October 28, 2020
By Jenny Chen

Editor’s Note: During National Breast Cancer Awareness Month, we’re celebrating the role of breastfeeding in breast cancer reduction as well as its many benefits for mother and child. To raise awareness, we published a timely review last week on the importance of assessing the evidence about risks and benefits of breastfeeding during pandemics. Such due diligence ensures mothers and infants benefit for as long as possible from the strengthened immune system and many other positive outcomes resulting from breastfeeding.

This week, we review research[i] that highlights evidence suggesting breastfeeding is safe in the setting of COVID-19 as long as proper infection control measures are in place. Please note that new guidance from the Centers for Disease Control and Prevention (CDC) addressing neonates potentially at risk for COVID-19 infection were published five days ago.[ii] The updated document refers to the growing body of research indicating that spread of the SARS-CoV-2 virus that causes COVID-19 appears to be primarily via respiratory droplets.

The update echoes previous recommendations stating that breastfeeding mothers should take measures, including but not limited to proper hand hygiene and wearing a mask, to minimize the risk of viral spread while nursing their infants. Moreover, revised considerations from the CDC now emphasize “the importance of maternal autonomy in the medical decision-making process” regarding mother-neonate contact.[iii] Earlier guidance previously provided by the CDC regarding breastfeeding still applies and can be found here.[iv]

The article reviewed this week is titled, “Breastfeeding mothers with COVID-19 infection: a case series.” It was published in August 2020 by Pereira et al in the International Breastfeeding Journal. Jenny Chen, a fourth-year medical student, summarized the article while on the fertility awareness elective offered by FACTS through Georgetown University School of Medicine. Currently in its third year, the FACTS elective continues to grow in popularity and now consists of two parts: Fertility Awareness-Based Methods (FABMs) for Family Planning and Fertility Awareness for Women’s Health. Learn more about this unique elective here.

Introduction  

Ever since the first COVID-19 case was reported on December 31, 2019, over 41 million individuals have been affected by the novel coronavirus named SARS-CoV-2. The pandemic has changed the daily routine of countless people, including breastfeeding mothers, and has led to specific recommendations regarding breastfeeding in women with presumptive or confirmed COVID-19. The World Health Organization (WHO), the CDC, and various international organizations continue to highly recommend breastmilk for neonates, as it contains antibodies that protect them against infections, and the significant benefits of breastfeeding appear to outweigh the risk to these infants.

As noted, the World Health Organization recommends that women with COVID-19 be encouraged to breastfeed if that is their desire, but to follow established guidelines and infection control precautions (summarized here). Other groups, like the Union of European Neonatal and Perinatal Societies, recommend tight restrictions for breastfeeding in asymptomatic COVID-19 mothers; if an infected mother is too ill, the child is separated from the mother and nourished with fresh expressed breastmilk.

The retrospective series of case studies reported by Pereira et al assessed 22 neonates that were breastfed by their COVID-19 positive mothers. The researchers studied breastfeeding differences and sought to identify problems as well as evaluate the risk of infection to newborns breastfed by mothers diagnosed with COVID-19

Methodology

Between March 14, 2020 and April 14, 2020, 23 mothers with COVID-19 were recruited for a retrospective case series study. One patient withdrew her informed consent while 22 mothers remained in the study. The goal of the research was to identify whether lactation in mothers with COVID-19 contributed to an additional risk of infection or complications in their newborn children.

Data collected included maternal and gestational age, type of delivery, symptoms of infection or presence of pneumonia, results of neonatal RT-PCR testing,* skin-to-skin contact, medications, breastfeeding complications, and more. Within the first two hours following delivery, all neonates were tested for COVID-19 using quantitative RT-PCR testing with samples obtained via nasopharyngeal swab. Upon hospital discharge, all COVID-19 positive mothers received specific written recommendations for maternal breastfeeding during the COVID-19 pandemic. 

Results

During the first thirty days of the pandemic, 23 deliveries by mothers with COVID-19 were attended to at University Hospital Puerta de Hierro; 22 of these patients were included in the final study. Of these 22 mothers, 20 (90.9%) decided to breastfeed their newborns during the hospitalization, but the percentage of breastfeeding dropped to 77% by 1.8 months. In 6 of 22 (37.5%) cases, supplementary feeding was required until the mothers achieved exclusive breastfeeding.

