Note: This is the seventeenth of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available.

Clinical Context

The COVID-19 pandemic continues to take its toll worldwide, with exponential increases in cases and deaths affecting nearly all countries. Transmission via respiratory droplets released during a cough or sneeze appears to be the primary route, but virus has also been identified in the feces and has been shown to survive on surfaces for periods of up to several days. Persons at highest risk of becoming infected with SARS-CoV-2 appear to be individuals in close, prolonged contact with persons with COVID-19, even though the latter may still be asymptomatic or have experienced clinical recovery.

Given the above considerations, postpartum contact with and breastfeeding of an infant born to a mother with COVID-19 may present clear risks. Counterbalancing these risks are the known benefits to mother and child of close contact and breastfeeding. Different organizations, countries, and experts vary in how they calculate this balance.

Synopsis and Perspective

Breastfeeding decisions for women with COVID-19 must counterbalance the risk for infection to the infant with the known health benefits of close contact and breastfeeding to the infant and mother; yet, different organizations, countries, and experts vary in how they calculate this balance, which is challenging, given gaps in knowledge concerning SARS-CoV-2 transmission.

In Wuhan, China, the original epicenter of the pandemic, current protocol leans toward the side of caution, with mother-infant separation and discouraging breastfeeding until the mother is deemed no longer infectious. In Italy, the pendulum swings toward rooming-in of the mother with COVID-19 and her infant, with European Union (EU) professional societies endorsing these guidelines.

Citing the benefits of breastfeeding for the infant, mother, and global public health, the World Health Organization (WHO) tends to side with the EU whereas the Centers for Disease Control and Prevention (CDC) currently seems to favor the Asian approach. Despite their contrasting views, all these organizations acknowledge at least some role of the mother’s informed choice and offer strategies to mitigate the risk for infant infection when mothers with COVID-19 opt for breastfeeding.

China Recommends Infant Isolation

According to their experience with clinical management for pregnant women and newborns with COVID-19 pneumonia, Tongji Hospital, in Wuhan, China, has revised their proposed guidelines for care of such patients.^[1] This guidance addresses mode of mother-to-child transmission, management of postpartum fever, neonatal isolation, and breastfeeding.

Possible modes of SARS-CoV-2 transmission from mother to newborn include vertical transmission from mother to fetus, close contact transmission, droplet transmission from family or visitors, and hospital-acquired infections. Newborns with potential exposure should be isolated, monitored, and tested for SARS-CoV-2 using nucleic acid testing.

Most reports to date suggest lack of evidence for vertical transmission of SARS-CoV-2 but acknowledge that no definitive conclusions can yet be drawn. In contrast, however, Wang and colleagues wrote, "It has been reported that a case of SARS-CoV-2 infection with positive nucleic acid of pharyngeal swab virus occurred in a baby only 36 [hours] after birth, and the mother was a confirmed case of SARS-CoV-2 infection. Therefore, the existence of mother-to-child transmission of SARS-CoV-2 remains to be verified. In addition, breastfeeding should not be performed if the mother was infected by SARS-CoV-2."

Tongji Hospital also mandates that newborns confirmed to be infected with SARS-CoV-2 be kept in an isolated observation ward for at least 14 days and that persons with suspected infection should be transferred to an isolation ward for observation or treatment until the recovery standard is met. Rooming-in of mother and infant in the same room is permitted only when the mother has 2 consecutive negative SARS-CoV-2 nucleic acid tests, 1 day apart, and only with informed consent.

Other recommendations from Tongji Hospital are to clean newborns as soon as possible; to examine mothers for postpartum fever and to test persons with COVID-19 symptoms for evidence of SARS-CoV-2 infection; to defer completion of newborn disease screening and hearing testing until "after the end of the epidemic"; and to discourage breastfeeding in "suspected cases, uncured clinically diagnosed cases and uncured confirmed cases."

