A study of breastfeeding practices, SARS-CoV-2 and its antibodies in the breast milk of mothers confirmed with COVID-19

Prevalence and duration of SARS-CoV-2 fecal shedding in breastfeeding dyads following maternal COVID-19 diagnosis

Background

There is a paucity of data on the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in feces of lactating women with coronavirus disease 2019 (COVID-19) and their breastfed infants as well as associations between fecal shedding and symptomatology.

Objective

We examined whether and to what extent SARS-CoV-2 is detectable in the feces of lactating women and their breastfed infants following maternal COVID-19 diagnosis.

Methods

This was a longitudinal study carried out from April 2020 to December 2021 involving 57 breastfeeding maternal-infant dyads: 33 dyads were enrolled within 7 d of maternal COVID-19 diagnosis, and 24 healthy dyads served as controls. Maternal/infant fecal samples were collected by participants, and surveys were administered via telephone over an 8-wk period. Feces were analyzed for SARS-CoV-2 RNA.

Results

Signs/symptoms related to ears, eyes, nose, and throat (EENT); general fatigue/malaise; and cardiopulmonary signs/symptoms were commonly reported among mothers with COVID-19. In infants of mothers with COVID-19, EENT, immunologic, and cardiopulmonary signs/symptoms were most common, but prevalence did not differ from that of infants of control mothers. SARS-CoV-2 RNA was detected in feces of 7 (25%) women with COVID-19 and 10 (30%) of their infants. Duration of fecal shedding ranged from 1-4 wk for both mothers and infants. SARS-CoV-2 RNA was sparsely detected in feces of healthy dyads, with only one mother's and two infants' fecal samples testing positive. There was no relationship between frequencies of maternal and infant SARS-CoV-2 fecal shedding (P=0.36), although presence of maternal or infant fever was related to increased likelihood (7-9 times greater, P≤0.04) of fecal shedding in infants of mothers with COVID-19.

Breastfeeding vs. breast milk transmission during COVID-19 pandemic, which is more important?

The catastrophic coronavirus disease 2019 (COVID-19) pandemic has raised many health questions, and whether breast milk from SARS-CoV-2 infected mothers may be a vector for SARS-CoV-2 transmission has become a hot topic of concern worldwide. Currently, there are extremely limited and conflicting data on the risk of infection in infants through breastfeeding. For this reason, we investigated almost all current clinical studies and systematically analyzed the presence of SARS-CoV-2 and antibodies in the breast milk of mothers infected with SARS-CoV-2, their effects on newborns, and the mechanisms involved. A total of 82 studies were included in this review, of which 66 examined the presence of SARS-CoV-2 in breast milk samples from mothers diagnosed with COVID-19, 29 reported results of antibody detection of SARS-CoV-2 in breast milk, and 13 reported both nucleic acid and antibody test results. Seventeen studies indicated the presence of detectable SARS-CoV-2 nucleic acid in breast milk samples, and only two studies monitored viral activity, both of which reported that infectious viruses could not be cultured from RNA-positive breast milk samples. All 29 studies indicated the presence of at least one of the three antibodies, IgA, IgG and IgM, in breast milk. Five studies indicated the presence of at least one antibody in the serum of breastfed newborns. No COVID-19-related deaths were reported in all 1,346 newborns. Our study suggests that direct breastfeeding does not pose an additional risk of infection to newborns and that breast milk is a beneficial source of anti-SARS-CoV-2 antibodies that provide passive immune protection to infants. In addition, direct breastfeeding would provide maternal benefits. Our review supports the recommendation to encourage direct breastfeeding under appropriate infection control guidelines. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier: 458043.

Assessment of SARS-CoV-2 neutralizing antibody titers in breastmilk from convalescent and vaccinated mothers

Breastmilk contains antibodies that could protect breastfed infants from infections. In this work, we examined if antibodies in breastmilk could neutralize SARS-CoV-2 in 84 breastmilk samples from women that were either vaccinated (Comirnaty, mRNA-1273, or ChAdOx1), infected with SARS-CoV-2, or both infected and vaccinated. The neutralization capacity of these sera was tested using pseudotyped vesicular stomatitis virus carrying either the Wuhan-Hu-1, Delta, or BA.1 Omicron spike proteins. We found that natural infection resulted in higher neutralizing titers and that neutralization correlated positively with levels of immunoglobulin A in breastmilk. In addition, significant differences in the capacity to produce neutralizing antibodies were observed between both mRNA-based vaccines and the adenovirus-vectored ChAdOx1 COVID-19 vaccine. Overall, our results indicate that breastmilk from naturally infected women or those vaccinated with mRNA-based vaccines contains SARS-CoV-2 neutralizing antibodies that could potentially provide protection to breastfed infants from infection.

