Breastfeeding in COVID-19: A Pragmatic Approach

Investigating the mode of transmission of COVID-19 through genital secretions, semen, the birth canal, and lactation: A systematic review

In a global pandemic, the coronavirus has brought new challenges to reproductive and sexual health. This systematic review has been conducted with the aim of investigating a) the transmission of coronavirus disease 2019 (COVID-19) through female-to-male sexual secretions and vice versa, b) vertical transmission to the fetus, c) transmission to the newborn through the birth canal, and d) transmission through breast milk. In this review study, to find related articles, databases were searched using English and Persian keywords from the beginning of 2019 to the end of 2023. Based on the entry and exit criteria and the qualitative evaluation of the studies based on the STROBE criterion, the final studies were summarized. According to the initial search, 5970 articles were reviewed. After removing duplicate articles and the inappropriateness of the title, the abstract of the article was not related to the objectives of the project, there was no relevant study, and retrospective studies were excluded. Finally, 120 articles were selected as final articles. The general results show that transmission of the virus through the vagina to the blood of the fetus causing septicemia, vertical transmission from the mother to the fetus, transmission through the water bag, genital secretions, and ejaculate fluid are considered rare and ruled out. Transmission through rectal secretions during anal or oral sex requires more extensive studies. It is not possible to transmit the virus through breast milk. The long-term reproductive impact of COVID-19 on the reproductive systems of women and men is unclear.

Nurses' and Midwives' Awareness of the Recommended Breastfeeding Practices During the Pandemic of COVID-19 and the Associated Factors in Jordan

Introduction

The COVID-19-related restrictions imposed to reduce viral transmission have highlighted the need to support the importance of maternal breastfeeding. Clear guidelines for consistent practices across settings have been drawn up on the basis of the best available data. Emerging recommendations call to increase nurses' and midwives' awareness of these guidelines.

Objective

This study aimed to explore nurses' and midwives' awareness of the recommended breastfeeding practices and associated factors in Jordan during the COVID-19 pandemic.

Methods

An online descriptive cross-sectional design was adopted. This study was conducted in clinical settings representing Jordan's North, Middle, and Southern regions. One hundred seventy nurses and midwives were selected through a convenient sampling technique.

Results

The mean total score of the awareness was 7.78 (SD = 1.60); 62.9% of participants were highly aware of the recommended breastfeeding practices. Nurses and midwives who were aware of the recommended breastfeeding practices during the pandemic of COVID-19 (90.7%) were more likely to perceive COVID-19 preventive measures as effective than those who were not aware of breastfeeding practices (74.6%) (χ2  = 7.886, p = .005), while work experience in years (χ2  = 8.966, p < .01) was significantly associated with awareness of the breastfeeding recommended practices.

Conclusion

Most Jordanain nurses and midwives were highly aware of the recommended breastfeeding practices during COVID-19 pandemic. This awareness was positively associated with working experience and perceiving that the preventive measures of COVID-19 are effective. Educational programs for nurses and midwives about breastfeeding practice recommendations are necessary to help mothers obtain appropriate care and education.

Skin-to-skin contact in mothers with suspected, probable, or confirmed COVID-19

BACKGROUND

The World Health Organization recommends skin-to-skin contact (SSC) in newborns of mothers with COVID-19, applying infection prevention and control measures, and after a process of antenatal counseling on the possible risks and benefits. In this study, the reasons given for and against postnatal SSC in mothers with COVID-19 were reviewed.

METHOD

Between November and December 2020, we conducted a scoping review. Twenty-six relevant studies were identified. The results were extracted and presented narratively.

RESULTS

The reasons described for avoiding SSC have include contradictory recommendations, risk of virus transmission, impossibility of universal antepartum maternal screening for COVID-19, work overload, and ethical considerations. The reasons given for the maintenance of SSC include maternal and infant benefits of SSC, previous experiences in viral outbreaks, protection of newborns against infections, decreased contact with professionals, caregivers and surfaces, and preservation of natural processes.

