Breastfeeding is the cornerstone of infant and young child survival, nutrition and development and maternal health.
The World Health Organization recommends exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with appropriate complementary foods for up to 2 years and beyond.1
Early and uninterrupted skin-to- skin contact, rooming-in2 and kangaroo mother care3 also significantly improve neonatal survival and reduce morbidity and are recommended by WHO.
However, concerns have been raised about whether mothers with COVID-19 can transmit the SARS-CoV-2 virus to their infant or young child through breastfeeding. Recommendations on mother-infant contact and breastfeeding must be based on a full consideration of not only of the potential risks of COVID-19 infection of the infant, but also the risks of morbidity and mortality associated with not breastfeeding, the inappropriate use of infant formula milks, as well as the protective effects of skin-to-skin contact.
This scientific brief examines the evidence to date on the risks of transmission of COVID-19 from an infected mother to her baby through breastfeeding as well as evidence on the risks to child health from not breastfeeding.
WHO recommends that mothers with suspected or confirmed COVID-19 should be encouraged to initiate or continue to breastfeed. Mothers should be counselled that the benefits of breastfeeding substantially outweigh the potential risks for transmission.
Mother and infant should be enabled to remain together while rooming-in throughout the day and night and to practice skin-to-skin contact, including kangaroo mother care, especially immediately after birth and during establishment of breastfeeding, whether they or their infants have suspected or confirmed COVID-19.
A living systematic review of evidence that followed the procedures of the Cochrane handbook for systematic reviews of interventions was carried out with the latest search done on 15 May 2020 to identify studies including mothers with suspected or confirmed COVID-19 and their infants or young children.
The search was conducted on Cochrane Library, EMBASE (OVID), PubMed (MEDLINE), Web of Science Core Collection (Clarivate Analytics) and the WHO Global Database. A total of 12,198 records were retrieved, 6945 were screened after removing duplicates, and 153 records with mother-infant dyads in which the mother had COVID-19 were included in full-text review.
A total of 46 mother-infant dyads had breastmilk samples tested for COVID-19. All mothers had COVID-19, while 13 infants tested COVID-19 positive. Breastmilk samples from 43 mothers were negative for the COVID-19 virus while samples from 3 mothers tested positive for viral particles by RT-PCR. Among the 3 infants whose mothers’ breastmilk tested positive for virual RNA particles, not live virus, one infant tested positive for COVID-19 but infant feeding practices were not reported. The two other infants tested negative for COVID-19; one was breastfed, and the other newborn was fed expressed breast milk after viral RNA particles were no longer detected. In the single child with COVID-19, it was unclear through which route or source the infant became infected, i.e. through breastmilk or droplet from close contact with the infected mother.
A preprint article reported secretory immunoglobulin A (sIgA) immune response against the COVID-19 virus found in 12 of 15 breastmilk samples from mothers with COVID-19.
The implications of this finding on the effect, duration and protection against COVID-19 for the child was not addressed.
To date, studies of mother-infant dyads with data on feeding practices and COVID-19 infection have come from case reports, case series or a report of a family cluster. Other study designs such as cohort studies or case-control studies were eligible for inclusion, but none were identified. We are thus unable to measure and compare risks of infection based on feeding practices.
Although 1 of the 3 infants of mothers with viral particles in breast milk had COVID-19, it was unclear through which route or source the infant was infected, i.e., through breastfeeding or close contact with the mother or other infected person. RT-PCR detects and amplifies viral genetic material in samples, such as breastmilk, but does not provide information on viability or infectivity of the virus. Documented presence of replicative COVID-19 virus in cell culture from breast milk and infectivity in animal models are needed to consider breast milk as potentially infectious.
The presence of IgA in breast milk is one of the ways in which breastfeeding protects infants against infection and death. IgA antibodies with reactivity to the COVID-19 virus have been detected in breastmilk of mothers previously infected with COVID-19 but their strength and durability have not yet been adequately studied to address protection from COVID-19 among breastfed infants.