Breastfeeding during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused many significant changes to all aspects of day to day life. The disease has spread and reached pandemic proportions. The principle route of transmission is the respiratory route. Infants, pregnant women and breastfeeding mothers have all been affected. Many interventions and guidelines from important societies have been instituted in order to curb the transmission of the disease. These have involved both pharmacological and non-pharmacological methods. COVID-19 vaccines have also emerged as important methods of primary prevention of the disease. But several questions have been raised concerning the safety and efficacy of their use in pregnant and breastfeeding mothers. It has also not been clear if the vaccines are effective in generating a robust immune response in the pregnant women and breastfeeding mothers to confer passive immunity to the fetuses and infants, respectively. And they have not been tested in infants. The aspect of infant feeding has equally been affected. Although breast milk has not been known to serve as the vehicle of transmission of the virus, there is still some lack of uniformity of practice regarding breastfeeding when a mother has SARS-CoV-2 infection. This has led to infant feeding being done by the use of commercial formula feeds, pasteurized human donor breast milk, feeding on the mother's own expressed breast milk by a care giver and directly breastfeeding with skin to skin contact. This is despite breast milk being the most physiologically appropriate type of feed for infants. Therefore the pertinent question remains; should breastfeeding continue during the pandemic continue? This review also seeks to analyse the vast amount of scientific information regarding the subject and to synthesize science-based information.

Anti-SARS-CoV-2 Immunoglobulins in Human Milk after Coronavirus Disease or Vaccination-Time Frame and Duration of Detection in Human Milk and Factors That Affect Their Titers: A Systematic Review

Human milk (HM) of mothers infected with or vaccinated against SARS-CoV-2 contains specific immunoglobulins, which may protect their offspring against infection or severe disease. The time frame and duration after infection or vaccination, during which these immunoglobulins are detected in HM, as well as the major factors that influence their levels, have not been fully elucidated. This systematic review aimed to collect the existing literature and describe the immune response, specifically regarding the immunoglobulins in HM after COVID-19 disease or vaccination in non-immune women. We conducted a systematic search of PubMed and Scopus databases to identify studies published up until 19 March 2023. In total, 975 articles were screened, and out of which 75 were identified as being relevant and were finally included in this review. Infection by SARS-CoV-2 virus primarily induces an IgA immune response in HM, while vaccination predominantly elevates IgG levels. These immunoglobulins give HM a neutralizing capacity against SARS-CoV-2, highlighting the importance of breastfeeding during the pandemic. The mode of immune acquisition (infection or vaccination) and immunoglobulin levels in maternal serum are factors that seem to influence immunoglobulin levels in HM. Further studies are required to determine the impact of other factors, such as infection severity, lactation period, parity, maternal age and BMI on immunoglobulin level in HM.

Neonatal outcomes and indirect consequences following maternal SARS-CoV-2 infection in pregnancy: a systematic review

OBJECTIVES

To identify the association between maternal SARS-CoV-2 infection in pregnancy and individual neonatal morbidities and outcomes, particularly longer-term outcomes such as neurodevelopment.

DESIGN

Systematic review of outcomes of neonates born to pregnant women diagnosed with a SARS-CoV-2 infection at any stage during pregnancy, including asymptomatic women.

DATA SOURCES

MEDLINE, Embase, Global Health, WHOLIS and LILACS databases, last searched on 28 July 2021.

ELIGIBILITY CRITERIA

Case-control and cohort studies published after 1 January 2020, including preprint articles were included. Study outcomes included neonatal mortality and morbidity, preterm birth, caesarean delivery, small for gestational age, admission to neonatal intensive care unit, level of respiratory support required, diagnosis of culture-positive sepsis, evidence of brain injury, necrotising enterocolitis, visual or hearing impairment, neurodevelopmental outcomes and feeding method. These were selected according to a core outcome set.

DATA EXTRACTION AND SYNTHESIS

Data were extracted into Microsoft Excel by two researchers, with statistical analysis completed using IBM SPSS (Version 27). Risk of bias was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

The search returned 3234 papers, from which 204 were included with a total of 45 646 infants born to mothers with SARS-CoV-2 infection during pregnancy across 36 countries. We found limited evidence of an increased risk of some neonatal morbidities, including respiratory disease. There was minimal evidence from low-income settings (1 study) and for neonatal outcomes following first trimester infection (17 studies). Neonatal mortality was very rare. Preterm birth, neonatal unit admission and small for gestational age status were more common in infants born following maternal SARS-CoV-2 infection in pregnancy in most larger studies.

CONCLUSIONS

There are limited data on neonatal morbidity and mortality following maternal SARS-CoV-2 infection, particularly from low-income countries and following early pregnancy infections. Large, representative studies addressing these outcomes are needed to understand the consequences for babies born to women with SARS-CoV-2.

PROSPERO REGISTRATION NUMBER

CRD42021249818.

Impact of the COVID-19 pandemic on maternal mental health, early childhood development, and parental practices: a global scoping review

BACKGROUND

In March 2020, the COVID-19 outbreak was declared a pandemic by the World Health Organization (WHO), generating stark economic and social repercussions that directly or indirectly affected families' wellbeing and health status.