CONCLUSIONS

The recommendation to allow SSC is based primarily on the acceptance that horizontal perinatal transmission is unlikely if correct hygiene precautions are taken and that the benefits of SSC outweigh the potential risks of neonatal COVID-19 infection. Knowing the reasons that have motivated the current recommendations on SSC is essential to be able to carry out an effective prenatal parental education that allows a shared decision to be made.

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.

Effect of Training Program on Knowledge and Practice of Breast feeding Women During COVID-19

Aim

Evaluate the effect of the training program on knowledge and practice of breastfeeding women during coronavirus disease 2019 (COVID-19).

Methods

One-group pretest/post-test quasiexperimental research design was utilized to accomplish the aim of this study. The study was carried out at the primary health care units Ad Dar Al Baida 1, Ad Dar Al Baida 2, Al Aziziyah at Riyadh Province of Saudi Arabia. The study included a convenience sample of 100 breastfeeding women.

Tool

A structured interviewing questionnaire sheet was used for data collection that included three parts knowledge, reported practice, and demographic characteristics.

Results

More than one-quarter (30%) and (28%) of studied women had satisfactory knowledge-related causes, risk factor and signs, symptoms of COVID-19 at preintervention, while the majority 85% and 86% of them had satisfactory knowledge postintervention at p-value <.01**. In addition, less than one-fifth (17%) and (16%) of studied women had satisfactory knowledge about Breastfeeding guidelines during COVID-19 and care of breastfeeding women during COVID-19, compared with most of them (89%) and (92%) postintervention at p-value <.01**.

Conclusion

Based on our current study, it was concluded that the educational program effectively improves breastfeeding women's knowledge and practices. There was a highly statistically significant positive linear correlation between the breastfeeding women's knowledge and reported practices regarding COVID-19 infection before and after the implementation of the educational program at p < .0.

An outbreak of infection due to severe acute respiratory corona virus-2 in a neonatal unit from a low and middle income setting

Introduction

The provision of kangaroo mother care (KMC) involving continuous skin-to-skin care (SSC) is an important intervention in neonatal care, which is recommended even when women are infected with severe acute respiratory syndrome coronavirus (SARS-CoV-2). We report on a nosocomial outbreak of SARS-CoV-2 infections in a KMC ward.

Methods

Contact tracing was conducted following the diagnosis of SARS-CoV-2 in a mother lodging in the KMC ward. All mother-newborn dyads in the KMC and healthcare workers (HCW) were tested for SARS-CoV-2 within 24-72 h of diagnosing the index case. Nasopharyngeal swab samples were obtained and tested from contacts, with a nucleic acid amplification test (NAAT) assay. Next-generation sequencing was done on positive samples. The secondary attack rate (SAR) was calculated assuming that the mother who presented with symptoms was the source of infection.

Results

Twelve (70.6%) of 17 mothers and 8 (42.1%) of 19 neonates who were in the KMC ward with the index case were found to be positive with SARS-CoV-2. Seven (87.5%) of the 8 neonates who tested positive had mothers who also tested positive. Seventy-five percent (9/12) of the mothers and 62.5% (5/8) of the neonates who tested positive were asymptomatic. Eight (27.6%) of 29 HCW were found to be positive and were all asymptomatic. One neonate died from Acinetobacter baumannii sepsis, and his post-mortem lung histopathology showed features compatible with SARS-CoV-2 pneumonia. The sequencing of 13 specimens, which included 1 mother-newborn dyad, indicated clustering to the same phylogenetic lineage with identical mutations. In assessing for factors contributing to this outbreak, it was found that spaces between beds were less than 1 m and mothers had their meals around the same table at the same time.

Conclusion

We report on a nosocomial outbreak of SARS-CoV-2 in a KMC ward, affecting a high number of mothers and neonates, and to a lesser extent HCWs. Although it is difficult to point to the index case as the source of this outbreak, as asymptomatic individuals can spread infection, the inadequate adherence to non-pharmaceutical interventions was assessed to have contributed to the spread of infection. This highlights the need for awareness and adherence to mitigation strategies to avoid SARS-CoV-2 outbreaks.