Factors underlying these stringent recommendations include evidence that even asymptomatic persons may be infected with SARS-CoV-2 and spread it to others. In addition, some antiviral agents used in China, such as lopinavir and ritonavir, can be secreted in rat milk, but it is uncertain whether secretion into breast milk occurs in women taking these drugs.

Italy, EU More Lenient

In contrast, interim indications regarding breastfeeding and COVID-2019 issued by the Italian Society of Neonatology and endorsed by the Union of European Neonatal & Perinatal Societies^[2] call for a more lenient approach, pending further evidence.

"Besides the possible consequences of COVID-19 infection on a pregnant woman and the fetus, a major concern is related to the potential effect on neonatal outcome, the appropriate management of the mother-newborn dyad and finally the compatibility of maternal COVID-19 infection with breastfeeding," the authors wrote.

If a mother who is COVID-19--positive or who is a person under investigation (PUI) for COVID-19 is asymptomatic or has few symptoms at delivery, rooming in is feasible and direct breastfeeding is advisable but with strict infection control measures.

"On the contrary, when a mother with COVID-19 is too sick to care for the newborn, the neonate will be managed separately and fed fresh expressed breast milk, with no need to pasteurize it, as human milk is not believed to be a vehicle of COVID-19," the authors concluded.

Could Donor Milk Banking Help Fill the Gap?

An international perspective^[3] cited the many benefits of breast milk to the newborn and lamented the effect of the COVID-19 pandemic on donor milk banking, which could fill the gap in situations where infected mothers are unable to breastfeed.

"Donor milk banking is predicated always on the protection, promotion and support of breastfeeding," wrote Kathleen A. Marinelli, MD. "We believe this deadly virus is not transmitted through mother’s milk. We do not know if there is vertical transmission or not."

She noted that newborns may be a high-risk group for COVID-19, as they are for other viral infection. Although the present lack of herd immunity against SARS-CoV-2 reduces the likelihood of specific immune factors against it in human milk, one mother with severe acute respiratory syndrome (SARS) was shown to have anti-SARS-CoV antibody in her postpartum milk.

“[A]s we know, there are so many immune factors in, and immune functions of, human milk, that its provision to our youngest and very vulnerable must continue to be of paramount importance,” Marinelli wrote.

The perspective reviewed available evidence to date. In a Wuhan case series of 9 pregnant women with COVID-19 in January 2020, 6 mothers were tested and all samples were negative for SARS-CoV-2 in amniotic fluid, cord blood, neonatal throat swabs, and milk samples.

“The ability to provide support and to protect our breastfeeding mothers becomes extremely difficult where the virus is rampant,” Marinelli concluded. “If we cannot support breastfeeding, how will we ensure a supply of donor milk? In populations with large areas under quarantine or “lockdown,” how are we to move “safe” milk from the donors to the milk banks? In the bigger picture, what does this mean for the health of our children, as we may in fact see breastfeeding rates, and the supply and use of donor milk, decrease during this very unstable and concerning of times."