AIMS

This review aims at mapping the existing evidence on the impact of the COVID-19 pandemic on maternal mental health, early childhood development, and parental practices, worldwide, to identify evidence gaps and better inform future delivery of care and health policy measures.

METHODS

Following the protocol defined by PRISMA-ScR, this scoping review has searched for relevant studies published between January 2020 and June 2021, selecting evidence sources based on pre-established criteria. From a total of 2,308 articles, data were extracted from 537 publications from 35 countries on all three health domains.

RESULTS

The combined stressors brought forth by the pandemic have exerted a heavy burden on the mental health of mothers and the development of young children, partly mediated by its impact on parental practices.

CONCLUSIONS

Despite remaining gaps, we have identified sufficient evidence pointing to an urgent need for more concerted global research efforts and rapid policy responses to timely address severe and pervasive negative impacts to the mental health of mothers and children at a key developmental stage.

Records of antibodies in breast milk in postpartum women who have been vaccinated or exposed to COVID-19: A systematic review

Background: Breast milk is a critical element in developing a baby's immunity through immune transfer. Antibodies are an essential unit of immunity against infection with the SARS-CoV-2 virus. This paper explores antibodies in breast milk in postpartum women who have been vaccinated or exposed to coronavirus disease 2019 (COVID-19). Duration of antibody appearance was studied to determine the adequate time in transferring antibodies by breastfeeding. Methods: Three databases, PubMed, Google Scholar, and ScienceDirect, were used as sources of articles. Inclusion criteria applied in selecting articles were prospective observational study or experimental design study in English, evaluating antibodies in breast milk, and conducted between 2019-2021. Article quality and risk of bias were assessed with Critical Appraisal Skills Programme (CASP). The data found were synthesized in a narrative manner. Results: This systematic review included 20 articles. A total of 306 postpartum women who were infected with COVID-19, 20 postpartum women who had viral symptoms and 495 postpartum women who had been vaccinated were studied. Immunoglobulin A (IgA) and immunoglobulin G (IgG) antibodies were found in the breast milk of infected and vaccinated postpartum women. SARS CoV-2 infection is associated with the presence of IgA dominant, whereas vaccination is related to the presence of IgG dominant. Antibodies persisted from day 10 of onset to 10 months in infected postpartum women and started from three days to six weeks in vaccinated postpartum women. Meta-analysis could not be carried out due to the variety of articles. Conclusions: Antibodies found in breast milk in infected and vaccinated postpartum women have different dominant types. Further research needs to be done regarding the mechanism of antibody transfer in breast milk, longer research duration and studies that directly examine the comparison of antibodies in breast milk in vaccinated and infected postpartum women. Registration: PROSPERO ( CRD42022340859, 23 June 2022).

Impact of Coronavirus Disease-2019 on Hospital Care for Neonatal Opioid Withdrawal Syndrome

OBJECTIVE

To compare prenatal exposures, hospital care processes, and hospitalization outcomes for opioid-exposed newborns before and during the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

In this multicenter retrospective analysis, data were collected from 19 Massachusetts hospitals, including 5 academic and 14 community hospitals. The pre-COVID-19 cohort was defined as births occurring during March 1, 2019-February 28, 2020, and the COVID-19 cohort was defined as births occurring during March 1, 2020-December 31, 2020. Opioid-exposed newborns born at ≥35 weeks of gestation were included. Differences in prenatal substance exposures, hospital care processes, and neonatal opioid withdrawal syndrome (NOWS) outcomes, including pharmacologic treatment for NOWS (PharmTx), length of stay (LOS), and as-needed (prn) treatment failure rates, were evaluated.

RESULTS

There were 663 opioid-exposed newborns in the pre-COVID-19 group and 476 in the COVID-19 group. No between-group differences were seen in prenatal substance exposures or the need for PharmTx. Compared with the pre-COVID-19 group, in the COVID-19 group there was less rooming-in after maternal discharge (53.8% vs 63.0%; P = .001) and less care in the pediatric unit setting (23.5% vs 25.3%; P = .001), longer LOS (adjusted risk ratio, 1.04; 95% CI, 1.01-1.08), and a higher rate of breast milk receipt at discharge (aOR, 2.03; 95% CI, 1.22-3.39). Within the subset of academic centers, more infants failed prn treatment in the COVID-19 group (53.8% vs 26.5%, P = .02; aOR, 3.77; 95% CI, 0.98-14.5).

CONCLUSIONS

Among the hospitals in our collaborative, hospital processes for NOWS, including care setting, rooming-in, and LOS were negatively impacted in the COVID-19 group, particularly in academic medical centers.

