Experience regarding other respiratory virus pandemics are based in a largest series of cases about SARS infection includes 12 pregnant patients of which only five infants were born with no evidence of perinatal transmission [
17]. Although no information about breastfeed is reported [
17]. The Society of Obstetricians and Gynaecologists of Canada recommends SARS infected mothers not to breastfeed until recovered from infection as well as isolation from the neonate until the mother is no longer infectious [
18]. Pregnant women affected with MERS infection appears to have worse clinical outcomes that patients with SARS. Only 11 pregnancies associated cases have been documented with 91% having adverse clinical outcomes [
19]. There is no experience reported on breastfeeding and MERS infection.
The most important societies, such as WHO, UNICEF, ISUOG, RCOG and ABM promote breastfeeding in this COVID-19 pandemic but with special precautions. They also encourage, whenever possible, the skin-to-skin care, especially after birth in order to facilitate their adaptation to the outside world (stabilizing baby’s temperature, breathing rate, heart rate, and blood sugar) and the establishment of breastfeeding [
20‐
24]. The directions of Italian Society of Neonatology (SIN), Spanish Society of Neonatology (SeNeo) and Union of European Neonatal & Perinatal Societies (UENPS) follow these recommendations and they promote the joint management of the mother and her infant [
25]. As well, they warn that it is important to practice respiratory hygiene, including during feeding, such as the use of a medical mask, perform hand hygiene before and after contact with the infant, and routinely clean and disinfect surfaces where the symptomatic mother was in contact with [
25,
26].
However, the current recommendations in this pandemic from de Center for Disease Control and Prevention (CDC), and also from the Chinese Pediatrics COVID-19 Working Group, should be considered, as the first choice, to separate temporarily the mother who has confirmed COVID-19 or is “mother under investigation”, from the newborn to reduce the risk of transmitting the virus [
27]. During this period, they recommend the expression of milk with adequate hygiene measures, in order to maintain lactation once they are in direct contact with their children [
27‐
29]. On the other hand, the other societies claim that the impact on separation of mothers and neonates might result in infant formula feeding [
20].
Breastfeeding advice during the COVID-19 outbreak
According with the new evidence, the Breastfeeding Committee at Puerta de Hierro University Hospital in Madrid (Spain) approved the breastfeeding in COVID-19 newly born with the adequate individual protection measures and with the informed consent of the mother.
Even though there does not seem to be vertical transmission between mother and child, after birth the newborn is susceptible to person-to-person spread by being in contact with his mother. For this reason at the beginning of the pandemic no contact between the newborn and the mother was allowed and breastfeeding was not recommended [
30], but soon after international recommendations were established suggesting that the benefits of breastfeeding and the mother and child connection outweighed the risk of transmission [
20,
24,
31].
From the emotional wellbeing perspective, avoiding mother-baby separation following delivery also enhances mother-baby bonding process. Breastfeeding and early mother-baby contact may facilitate mother-baby bond [
32]. Breastfeeding also decreases the risk of developing postpartum depression [
33]. Whenever possible, breastfeeding should be encouraged at any time. For mothers and babies who were separated due to their medical condition, breastfeeding may help in the bonding process as it can protect against mental health problems. In our case series study of mothers with COVID-19, close to 65% of them performed skin to skin contact with their newborns and close to 55% of them achieved spontaneously breastfeeding during the first hour.
There are a number of precautions during breastfeeding that should be followed to minimize the risk of transmission [
34]: practicing respiratory hygiene (wearing a face mask or suitable alternative), washing hands thoroughly before and after contact with the baby, routinely cleaning and disinfecting any surfaces touched, cleaning thoroughly any infant feeding equipment (including breast pumps, bottles and teats) before and after use and avoid falling asleep with the baby. In our study we have not diagnosed any infections in newborns.
In this scenario, we identified three turning points which may be left unanswered in the discussion and based on our recent experience, we believe that the best approach to solve these problems are:
a) The first issue is that breastfeeding in COVID-19 patients under pharmacological treatment is only acceptable if the parents are informed about the possible risks. The most extended treatments used to treat the COVID-19 infection such as azithromycin, hydroxychloroquine sulfate, lopinavir-ritonavir, tocilizumab and methylpredinosolone, are excreted in very small amounts in breast milk [
35‐
41]. Although no specific studies have been conducted, it seems that most common medicines used for SARS-CoV-2 infection are safe and compatible with breastfeeding, so there are no contraindications or special recommendations to follow regarding the pharmacological treatment that breastfeeding mothers receive. The parents should be informed about this expected minimal exposure of their newborns to the medications.
Our data suggest the compatibility between breastfeeding and treatment for mothers with COVID-19. Most of them (80%), chose to breastfeed their babies. Additionally, for mothers who are temporarily separated from their babies, a transitory supplementation feeding (with pasteurized donor human milk or infant formula) could be a solution until exclusive breastfeeding can be establish.
b) A second problem is that breastfeeding in COVID-19 patients with severe symptoms or with high viral load could increase viral transmission. When mothers and neonates are separated the recommendations are to express milk to provide it to their infants, but when the mothers are unwell, with fever, in need of oxygen therapy and are even admitted to the intensive care unit, expressing milk might be a real challenge for them.
We think that to achieve this, mothers must have an important external help and guidance: specialists who help them with extraction techniques and emotionally support them. They should also be offered support to be able to make the decision to stop breastfeeding if it becomes a burden. These women should explore the possibility of re-lactation (restarting breastfeeding after a gap), wet nursing (another woman breastfeeding or caring for your child) or using donor human milk. Which approach to use will depend on cultural context, acceptability, and the availability of support services. In our study, out of 11 symptomatic patients, nine mothers required temporary separation mother-baby. In these cases, newborns were transfer to the neonatology unit. During this period, 50% of mothers with mild symptoms required supplementing their newborns for 48 h. At the end of the follow-up period, close to 65% of symptomatic mothers with COVID-19 breastfeed their babies: 6 exclusive breastfeeding and 1 supplementing with infant formula.
c) The third issue is how to manage breastfeeding while the newborn is admitted inside the NICU. In these cases, two special challenges are going to be presented to the COVID-19 mothers; the first that they must be isolated and will not be allowed to visit the neonatal units due to the risk of contagion (NICU or ICU admission rate was between 16 to 18 days). And the second, that even if they express their milk and follow the recommendations of the WHO and IHAN, the professionals responsible for their newborns may not accept it because of the risk that the milk or its containers are contaminated. Again, in this situation, emotional support for these mothers must be always offered. In our experience, achieving exclusive breastfeeding is possible even though the infants were admitted or isolated for prolonged periods; the infants of cases 1, 2 and 3 ended up with exclusive breastfeeding after a feed gap were a combination of pasteurized donor human milk and mother’s expressed breast milk was given to them.
In summary, despite all difficulties, 82% of newborns to mothers with COVID-19 were breastfed for the first month, decreasing to 77% at 1.8 months, being 73% of them exclusive breastfeeding, although more than a third of them required complementary breastfeeding temporarily. This event occurred with minimal maternal and newborn complications, and no neonates were infected during breastfeeding.