the Lactational Amenorrhea Method (LAM) for temporary family planning. Any interruption to breastfeeding practices, even if partial, may compromise a woman’s ability to use this method effectively to delay pregnancy. Given the benefits LAM provides for a woman’s reproductive health, breastfeeding by the COVID-19 positive mother hoping to avoid or delay another pregnancy becomes even more important.

As physicians, practitioners, medical students, and educators working during the COVID-19 pandemic, many of us will undoubtedly hear this poignant question from our patients: “What will happen to me and my baby if I have the virus?” And while the answer may include layers of masks, increased hand hygiene, and perhaps extra precautions for medical professionals, mothers-to-be should be reassured they pose a minimal threat to their newborns, and that their new babies will continue to look to them––just as they always have––for protection and survival.

*Editor’s Note: Next week, we will review a 2020 article that suggests breastfeeding is safe in the setting of COVID-19 as long as proper infection control measures are in place. CDC guidelines currently state, “Breast milk is the best source of nutrition for most infants. We do not know whether mothers with COVID-19 can transmit the virus via breast milk, but the limited data available suggest this is not likely. A mother with confirmed COVID-19 should be counseled to take precautions to avoid spreading the virus to her infant, including handwashing and wearing a cloth face covering.”[iv]


References

[i] Anstey EH, Shoemaker ML, Barrera CM, O’Neil ME, Verma AB, Holman DM. Breastfeeding and Breast Cancer Risk Reduction: Implications for Black Mothers. Am J Prev Med. 2017;53(3S1):S40-S46. doi:10.1016/j.amepre.2017.04.024.
[ii] Babita, Kumar N, Singh M, Malik JS, Kalhan M. Breastfeeding reduces breast cancer risk: a case-control study in north India. Int J Prev Med. 2014;5(6):791-795.
[iii] Gribble, K., Mathisen, R., Ververs, M. et al. Mistakes from the HIV pandemic should inform the COVID-19 response for maternal and newborn care. Int Breastfeed J 15, 67 (2020). https://doi.org/10.1186/s13006-020-00306-8.
[iv] https://www.cdc.gov/coronavirus/2019-ncov/hcp/care-for-breastfeeding-women.html.

 

Author Bio: Sara Peterson is a fourth-year medical student at Kansas City University in Kansas City, Missouri. Prior to medical school, Sara earned a Bachelor of Arts in English Writing from UC Berkeley in 2013, and a Master of Science in Physiology & Biophysics at Georgetown University in 2016. With goals to become a full-scope family medicine physician, she participated in the FACTS online elective to gain a more complete understanding of family planning and women’s health.
 

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