Detectable SARS-CoV-2 in Human Breast Milk: A Turkey Experience

Breastfeeding is considered the strongest postnatal bond between mother and baby and is the best source of nutrition that has implications for infant health and development. However, the global COVID-19 epidemic process and the lack of full understanding of vertical transmission of SARS-CoV-2 have significantly reduced breastfeeding practice. The aim of this study is to investigate the presence of SARS-CoV-2 virus in the milk of lactating mothers with COVID-19 disease and to provide scientific evidence on whether breastfeeding will be safe. For this purpose, breast milk samples were collected from 60 women with COVID-19 in Şanlıurfa city of Turkey, and breast milk samples were tested for the presence of SARS-CoV-2 RNA by RT-PCRs. As a result of the analysis, SARS-CoV-2 RNA was not detected in any breast milk. According to the results obtained in this study, it was concluded that there is no evidence of mother-to-child transmission of SARS-CoV-2 through breast milk and that mothers can safely breastfeed their children in this process. We think that it will be possible with more in-depth analyzes and comprehensive studies to fully understand whether the SARS-CoV-2 virus is transmitted to infants through breast milk.

Recommendations for breastfeeding during Coronavirus Disease 2019 (COVID-19) pandemic

Background

Coronavirus Disease 2019 (COVID-19) has spread worldwide. The safety of breastfeeding of SARS-CoV-2-positive women has not yet reached a consensus among the scientific community, healthcare providers, experts in lactation care, health organizations and governments. This study was conducted to summarize the latest evidence about the safety of breastfeeding among suspected/confirmed infected mothers and to summarize the recommendations on breastfeeding during COVID-19 from different organizations.

Methods

A comprehensive literature review of publications about the safety of breastfeeding among SARS-CoV-2-infected mothers was conducted. Scientific databases were searched up to 26 May 2021. The evidence was summarized into five perspectives according to a framework proposed by van de Perre et al. with certain modifications. Moreover, websites of different health organizations were visited to gather the recommendations for breastfeeding.

Results

The current evidence demonstrated that the majority of infants breastfed by infected mothers were negative for SARS-CoV-2. Breast milk samples from suspected/infected mothers mainly demonstrated negative results in SARS-CoV-2 viral tests. There was insufficient evidence proving the infectivity of breast milk from infected mothers. Recent studies found other transmission modalities (e.g., milk containers, skin) associated with breastfeeding. Specific antibodies in the breast milk of infected mothers were also found, implying protective effects for their breastfed children. According to van de Perre’s criteria, the breast milk of infected mothers was unlikely to transmit SARS-CoV-2. Owing to the low quality of the current evidence, studies with a more robust design are needed to strengthen the conclusion regarding the safety of breastfeeding. Further studies to follow up the health status of infants who were directly breastfed by their suspected/infected mothers, to collect breast milk samples at multiple time points for viral tests and to examine specific antibodies in breast milk samples are warranted. Current recommendations on breastfeeding during COVID-19 from different organizations are controversial, while direct breastfeeding with contact precautions is generally suggested as the first choice for infected mothers.

Conclusions

This review determined the safety of breastfeeding and identified the focus for further research during the COVID-19 pandemic. Recommendations on breastfeeding are suggested to be updated in a timely manner according to the latest evidence.

SARS-CoV-2 RNA and antibody detection in breast milk from a prospective multicentre study in Spain

OBJECTIVES

To develop and validate a specific protocol for SARS-CoV-2 detection in breast milk matrix and to determine the impact of maternal SARS-CoV-2 infection on the presence, concentration and persistence of specific SARS-CoV-2 antibodies.

DESIGN AND PATIENTS

This is a prospective, multicentre longitudinal study (April-December 2020) in 60 mothers with SARS-CoV-2 infection and/or who have recovered from COVID-19. A control group of 13 women before the pandemic were also included.

SETTING

Seven health centres from different provinces in Spain.

MAIN OUTCOME MEASURES

Presence of SARS-CoV-2 RNA in breast milk, targeting the N1 region of the nucleocapsid gene and the envelope (E) gene; presence and levels of SARS-CoV-2-specific immunoglobulins (Igs)-IgA, IgG and IgM-in breast milk samples from patients with COVID-19.

RESULTS

All breast milk samples showed negative results for presence of SARS-CoV-2 RNA. We observed high intraindividual and interindividual variability in the antibody response to the receptor-binding domain of the SARS-CoV-2 spike protein for each of the three isotypes IgA, IgM and IgG. Main Protease (MPro) domain antibodies were also detected in milk. 82.9% (58 of 70) of milk samples were positive for at least one of the three antibody isotypes, with 52.9% of these positive for all three Igs. Positivity rate for IgA was relatively stable over time (65.2%-87.5%), whereas it raised continuously for IgG (from 47.8% for the first 10 days to 87.5% from day 41 up to day 206 post-PCR confirmation).

CONCLUSIONS

Our study confirms the safety of breast feeding and highlights the relevance of virus-specific SARS-CoV-2 antibody transfer. This study provides crucial data to support official breastfeeding recommendations based on scientific evidence. Trial registration number NCT04768244.