Highlights

• Several organizations, including the American College of Obstetrics and Gynecology,^[4] CDC,^[5] and WHO,^[6] offer recommendations regarding breastfeeding and postpartum care for women with COVID-19.
• Given the scarcity of evidence to date, these organizations plan to update their recommendations regularly as new data become available.
• Whether or not vertical transmission of SARS-CoV-2 can occur from mother to child is still unclear.
• In 6 mothers with COVID-19 who were tested for SARS-CoV-2, no samples of amniotic fluid, breast milk, cord blood, or neonatal pharyngeal swabs tested positive.^[3]
• Although SARS-CoV-2 and severe acute respiratory syndrome novel coronavirus (SARS-CoV) have not to date been detected in breast milk, data are also insufficient regarding possible transmission by this route.
• One mother with SARS-CoV was shown to have anti-SARS-CoV antibodies in postpartum breast milk.
• According to the CDC,^[7] it may be wise for the mother with COVID-19 and her infant to be in separate rooms until the mother’s transmission-based precautions are discontinued.
• It is unknown whether newborns with COVID-19 are at increased risk for severe complications, but the risk for postnatal transmission via contact with infectious respiratory secretions could be lowered by temporarily separating the mother with confirmed or suspected COVID-19 from her infant.
• The healthcare team should discuss the risks and benefits of temporary separation of the mother from her baby, and the infant should be in a separate isolation room while they remains PUIs.
• Healthcare facilities should consider limiting visitors other than a healthy parent or caregiver, and visitors, including individuals providing care for the infant, should wear appropriate personal protective equipment (PPE).
• The decision to discontinue temporary separation should consider disease severity, signs and symptoms, and laboratory testing for SARS-CoV-2, and it should be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials.
• If rooming-in of the newborn with their ill mother in the same hospital room occurs because of the mother’s wishes or facility limitations, measures may be implemented to reduce newborn exposure to SARS-CoV-2, such as a curtain between the mother and newborn, keeping the newborn ≥ 6 feet away, and use of a face mask and hand hygiene before each close contact.
• To establish and maintain milk supply, mothers who plan to breastfeed should be encouraged to express their breast milk during temporary separation, using a dedicated breast pump if possible, as well as hand hygiene and thorough cleaning of the pump and its parts.
• For breastfeeding guidance in the immediate postpartum setting, the CDC recommends the same precautions as detailed for inpatient obstetric care.
• The CDC has provided guidance on breastfeeding for patients with COVID-19 to prevent spread to the baby. This includes washing of hands, wearing a face mask and appropriate handling of pumps and bottle parts.^[8]
• Women with COVID-19 who are considering breastfeeding should discuss this decision with their family and healthcare team, bearing in mind that breast milk is the best source of nutrition for most infants and confers immunity against many illnesses.^[4]
• According to the WHO, early, exclusive breastfeeding and close contact help infants to thrive, promote sensory and cognitive development, protect the infant against infectious and chronic diseases, and lower infant mortality from diarrhea, pneumonia, or other common childhood illnesses.^[9]
• Evidence has long been accumulating for the health advantages of breastfeeding, including maternal benefits such as lower risk for ovarian and breast cancer and health benefits for the child that extend into adulthood.
• For the population as a whole, the WHO and UNICEF therefore recommend starting breastfeeding within the first hour of life; exclusive breastfeeding for the first 6 months; and continued breastfeeding, with appropriate complementary foods, for ≤ 2 years or beyond.
• To avoid transmission to their infant, women with COVID-19 should follow CDC handwashing protocol before and after touching their baby or any breast pump or bottle parts; practice respiratory hygiene; wear a face mask during breastfeeding if possible; clean all pump and bottle parts after use according to CDC recommendations; and routinely clean and disinfect surfaces they have touched.^[5]
• Alternatively, the mother could pump milk and a person without COVID-19 could feed the breast milk to the infant.
• Women should be supported in breastfeeding, in holding their newborn skin to skin, and in sharing a room with their baby, using good hand hygiene before and after and keeping all surfaces clean.^[6]
• Women who are too ill from COVID-19 to breastfeed should consider feeding their infant by expressing milk, relactation, or using donor human milk, which may be in short supply because of social distancing and other constraints imposed by the pandemic. 
• Clinicians should advise their patients about modifications to postpartum care to reduce risk for transmission, which may include fewer or less frequent in-person visits or increased reliance on telemedicine with phone or online video visits.

Clinical Implications

• In a small sample of mothers with COVID-19 who were tested, no SARS-CoV-2 was detected in amniotic fluid, breast milk, or neonatal pharyngeal swabs, but whether or not vertical transmission of SARS-CoV-2 can occur from mother to child is still unclear.
• Professional organizations and countries differ in their recommendations regarding mother-infant contact and breastfeeding for mothers with COVID-19, but all agree that these decisions must counterbalance risk for infection to the infant with the known health benefits of breastfeeding to the infant and mother.
• Implications for the Healthcare Team: Decisions regarding mother-infant contact and breastfeeding for mothers with COVID-19 should be made by the mother and family in consultation with the healthcare team and should include respiratory and hand hygiene and other infection control precautions.

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