Protecting Breastfeeding during the COVID-19 Pandemic: A Scoping Review of Perinatal Care Recommendations in the Context of Maternal and Child Well-Being

The objective of this scoping review is to determine to what extent the recommendations on perinatal care protect breastfeeding during the COVID-19 pandemic. The review follows the PRISMA ScR Extension guidelines. The research was conducted in Scopus, Medline via Pubmed, and Web of Science databases from 1 March 2020 to 31 May 2021, using 392 combinations of keywords. We searched for reviews and original papers published in English providing recommendations on delivery mode, companion during labor, the possibility of skin-to-skin contact (SSC), breastfeeding, and visitors policy. After screening, 86 out of 8416 publications qualified for data extraction. The majority of them indicated that COVID-19 infection is not a sufficient reason for a cesarean section; however, on a national level, cesarean births in severely ill patients were overrepresented. A significant number of recommendations deprived mothers of the necessary support during their labor and stay in the maternity ward. A shared decision-making model was hardly visible. Only the earliest COVID-19 recommendations suspended direct breastfeeding; in later publications, decisions were related to the mother's health, but other options of natural feeding were rarely discussed.

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.

Breastfeeding in the context of the COVID-19 pandemic: A discussion paper

Breastfeeding offers one of the most fundamental global health benefits for babies. Breastmilk is lifesaving, providing not only nutrition but immunologic benefits and as such is strongly supported by the World Health Organization and leading healthcare associations worldwide. When the COVID-19 pandemic started in 2020, the impact of the restrictions to prevent the spread of the disease created challenges and questions about provision of safe, quality care, including breastfeeding practices, in a new 'normal' environment. Mothers were temporarily separated from their babies where infection was present or suspected, parents were prevented from being present on neonatal units and vital breastfeeding support was prevented. This discussion paper provides an overview of essential areas of knowledge related to practice for neonatal nurses and midwives who care for breastfeeding mothers and babies, in the context of the COVID-19 pandemic and the latest global guidance. Three areas will be discussed; the protective benefits of breastfeeding, keeping breastfeeding mothers and babies together and supporting mothers to breastfeed their babies. Finally, care recommendations are presented to serve as a summary of key points for application to practice for neonatal nurses and midwives.

Online breast-feeding support groups as a community asset in Lebanon after Beirut explosion

OBJECTIVE

Breast-feeding rates are unsatisfactory in Lebanon. Social media groups could play an important role in promoting breast-feeding in normal conditions and post crisis. The aim of this study is to identify breast-feeding challenges, facilitators and assets and to describe how community assets via social media could build community resilience to pandemic's and disaster's effects.

DESIGN

A two-phase qualitative content analysis was performed on posts and comments collected from a Facebook breast-feeding support group. Data were categorised into themes, categories and subcategories.

SETTING

Posts and comments retrieved from a Facebook breast-feeding support group in Lebanon during the month of August 2020.

PARTICIPANTS

Group members: mothers who breastfed, breast-feeding mothers and group admins that are lactation consultants.

RESULTS

In phase one, breast-feeding 'Challenges' identified were lack of support from peers and family, lack of supportive policies, lack of knowledge and maternal stress related to political instability, COVID-19 and economic crisis. 'Assets and facilitators' included community support and donations. In phase two, analysis revealed how assets were being used on social media platform to build community resilience post crisis, through access to social support in challenging times, community engagement, material resources and transformative potential.

CONCLUSION

Challenges faced during breast-feeding were diminished due to the support and assets received on a Facebook breast-feeding support group, and social media has been shown to be an important community asset implicated in empowering women to breastfeed and to build community resilience in moments of crisis.

Health care providers' awareness of breastfeeding practice recommendations during COVID-19 pandemic and associated factors in Northwest Ethiopia, 2021: A multicenter study

BACKGROUND

Prevention of coronavirus disease 2019 (COVID-19) transmission to newborns is one of the basic components of perinatal care in the era of the COVID-19 pandemic. As such, scientific evidence is compulsory for evidence-based practices. However, there was a scarcity of evidence on health care providers' awareness of breastfeeding practice recommendations during the COVID-19 pandemic in Ethiopia, particularly in the study setting.