SARS-CoV-2 RNA and antibody detection in breast milk from a prospective multicentre study in Spain

OBJECTIVES

To develop and validate a specific protocol for SARS-CoV-2 detection in breast milk matrix and to determine the impact of maternal SARS-CoV-2 infection on the presence, concentration and persistence of specific SARS-CoV-2 antibodies.

DESIGN AND PATIENTS

This is a prospective, multicentre longitudinal study (April-December 2020) in 60 mothers with SARS-CoV-2 infection and/or who have recovered from COVID-19. A control group of 13 women before the pandemic were also included.

SETTING

Seven health centres from different provinces in Spain.

MAIN OUTCOME MEASURES

Presence of SARS-CoV-2 RNA in breast milk, targeting the N1 region of the nucleocapsid gene and the envelope (E) gene; presence and levels of SARS-CoV-2-specific immunoglobulins (Igs)-IgA, IgG and IgM-in breast milk samples from patients with COVID-19.

RESULTS

All breast milk samples showed negative results for presence of SARS-CoV-2 RNA. We observed high intraindividual and interindividual variability in the antibody response to the receptor-binding domain of the SARS-CoV-2 spike protein for each of the three isotypes IgA, IgM and IgG. Main Protease (MPro) domain antibodies were also detected in milk. 82.9% (58 of 70) of milk samples were positive for at least one of the three antibody isotypes, with 52.9% of these positive for all three Igs. Positivity rate for IgA was relatively stable over time (65.2%-87.5%), whereas it raised continuously for IgG (from 47.8% for the first 10 days to 87.5% from day 41 up to day 206 post-PCR confirmation).

CONCLUSIONS

Our study confirms the safety of breast feeding and highlights the relevance of virus-specific SARS-CoV-2 antibody transfer. This study provides crucial data to support official breastfeeding recommendations based on scientific evidence. Trial registration number NCT04768244.

Titres and neutralising capacity of SARS-CoV-2-specific antibodies in human milk: a systematic review

OBJECTIVE

Synthesise evidence on production of SARS-CoV-2 antibodies in human milk of individuals who had COVID-19, and antibodies' ability to neutralise SARS-CoV-2 infectivity.

DESIGN

A systematic review of studies published from 1 December 2019 to 16 February 2021 without study design restrictions.

SETTING

Data were sourced from PubMed, MEDLINE, Embase, CNKI, CINAHL and WHO COVID-19 database. Search was also performed through reviewing references of selected articles, Google Scholar and preprint servers. Studies that tested human milk for antibodies to SARS-CoV-2 were included.

PATIENTS

Individuals with COVID-19 infection and human milk tested for anti-SARS-CoV-2 neutralising antibodies.

MAIN OUTCOME MEASURES

The presence of neutralising antibodies in milk samples provided by individuals with COVID-19 infection.

RESULTS

Individual participant data from 161 persons (14 studies) were extracted and re-pooled. Milk from 133 (82.6%) individuals demonstrated the presence of anti-SARS-CoV-2 immunoglobulin A (IgA), IgM and/or IgG. Illness severity data were available in 146 individuals; 5 (3.4%) had severe disease, 128 (87.7%) had mild disease, while 13 (8.9%) were asymptomatic. Presence of neutralising antibodies in milk from 20 (41.7%) of 48 individuals neutralised SARS-CoV-2 infectivity in vitro. Neutralising capacity of antibodies was lost after Holder pasteurisation but preserved after high-pressure pasteurisation.

CONCLUSION

Human milk of lactating individuals after COVID-19 infection contains anti-SARS-CoV-2-specific IgG, IgM and/or IgA, even after mild or asymptomatic infection. Current evidence demonstrates that these antibodies can neutralise SARS-CoV-2 virus in vitro. Holder pasteurisation deactivates SARS-CoV-2-specific IgA, while high-pressure pasteurisation preserves the SARS-CoV-2-specific IgA function.

[Recommendations for SARS-CoV-2/COVID-19 during Pregnancy, Birth and Childbed - Update November 2021 (Short Version)]

Since the onset of the SARS-CoV-2 pandemic, the German Society of Gynecology and Obstetrics and the Society for Peri-/Neonatal Medicine have published and repeatedly updated recommendations for the management of SARS-CoV-2 positive pregnancies and neonates. As a continuation of existing recommendations, the current update addresses key issues related to the prenatal, perinatal, and postnatal care of pregnant women, women who have recently given birth, women who are breastfeeding with SARS-CoV-2 and COVID-19, and their unborn or newborn infants, based on publications through September 2021. Recommendations and opinions were carefully derived from currently available scientific data and subsequently adopted by expert consensus. This guideline - here available in the short version - is intended to be an aid to clinical decision making. Interpretation and therapeutic responsibility remain with the supervising local medical team, whose decisions should be supported by these recommendations. Adjustments may be necessary due to the rapid dynamics of new evidence. The recommendations are supported by the endorsement of the professional societies: German Society for Perinatal Medicine (DGPM), German Society of Gynecology and Obstetrics (DGGG), German Society for Prenatal and Obstetric Medicine (DGPGM), German Society for Pediatric Infectiology (DGPI), Society for Neonatology and Pediatric Intensive Care Medicine (GNPI).

