What do we know about breastfeeding and COVID-19?
This paper summarises the present recommendations on counselling breastfeeding mothers during the COVID-19 pandemic. Present research shows that breastfeeding by infected, and vaccinated, mothers is safe. So, the overriding advice to mothers in South Sudan, and elsewhere, is to carry on giving the same messages: to start suckling immediately after birth, to exclusively breastfeed for the first six months and to breastfeed with complementary foods until at least two years of age. COVID-19 hygiene messages should be explained to mothers, their families and informal midwives/health workers taking into account local beliefs and resources.
Keywords: breastfeeding, COVID-19, hygiene, masks, vaccine, South Sudan
We know that breastmilk is the best food for babies. However, the COVID-19 pandemic has made some mothers worry whether the virus can be transmitted through their breastmilk and infect their babies. Some companies are exploiting the pandemic to promote breast milk substitutes.[1,2] So, it is important for us all, especially those caring for pregnant and lactating women to be aware of the latest advice on feeding babies during the pandemic.
Research into COVID-19 and breastfeeding is ongoing. Below are the current recommendations from the World Health Organization (WHO) and other reliable agencies which are being promoted in South Sudan. Health professionals can use this information when counselling mothers, and for messages to families and informal health workers/midwives from whom mothers may seek advice and support.
Why breastfeeding is important
If necessary, remind yourself and the families you counsel, why ‘breastfeeding is important’.
- Breast milk provides all the nutrients and water a baby needs for the first six months of life and about one third until the 2nd birthday; it protects the baby from many infections and reduces the risk of allergies;
- Suckling immediately after delivery makes the mother’s womb contract and reduces bleeding;
- Breastfeeding helps the mother and baby to bond. It helps the mother regain her pre-pregnancy weight, reduces her risk of some cancers and can delay the next pregnancy.
- Feeding breastmilk substitutes, especially with a bottle, increases the baby’s risk of infection and malnutrition.
If breastfeeding is interrupted it can take time for the mother to produce enough milk and for the baby to suckle strongly again.
Breastfeeding is even more important during the COVID-19 pandemic
Many organizations, including WHO, agree that there is presently no evidence that breastfeeding increases the risk of infants contracting COVID-19, and that skin-to-skin contact remains essential for the health of both mothers and newborns.[1,5,6] It is estimated that separating mothers from their babies and not breastfeeding would lead to many more infant deaths than those potentially attributable to COVID-19.
The many benefits of breastfeeding greatly outweigh any potential risks of a mother infecting her baby.[5,8] Infants are at more risk of catching the virus if they are in close contact with another infected person and do not have the protection provided by breastfeeding. So, during the pandemic, the advice to all mothers is to continue breastfeeding, and skin-to-skin contact as usual, while practicing good hygiene.[7,9] See Figure 1.
Figure 1. Decision Tree for breastfeeding and COVID-19. From: WHO. FREQUENTLY ASKED QUESTIONS: Breastfeeding and COVID-19. For health care workers. Which complements: Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected (CC BY-NC-SA 3.0 IGO) https://www.who.int/docs/default-source/reproductive-health/maternal-health/faqs-breastfeeding-and-covid-19.pdf?sfvrsn=d839e6c0_5
If a mother has COVID-19 or suspects she has COVID-19
The presence of maternal COVID-19 antibodies in the milk of an infected mother may increase her baby’s immunity against the virus. and may protect infants against respiratory and gastro-intestinal symptoms of COVID-19.
However, few lactating mothers in South Sudan know if they are infected as there is very limited testing and, what is available, is difficult for most people to access. As other upper respiratory tract infections are common, a woman infected with COVID-19 may not realise that she has that virus.
Therefore, if you, or the mother, suspects she has COVID-19 (for example, she has the symptoms) you should reassure her that she can safely breastfeed as normal while taking extra care with hygiene. Use locally appropriate messages and other media about COVID-19, and knowledge of the family’s beliefs and resources, to encourage the mother to:
- Wash her hands frequently, preferably with soap, before feeding the baby;
- Wear a mask during feeding – see below;
- Try to avoid coughing or sneezing while feeding. If she does, she should use a disposable tissue/cloth, immediately throw it away and, if possible, wash her hands again;
- Clean surfaces often that she, or infected people, have touched especially those the baby may touch.
The South Sudan National Guidelines on COVID-19 give more advice under ‘Guidelines on home care for COVID-19 cases’.
A lactating mother who has to isolate or quarantine may need your reassurance about feeding her baby because she may be frightened and away from her usual sources of support. If the mother is sick, she may need help to care for her baby. She should keep her baby near and care for her baby herself as far as possible – in order to reduce the risk of infection from other persons handling her baby. There is no need to isolate a breastfeeding baby and mother separately.
Masks and face coverings
- As a health professional, you will be aware of your national and international guidelines about wearing masks when feeding infants, but you may want to adjust the messages to fit family situations, resources and preferences. Most mothers cannot afford medical masks. Other masks, such as cloth ones, may not be effective, and/or can become a source of COVID-19 and other infections if not used, washed and dried properly.
- If mothers use medical masks, for example in health facilities, it is important to: - Replace a mask as soon as it becomes damp - Dispose of it immediately - Not re-use it - Not touch the front of the mask but untie it from behind.
- Never put masks or face coverings on children aged under 2 years because of the danger of suffocation.
Advice for mothers without COVID-19 symptoms
- Mothers without symptoms of coronavirus do not need to wear a mask when breastfeeding.