OBJECTIVE

The study aimed at assessing healthcare providers' awareness of breastfeeding practice recommendations during the COVID-19 pandemic and associated factors among healthcare providers in northwest Ethiopia, 2021.

METHODS

A multicenter cross-sectional study was conducted among 405 healthcare providers working in hospitals of Gondar province from November 15, 2020, to March 10, 2021. A simple random sampling technique was employed to select the study subjects. Data were collected via a structured-self-administered questionnaire. EPI INFO version 7.1.2 and SPSS version 25 were used for data entry and analysis respectively. Binary logistic regression analyses were done to identify associated factors and the adjusted odds ratio (AOR) with its 95% confidence interval (CI) at a p-value of <0.05 was used to declare significant association.

RESULTS

The healthcare providers' awareness of breastfeeding practice recommendations during the COVID-19 pandemic was 40.7% (95% CI: 35.9, 45.6). Working in a tertiary hospital (AOR = 3.69; 95% CI: 2.24, 6.08), using COVID-19 guideline updates (AOR = 3.34; 95% CI: 2.1, 5.3), being trained on COVID-19 (AOR = 2.78; 95% CI: 1.74, 4.47), owning a smartphone and/or a computer (AOR = 2.26; 95% CI: 1.39, 3.68), and perceiving that COVID-19 is dangerous (AOR = 1.78; 95% CI: 1.05, 3.01) were factors positively associated with healthcare providers' awareness of breastfeeding practice recommendations during the pandemic of COVID-19.

CONCLUSION

Only two in five healthcare providers were aware of recommendations on breastfeeding practice during the COVID-19 pandemic and related to information of accessibility information on COVID-19. Therefore, expanding COVID-19 related information through the provision of COVID-19 training and guidelines to all levels of hospitals would improve health care providers' awareness of breastfeeding practice recommendations amid the COVID-19 pandemic.

Clinical Characteristics of Newborn Infants Delivered to Pregnant Women With Laboratory-Confirmed COVID-19: A Single-Center Experience From Saudi Arabia

Introduction

In Saudi Arabia and countries around the world, clinical health practice has been transformed by the coronavirus 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During the early days of the pandemic, it was a major challenge to care for pregnant women with laboratory-confirmed COVID-19 and their newborn infants. In this article, we share our experience in the management of newborn infants delivered to mothers with laboratory-confirmed COVID-19.

Methods

A prospective single-center observational study was conducted at King Abdulaziz Medical City in Jeddah, National Guard Health Affairs, Saudi Arabia. Data collection started in March 2020 and was completed in October 2020. The inclusion criteria included mothers with laboratory-confirmed COVID-19 and their newborn infants.

Results

A total of 45 pregnant women with polymerase chain reaction (PCR)-confirmed COVID-19 were included in the study. Their mean age was 30.23±5.92 years. The mode of delivery was spontaneous vaginal delivery in 27 women (60%), cesarean section in 15 women (33.3%), and assisted vaginal delivery in three women (6.7%). Three mothers (6.7%) required intensive care unit admission. A total of 45 babies were born and 25 were females (55.6%), 20 males (44.4%). None of the babies had specific symptoms related to COVID-19. All babies were tested negative on the two COVID-19 nasopharyngeal swabs. Babies were initially admitted to the NICU and one baby required prolonged NICU stay due to extreme prematurity (23 weeks), one baby died due to hypoxic-ischemic encephalopathy and respiratory distress syndrome, and the remaining babies were discharged home in a stable condition.

Conclusion

Our experience suggests that maternal outcomes are generally favorable and no difference between vaginal and cesarean delivery in the risk of virus transmission. With strict implementation of infection prevention measures, mother-to-infant transmission is very unlikely. Early bathing of the newborn infant is preferred to reduce the risk of transmission of infection to newborn infants and the hospital staff. Breastfeeding is safe if performed under strict infection prevention measures.

Baby Friendly Hospital Initiative Breastfeeding Outcomes in Mothers with COVID-19 Infection During the First Weeks of the Pandemic in Spain

BACKGROUND

Adherence to the Ten Steps of the Baby-Friendly Hospital Initiative has been shown to have a protective role for the initiation and maintenance of breastfeeding.