Nursing care recommendation for pediatric COVID-19 patients in the hospital setting: A brief scoping review

BACKGROUND

The hospitalization of children during the COVID-19 pandemic has affected their physical and mental health. Pediatric nurses have faced challenges in providing high-quality nursing care for children and their families. However, the pediatric nursing care recommendations for COVID-19 patients in the hospital setting remain unclear. The current scoping review provides recommendations for nursing interventions for pediatric COVID-19 patients in the hospital setting.

METHODS AND FINDINGS

The selected articles containing management and nursing recommendations for COVID-19 that have occurred in pediatric patients ages 0-19 years old. A search strategy was developed and implemented in seven databases. We included peer-reviewed articles that reported observational or interventional studies, as well as policy papers, guides or guidelines, letters and editorials, and web articles. A total of 134 articles and other documents relevant to this review were included. We categorized the results based on The Nursing Intervention Classification (NIC) taxonomy which consists of six domains (e.g., Physiological: Basic); eleven classes (e.g., Nutrition Support); and eighteen intervention themes (e.g., Positioning, Family Presence Facilitation, Family Support, and Discharge Planning).

CONCLUSION

Apart from the intervention of physical problems, there is a need to promote patient- and family-centered care, play therapy, and discharge planning to help children and families cope with their new situation.

Association of Human Milk Antibody Induction, Persistence, and Neutralizing Capacity With SARS-CoV-2 Infection vs mRNA Vaccination

Importance

Long-term effect of parental COVID-19 infection vs vaccination on human milk antibody composition and functional activity remains unclear.

Objective

To compare temporal IgA and IgG response in human milk and microneutralization activity against SARS-CoV-2 between lactating parents with infection and vaccinated lactating parents out to 90 days after infection or vaccination.

Design, Setting, and Participants

Convenience sampling observational cohort (recruited July to December 2020) of lactating parents with infection with human milk samples collected at days 0 (within 14 days of diagnosis), 3, 7, 10, 28, and 90. The observational cohort included vaccinated lactating parents with human milk collected prevaccination, 18 days after the first dose, and 18 and 90 days after the second dose.

Exposures

COVID-19 infection diagnosed by polymerase chain reaction within 14 days of consent or receipt of messenger RNA (mRNA) COVID-19 vaccine (BNT162b2 or mRNA-1273).

Main Outcomes and Measures

Human milk anti-SARS-CoV-2 receptor-binding domain IgA and IgG and microneutralization activity against live SARS-CoV-2 virus.

Results

Of 77 individuals, 47 (61.0%) were in the infection group (mean [SD] age, 29.9 [4.4] years), and 30 (39.0%) were in the vaccinated group (mean [SD] age, 33.0 [3.4] years; P = .002). The mean (SD) age of infants in the infection and vaccinated group were 3.1 (2.2) months and 7.5 (5.2) months, respectively (P < .001). Infection was associated with a variable human milk IgA and IgG receptor-binding domain-specific antibody response over time that was classified into different temporal patterns: upward trend and level trend (33 of 45 participants [73%]) and low/no response (12 of 45 participants [27%]). Infection was associated with a robust and quick IgA response in human milk that was stable out to 90 days after diagnosis. Vaccination was associated with a more uniform IgG-dominant response with concentrations increasing after each vaccine dose and beginning to decline by 90 days after the second dose. Vaccination was associated with increased human milk IgA after the first dose only (mean [SD] increase, 31.5 [32.6] antibody units). Human milk collected after infection and vaccination exhibited microneutralization activity. Microneutralization activity increased throughout time in the vaccine group only (median [IQR], 2.2 [0] before vaccine vs 10 [4.0] after the first dose; P = .003) but was higher in the infection group (median [IQR], 20 [67] at day 28) vs the vaccination group after the first-dose human milk samples (P = .002). Both IgA and non-IgA (IgG-containing) fractions of human milk from both participants with infection and those who were vaccinated exhibited microneutralization activity against SARS-CoV-2.

Conclusions and Relevance

In this cohort study of a convenience sample of lactating parents, the pattern of IgA and IgG antibodies in human milk differed between COVID-19 infection vs mRNA vaccination out to 90 days. While infection was associated with a highly variable IgA-dominant response and vaccination was associated with an IgG-dominant response, both were associated with having human milk that exhibited neutralization activity against live SARS-CoV-2 virus.

Impact of the Coronavirus Disease (COVID-19) Pandemic on Neonatal Nutrition: Focus on Low- and Middle-Income Countries

Purpose of Review

This review serves to account for the published literature regarding the changing impact of the COVID-19 pandemic with a focus on neonatal nutrition in low- and middle-income countries.