Advice for mothers with COVID-19 symptoms
- WHO says, “Mothers with symptoms of COVID-19 are advised to wear a medical mask, but, even if this is not possible, breastfeeding should be continued.”
- Outside health facilities medical masks are rarely available so encourage a mother to wear a cloth face covering when breastfeeding or interacting with her baby. This reduces the risk of droplets with COVID-19 being spread to the infant. Make sure she knows how to wear the face covering correctly and is able to wash and dry it safely – Figure 2. Visitors to the baby should wear a face covering.
- Wearing a face covering may be a challenge (and its use may need to be discussed with the family), if it prevents a baby bonding with his mother, or if a child tries to pull it off.
If the mother is sick
If a mother has COVID-19 symptoms such as fever, cough or difficulty breathing, encourage her to continue breastfeeding if she feels able to. Advise her to drink plenty of fluids, particularly if she has a fever, and to eat as well as she can.
There is no evidence that breastfeeding changes the clinical course of COVID-19 in a mother.[3,15] Sometimes a mother who is ill may prefer to express her breastmilk so that she, or a non-infected person, can feed the baby using a clean cup and spoon. A mother who is ill may need help to express her milk. However, continuing to breastfeed may be easier and less stressful than expressing milk.
If a mother is too ill to breastfeed or express milk reassure her that you will help her re-lactate when she is feeling better. A mother can re- start to breastfeed as soon as she feels she can.
If a mother is unable to breastfeed or has decided not to breastfeed, and wants to use breastmilk substitutes, make sure that she follows the instructions on the packaging, takes extra care with hygiene and uses a cup and spoon, not a bottle, to feed the baby. Make sure that the family can access and use breastmilk substitutes safely for many months; if there are concerns counsel the family about making feeding decisions that can be continued.
Figure 2. How to wear a fabric mask
Vaccines for breastfeeding mothers
Health professionals should follow the national vaccination guidelines as to whether, or when, to vaccinate lactating women or women who plan to breastfeed. Several organizations, including WHO, recommend that a vaccinated woman initiates or continues breastfeeding. Recent research suggests that maternal vaccination results in SARS-CoV-2-specific immunoglobulins in breast milk. However, it is unclear whether this could be protective for infants. Note that guidelines for pregnant women may be different.
Marketing of breastmilk substitutes and breastfeeding myths
Some manufacturers of breastmilk substitutes have been undermining confidence in breastfeeding by using the pandemic as an opportunity to advise on infant feeding. For example, by suggesting unnecessary hygiene measures, using expressed breastmilk, and separating babies from their mothers.[1,2] As well as this false information there the many myths surrounding COVID-19 and breastfeeding. It is our job, as health professionals, to be aware of these and to give, in sympathetic, culturally-relevant ways, correct information and support to breastfeeding women and their families.
Acknowledgements: The SSMJ team thank Genevieve Becker, Ayat Jervase and Barbara Nalubanga for help in preparing this article.
There are no conflicts of interests and no funding was received.
- van Tulleken C et al Marketing of breastmilk substitutes during the COVID-19 pandemic. The Lancet 2020 DOI:https://doi.org/10.1016/S0140-6736(20)32119-X
- Ching C, Zambrano P, Nguyen T, et al. Old tricks, new opportunities: how companies violate the international code of marketing of breast-milk substitutes and undermine maternal and child health during the COVID-19 Pandemic. International Journal of Environmental Research and Public Health 2021;18:2381. DOI: 10.3390/ijerph18052381
- Johns Hopkins Center for Humanitarian Health. Repository on COVID-19, Breastfeeding, Infant Feeding, and Breast Milk (updated weekly).
- Savage F et al. Nutrition for Developing Countries. Oxford University Press. 2015
- World Health Organization Brief. Breastfeeding and COVID-19 Scientific Brief 23 June 2020
- Kumar J et al SARS-CoV-2 detection in human milk: a systematic review. February 2021
- World Health Organization News 16 March 2021 New research highlights risks of separating newborns from mothers during COVID-19 pandemic.
- Rollins N, Minckas N, Jehan F, et al. A public health approach for deciding policy on infant feeding and mother–infant contact in the context of COVID-19. The Lancet Global Health. 2021.
- World Health Organization. Frequently Asked Questions: Breastfeeding and COVID-19 For health care workers. May 2020.
- Ryan MP et al. Characterization of SARS-CoV-2 RNA, antibodies, and neutralizing capacity in milk produced by women with COVID-19.
- da Costa et al. Breastfeeding importance and its therapeutic potential against SARS-CoV-2.
- National Taskforce for COVID-19. The South Sudan National Guidelines on COVID-19. ‘Guidelines on Home care for COVID-19 Cases’. August 2020.
- UNICEF. No date. Breastfeeding during the COVID-19 pandemic: Tips on keeping your baby healthy and safe.
- World Health Organization. Coronavirus disease (COVID-19) advice for the public: When and how to use masks
- World Health Organization News. 7 May 2020 Coronavirus disease (COVID-19): Breastfeeding
- World Health Organization vaccine. Feb 2021 Coronavirus disease (COVID-19): Vaccines safety
- Baird JK et al. SARS-CoV-2 antibodies detected in human breast milk postvaccination. 2021.
- Swain D et al. Review Article Busting of myths and misconceptions about breast feeding during COVID-19 pandemic and its societal importance: a brisk review. Int J Reprod Contracept Obstet Gynecol. 2021 Feb;10(2):818-824 See Table 1.
- World Health Organization Africa. Viral facts Africa.