RESEARCH AIMS

(1) To determine the breastfeeding rate during the first 6 months of life in children of mothers diagnosed with COVID-19 infection at the time of birth; and (2) to assess the possible influence of being born in a center with Baby-Friendly Hospital Initiative accreditation.

METHODS

This was a two-group comparative longitudinal observational study of infants born to mothers with COVID-19 at the time of birth, between March 13-May 31, 2020 (the first wave of the pandemic) in Spain. Fourteen Spanish hospitals participated, five (35.7%) were Baby-Friendly Hospital Initiative accredited. Type of feeding was assessed prospectively at discharge, 1, 3, and 6 months of age. A total of 248 newborns were included in the study.

RESULTS

A total of 117 (47.3%) newborns were born in Baby-Friendly Hospital Initiative (BFHI) accredited centers. These centers applied skin-to-skin contact with greater probability (OR = 1.9; 95% CI [1.18, 3.29]) and separated the newborns from their mothers less frequently (OR = 0.46; 95% CI [0.26, 0.81]) than non-accredited centers. No differences were observed in relation to the presence of a companion at the time of birth. At discharge, 49.1% (n = 57) of newborns born in BFHI-accredited centers received exclusive breastfeeding versus 35.3% (n = 46) in non-accredited centers (p = .03). No differences were observed in breastfeeding rates throughout follow-up.

CONCLUSIONS

The exclusive breastfeeding rate at discharge in children of mothers with COVID-19 infection at birth was higher in Baby-Friendly Hospital Initiative accredited centers, which most frequently applied skin-to-skin contact at birth as well as rooming-in.

The breastfeeding experiences of COVID-19-positive women: A qualitative study in Turkey

Aim

The aim of the study was to determine the breastfeeding experiences of COVID‐19‐positive women.

Methods

This was a qualitative study of 14 women diagnosed with COVID‐19. One‐to‐one telephone interviews were conducted and recorded. The data were analyzed thematically.

Results

Three main themes were identified. Theme 1 was “increased emotional load,” outlining the emotional effects of the disease in the women, such as feeling sad and inadequate, in addition to anxiety and fear. Theme 2 was “breastfeeding during the disease,” which illustrated the effects of the treatment process on the women, the disease‐related symptoms, their influence on breastfeeding attitudes and behavior, and the effects of social media and television. Theme 3 was “perceived social support and need,” defining the social support perceived and expected by the women during isolation with needs.

Conclusion

Women who could not get the professional support they expected had to face the difficult choice between taking medical treatment and breastfeeding. Many women refused drug treatment for COVID‐19 and continued to breastfeed with all the resultant emotional and physical difficulties, as they believed in the benefits of mother's milk. The experiences of the women were discussed with an approach that enabled developing health care services further. It was concluded that Turkish health care professionals need to develop an evidence‐based and female‐centered approach for COVID‐19 management in breastfeeding women.

COVID-19 guidelines for pregnant women and new mothers: A systematic evidence review

BACKGROUND

Nearly a year after COVID-19 was initially detected, guidance for pregnant and new mothers remains varied.

OBJECTIVE

The goal of this systematic review is to summarize recommendations for three areas of maternal and fetal care-breastfeeding, post-partum social distancing, and decontamination.

SEARCH STRATEGY

We searched PubMed, Embase and Web of Science spanning from inception to November 9, 2020.

SELECTION CRITERIA

Articles were included if they focused on COVID-positive mothers, commented on at least one of the three areas of interest, and were published in English.

DATA COLLECTION AND ANALYSIS

Our combined database search yielded 385 articles. After removing duplicates and articles that did not cover the correct populations or subject matter, a total of 74 articles remained in our analysis.

MAIN RESULTS

Most articles recommended direct breastfeeding with enhanced precaution measures. Recommendations regarding post-partum social distancing varied, although articles published more recently often recommended keeping the mother and newborn in the same room when possible. Decontamination recommendations emphasized mask wearing, good hand hygiene, and proper cleaning of surfaces.

CONCLUSION

In general, there was a focus on shared decision making when approaching topics such as breastfeeding and post-partum social distancing. Guidelines for decontamination were fairly uniform.