Recent Findings

Initial national and international guidelines regarding breastfeeding were often contradictory. Lack of clear guidelines resulted in separation of mother-neonate dyads and the reliance on non-human sources of milk at institutional levels. Mothers and families were less likely to initiate and/or continue breastfeed during the pandemic due to confusion regarding guidelines, lack of support for lactation, and concern for infection transmission to their neonates. Continued research in neonatal nutrition, however, continues to support the use of breastmilk as the optimal nutritional source for neonates.

Summary

Despite concerns for increased risk of COVID-19 transmission with breastfeeding, the use of breastmilk with preserved and combined mother-baby care is associated with improved neonatal nutrition.

[Recommendations for SARS-CoV-2/COVID-19 during Pregnancy, Birth and Childbed - Update November 2021 (Long Version)]

Since the onset of the SARS-CoV-2 pandemic, the German Society of Gynecology and Obstetrics and the Society for Peri-/Neonatal Medicine have published and repeatedly updated recommendations for the management of SARS-CoV-2 positive pregnancies and neonates. As a continuation of existing recommendations, the current update addresses key issues related to the prenatal, perinatal, and postnatal care of pregnant women, women who have given birth, women who have recently given birth, women who are breastfeeding with SARS-CoV-2 and COVID-19, and their unborn or newborn infants, based on publications through September 2021. Recommendations and opinions were carefully derived from currently available scientific data and subsequently adopted by expert consensus. This guideline - here available in the long version - is intended to be an aid to clinical decision making. Interpretation and therapeutic responsibility remain with the supervising local medical team, whose decisions should be supported by these recommendations. Adjustments may be necessary due to the rapid dynamics of new evidence. The recommendations are supported by the endorsement of the professional societies: German Society for Perinatal Medicine (DGPM), German Society of Gynecology and Obstetrics (DGGG), German Society for Prenatal and Obstetric Medicine (DGPGM), German Society for Pediatric Infectiology (DGPI), Society for Neonatology and Pediatric Intensive Care Medicine (GNPI).

COVID-19 and breastfeeding: can SARS-CoV-2 be spread through lactation?

SARS-CoV-2 is a new betacoronavirus that was first reported in the Hubei province, China, in December 2019. The virus is likely transmitted through air droplets. However, there are reported cases where SARS-CoV-2-RNA was found in other samples, such as blood or stool. Nonetheless, there is limited information concerning the presence of viral RNA in pregnancy-related samples, specifically breast milk. However unlikely, there is still uncertainty regarding the possibility of vertical transmission from mother to infant through breastfeeding. This review aims to synthetize the literature written so far on this topic. Despite not being extensively researched, vertical transmission through breast milk seems unlikely. Case series showed that milk samples from mothers with COVID-19 were almost entirely negative. So far, there have been only 9 recorded cases of viral shedding in milk samples, uncertain however of the viability of the particles. Furthermore, WHO and UNICEF strongly encourage commencing breastfeeding after parturition, underlining the benefits of lactation. Moreover, some studies have proven the existence of IgG and IgA anti-SARS-CoV-2-antibodies in the maternal milk that could possibly play an important part in the neonate’s protection against the virus. Vertical transmission through lactation seems unlikely, most studies pointing towards the safety of breastfeeding. However, further larger-scale studies need to be performed in order to clarify a yet uncertain matter.

COVID-19 vaccination in pregnancy and postpartum

Pregnant women were excluded from the initial phase 3 clinical trials of COVID-19 vaccines resulting in limited data on their efficacy and safety during pregnancy and postpartum. As a result, since December 2020, there has been conflicting advice from public health, governmental, and professional authorities on this matter. From the end of 2020 up to now, some consensus guidance has been published with a prevalent precautionary approach on the administration of vaccines in pregnant women, in breastfeeding ones, or for those who are planning a pregnancy (either spontaneously or with assisted technologies). After the first few months of vaccine administration in some countries, more permissiveness seems to prevail, although with inconsistencies. Some little indicative advice, their inconsistency around the world and their changes in a short time have probably disoriented both women and their health care providers and placed the burden of decision making upon women and their health care providers without information to assist in making an informed choice. We reviewed the COVID-19 vaccination guidance for pregnant and breastfeeding women published to date and evidence from cases of unplanned pregnancy during the course of vaccine trials, preclinical experimental and observational clinical studies, and discuss their implications. In this way, we have tried to identify the safety of COVID-19 vaccines for pregnant or breastfeeding women, and their offspring.