Of the 22 mothers diagnosed with COVID-19, 11 mothers were symptomatic. Of these patients, 4 mothers received treatment for COVID-19 before delivery and 4 mothers received treatment during the puerperium, the time from delivery of the placenta to the first few weeks after delivery. All 22 newborns tested negative via quantitative RT-PCR testing, although 2 preterm neonates required admission to the neonatal intensive care unit (NICU).

Of the newborns, 72.7% received exclusive breastmilk, with 37.5% needing temporary complementary feeding until exclusive breastfeeding was attained. Timely initiation of breastfeeding was seen in approximately 12 cases, whereas skin-to-skin contact in the delivery room was noted in 13 cases. In this study, no neonates were infected with the virus during breastfeeding. 

Discussion

COVID-19 spreads mostly via droplet transmission, but the virus has also been detected in blood and stool samples. However, viral spread in breastmilk, cord blood, placenta, or amniotic fluid has not been seen. All 22 newborns in this study tested negative to mothers diagnosed with COVID-19.

Some medical societies have published different guidelines that may or may not follow national or international recommendations. For instance, as of the time of the article by Pereira et al, the Society of Obstetricians and Gynaecologists of Canada did not recommend breastfeeding in mothers with COVID-19 until the mother was fully recovered. They also encouraged further isolation between mother and newborn until the mother was no longer infectious. Yet, most international organizations, including WHO, UNICEF, and RCOG, encourage breastfeeding with appropriate precautions along with skin-to-skin contact between mother and child.

In summary, most organizations recommend breastfeeding during the pandemic, as its benefits are bountiful with regards to the newborn as well as the mother. With proper hygiene protocols and infection control measures, breastfeeding despite a diagnosis of COVID-19 is safe.

Editor’s Note: Guidelines from organizations recommending breastfeeding in the setting of COVID-19 infection take into account the limited but reassuring research pointing to a lack of vertical transmission from mother to child, along with evidence for minimal risk to these neonates from breastfeeding with precautions. These important guidelines also weigh the significant benefits of breastfeeding to both mother and child.

For women who utilize FABMs like the Lactational Amenorrhea Method (LAM), the evidence suggests that exclusive breastfeeding can continue safely during the pandemic with proper infection control practices. A full review of breastfeeding benefits as well as national and international recommendations regarding breastfeeding in the setting of COVID-19 is beyond the scope of this article. To learn more about this timely topic, we refer our readers to the first article in this series, Breastfeeding during Pandemics: Protecting Mother and Child, and to the references listed below.

*Reverse Transcription Polymerase Chain Reaction


References

[i] Pereira, A., Cruz-Melguizo, S., Adrien, M. et al. Breastfeeding mothers with COVID-19 infection: a case series. Int Breastfeed J 15, 69 (2020). https://doi.org/10.1186/s13006-020-00314-8.
[ii] Centers for Disease Control and Prevention. Evaluation and Management Considerations for Neonates At Risk for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html. Accessed 27 Oct 2020.
[iii] Centers for Disease Control and Prevention. Evaluation and Management Considerations for Neonates At Risk for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html. Accessed 27 Oct 2020.
[iv] Centers for Disease Control and Prevention. Care for Breastfeeding Women. https://www.cdc.gov/coronavirus/2019-ncov/hcp/care-for-breastfeeding-women.html. Accessed 27 Oct 2020.

Additional Suggested Reading

  1. Breastfeeding advice during the COVID-19 outbreak. http://www.emro.who.int/noncommunicable-diseases/campaigns/breastfeeding-advice-during-the-covid-19-outbreak.html. Accessed 6 Jul 2020.
  2. Centers for Disease Control and Prevention. Interim guidance on breastfeeding for a mother confirmed or under investigation for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-guidancebreastfeeding.html. Accessed 6 Jul 2020.
  3. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed 27 Oct 2020.
  4. Maxwell C, McGeer A, Tai KFY, Sermer M. No. 225-management guidelines for obstetric patients and neonates born to mothers with suspected or probable severe acute respiratory syndrome (SARS). J Obstet Gynaecol Can. 2017;39(8):e130–7.

 

Author Bio: Jenny Chen is a fourth-year medical student at the Chicago College of Osteopathic Medicine. She recently completed Parts A and B of the FACTS fertility awareness elective and is pursuing residency training in family medicine.

 

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