Epitope-Specific Response of Human Milk Immunoglobulins in COVID-19 Recovered Women

The breastfeeding of infants by mothers who are infected with SARS-CoV-2 has become a dramatic healthcare problem. The WHO recommends that infected women should not abandon breastfeeding; however, there is still the risk of contact transmission. Convalescent donor milk may provide a defense against the aforementioned issue and can eliminate the consequences of artificial feeding. Therefore, it is vital to characterize the epitope-specific immunological landscape of human milk from women who recovered from COVID-19. We carried out a comprehensive ELISA-based analysis of blood serum and human milk from maternity patients who had recovered from COVID-19 at different trimesters of pregnancy. It was found that patients predominantly contained SARS-CoV-2 N-protein-specific immunoglobulins and had manifested the antibodies for all the antigens tested in a protein-specific and time-dependent manner. Women who recovered from COVID-19 at trimester I-II showed a noticeable decrease in the number of milk samples with sIgA specific to the N-protein, linear NTD, and RBD-SD1 epitopes, and showed an increase in samples with RBD conformation-dependent sIgA. S-antigens were found to solely induce a sIgA1 response, whereas N-protein sIgA1 and sIgA2 subclasses were involved in 100% and 33% of cases. Overall, the antibody immunological landscape of convalescent donor milk suggests that it may be a potential defense agent against COVID-19 for infants, conferring them with a passive immunity.

COVID-19 vaccination in pregnancy and postpartum

AIM

To identify whether COVID-19 vaccines should be administered in pregnant and breastfeeding women by reviewing the guidance and other evidence.

METHODS

We reviewed the COVID-19 vaccination guidance for pregnant and breastfeeding women published to date and evidence from preclinical experimental and observational clinical studies, and discuss their implications.

RESULTS

Pregnant women were excluded from the initial phase 3 clinical trials of COVID-19 vaccines resulting in limited data on their efficacy and safety during pregnancy and postpartum. As a result, since December 2020, there has been conflicting advice from public health, governmental, and professional authorities on this matter. From the end of 2020 up to now, some consensus guidance has been published with a prevalent precautionary approach on the administration of vaccines in pregnant women, in breastfeeding ones, or for those who are planning a pregnancy (either spontaneously or with assisted technologies). After the first few months of vaccine administration in some countries, more permissiveness seems to prevail, although with inconsistencies. At the moment, the results obtained by preclinical experimental and observational clinical studies suggest that the risks of the maternal COVID-19 outweigh the undocumented and hypothetical risks of the COVID-19 vaccines in pregnancy. Also, until two viral vector COVID-19 vaccines were associated with very rare thromboembolic events, all guidance had agreed that all approved COVID-19 vaccines could be administered in pregnancy. Actually, some concern has been expressed.

CONCLUSION

COVID-19 vaccines administered in pregnancy can reduce the risk of severe COVID-19 and their serious consequences for mothers and their offspring. However, many aspects remain to be clarified.

Lung microbiota dysbiosis and the implications of SARS-CoV-2 infection in pregnancy

There are a great number of beneficial commensal microorganisms constitutively colonizing the mucosal lining of the lungs. Alterations in the microbiota profile have been associated with several respiratory diseases such as pneumonia and allergies. Lung microbiota dysbiosis might play an important role in the pathogenic mechanisms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as elicit other opportunistic infections associated with coronavirus disease 2019 (COVID-19). With its increasing prevalence and morbidity, SARS-CoV-2 infection in pregnant mothers is inevitable. Recent evidence shows that angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2) act as an entry receptor and viral spike priming protein, respectively, for SARS-CoV-2 infection. These receptor proteins are highly expressed in the maternal-fetal interface, including the placental trophoblast, suggesting the possibility of maternal-fetal transmission. In this review, we discuss the role of lung microbiota dysbiosis in respiratory diseases, with an emphasis on COVID-19 and the possible implications of SARS-CoV-2 infection on pregnancy outcome and neonatal health.

Impact of SARS-CoV-2 Infection During Pregnancy on Infant Neurobehavioral Development: A Case-Control Study

Background: Previous studies on the pneumonia outbreak caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have focused on the general population and pregnant women, while little is known about the effects of SARS-CoV-2 on retardation during and after pregnancy. The purpose of this study was to evaluate the potential influence of SARS-CoV-2 on infant neurobehavioral development. Methods: A case-control study was conducted in Wuhan Maternal and Child Health Hospital, China. Nine pregnant women with SARS-CoV-2 infection and 9 controls matched by maternal age, parity, and status of chronic disease were included. Infantile neurobehavioral development was assessed through the Ages and Stages Questionnaires Edition 3 (ASQ-3). Results: The majority of pregnant women with SARS-CoV-2 experienced cesarean section (7 of 9), which was higher than the control group (5 of 9). The throat swabs of all newborn were negative. We found that compared with the control group, neonates of mothers with SARS-CoV-2 infection during pregnancy had lower scores in communication, gross movement, fine movement, problem solving, and personal-social domains; but only fine movement domain yielded statistical significance (P = 0.031). Conclusion: Infection with SARS-CoV-2 during pregnancy may have a certain impact on infant neurobehavioral development. Further studies with larger sample size are warranted for validation.