BREASTFEEDING SUPPORT DURING COVID-19 PANDEMIC
Written by: Tope Awelewa MBCHB, MPH, FAAP, IBCLC. Iowa AAP Chapter Breastfeeding Coordinator
Updated March 21, 2020
Why mothers need to breastfeed during a pandemic:
• Research has shown that breastfeeding is the optimum nutrition option for most infants especially during a viral pandemic crisis.1,2 Breast milk protects babies from infections with natural bioactive antibodies and targeted immunologic factors, hence, breastfed infants are less likely to have severe respiratory symptoms.1,3 Unlike formula, breast milk is readily available and reduces maternal anxiety about potential formula shortage and contamination during formula preparation. The release of oxytocin during breastfeeding promotes maternal wellness, relieves stress and anxiety. It is important that infants continue to breastfeed, or at the least, feed expressed breast milk when breastfeeding is not achievable. However, a pandemic crisis can make effective and continued breastfeeding difficult when there is a lot of anxiety about virus transmission and when sick caregivers must be separated from their infants. Healthcare providers have a unique role in supporting the breastfeeding dyad, ensuring optimization of breastfeeding benefits, and maintenance of maternal breast milk supply.4
Safety of breastfeeding and breast milk feeding during COVID-19 pandemic:5
• Per the CDC interim guidance5, person to person spread is mainly through respiratory droplets when an infected person coughs or sneezes. It is yet to be established that mothers can transmit the virus via breast milk. Available studies have shown that the virus is not detected in breast milk similar to another severe acute respiratory syndrome Corona Virus (SARS-CoV).5,6
• The decision to self- isolate, breastfeed or feed an infant expressed breast milk should be made in conjunction with the family respecting mother’s feeding desires.
• An infected mother or person under investigation (PUI) should exercise all caution to prevent the potential spread of the virus through respiratory droplet control measures including hand hygiene, maintenance of respiratory etiquettes and wearing of facemasks around the infant. Maintaining a distance of at least 6 feet from the infant, along with the use of physical barriers like curtains may be helpful in containing transmission when colocation is desired by the family.4
• An infected symptomatic mother can pump or express breast milk to establish and maintain supply while having a healthy caregiver give the baby the expressed breast milk. Cleaning of breast pump parts should continue to follow recommended CDC guidelines for proper cleaning and thorough disinfection of pump parts after each use.
• An infected symptomatic mother who desires to breastfeed should adhere strictly to previously described respiratory droplet control measures with hand hygiene and use of facemasks.
• An infected symptomatic mother or PUI can reduce transmission of the virus to the baby by self-isolating and enlisting the help of healthy caregivers to feed and take care of the baby until fever-free without use of antipyretics for at least 72 hours AND other symptoms of COVID-19 are subsiding AND at least 7 days have lapsed from the onset of symptoms.5
• All caregivers should wash hands before touching bottles, feeding or caring for the infant.
• A lot of information is evolving on COVID-19, please refer to the CDC website for updated guidance on breastmilk feeding by confirmed mothers with COVID-19.5
What mothers can do to protect breastfeeding and infants from COVID-19 infection:
• Wash your hands with soap and water for at least 20 seconds before touching your infant or feeding. Use an alcohol-based hand sanitizer with at least 60% alcohol when water is not available. Avoid touching your face, eyes, nose or mouth with unwashed hands.
• Clean visibly soiled or potentially contaminated surfaces to protect infants from infection.
• If you are sick and need to be separated from your baby, pump to empty your breast to maintain supply. Hands on pumping and hand expression is especially helpful in the first few days postpartum to establish breastmilk production. Pumping should occur about every 3 hours during the daytime and preferably no longer than 5 hours at night to maintain supply.
• If you feel sick, practice respiratory etiquette, cough or sneeze in your sleeve or disposable tissue. Dispose of any tissues used immediately. Call your health care provider’s office if you have a fever, cough, difficulty with breathing or if you feel you may have been exposed to someone with COVID-19.
• Community spread has been confirmed in Iowa, so mothers should practice social distancing avoiding public spaces and maintaining a six-feet distance whenever possible from contacts.
• Pregnant women, and nursing mothers should avoid close contact with anyone with respiratory symptoms. Mothers should avoid close contacts with individuals with probable COVID-19.
• Mothers should practice healthy habits to reduce stress as much as possible with adequate sleep, healthy eating and regular exercise. For more information, watch this helpful video on maximizing breastmilk supply: https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html
What healthcare providers can do to promote breastfeeding during a pandemic:
• Inform caregivers of measures to protect breastfeeding infants from contracting COVID-19.5
• Encourage attachment in the first hour of life and keep babies as close to their mothers as possible with skin to skin contact when this is not contraindicated. Helpful videos are available on First Droplets website at: www.firstdroplets.com
• Promote exclusive breastfeeding for the first six months with supplementation thereafter; continued breastfeeding for at least 12 months and longer as desired by both mother and child.1
• Assist mothers to troubleshoot common breastfeeding difficulties and provide reasonable expectations about breastfeeding in first few weeks postpartum.7
• Show mothers signs of effective latch and milk transfer. Nipple pain is often an indication of an inappropriate attachment. Helpful videos available on: https://globalhealthmedia.org/videos
• Teach mothers how to assess hydration and nutritional status with number of wet diapers (one per day of life until day 6); stool consistency (stools should transition from meconium on days 1 to 2 to brownish and yellow seedy on days 3 to 5); and stool frequency (one per day of life and at least 3 stools by Day 3 of life) in the first week of life.3,7
• Providers can conduct test weights, pre- and post-feeding to objectively assess effectiveness of breastfeeding sessions and milk transfer. A subjective sense of breast fullness pre-feeding and breast emptiness after a breastfeed could be indicative of milk transfer during a feeding session.
• Babies should feed with cues for about 8-12 times in a 24hour period. If feeding expressed breast milk, feeding volumes should be about 100kcal/kg/day or 150ml/kg/day by one week of life using birth weight.
• Recommend paced bottle feeding to mimic feeding at the breast and for easy transition from bottle to breastfeeding when bottle feeding. Watch IABLE video’s on paced bottle feeding at https://www.youtube.com/watch?v=GNMm4Twhvbs
• Mothers should be encouraged to pump frequently if separated from infant; or after every breastfeed if supplementation is deemed medically necessary to maintain breast milk supply.
• Advocate for readily available telemedicine breastfeeding support with lactation trained nurses, educators, midwives and lactation consultants.
• Re-lactation may be possible in highly motivated parents; especially when infants are less than 6 months but may be possible in infants up to one year; with frequent breast stimulation, frequent suckling and/or pumping, limiting supplementation to medical necessity and offering lots of positive reinforcement.
Breastfeeding education resources for promoting breastfeeding:
• The ABM clinical protocols present evidence-based protocols for common breastfeeding issues: https://www.bfmed.org/protocols
• Breastfeeding Series on: https://globalhealthmedia.org/videos: “Attaching your Baby at the Breast” and “What to Do about Nipple Pain”. Videos are available in multiple languages
• For hand expression instructions and teaching importance of the first hour of life, visit First Droplets website at: www.firstdroplets.com
• Breastfeeding education handouts for parents and providers on:
o https://lacted.org/iable-breastfeeding-education-handouts and
1. Eidelman AI. Breastfeeding and the use of human milk: an analysis of the American Academy of Pediatrics 2012 Breastfeeding Policy Statement. Breastfeed Med. 2012;7(5):323-324.
2. Prameela KK. Breastfeeding--anti-viral potential and relevance to the influenza virus pandemic. Med J Malaysia. 2011;66(2):166-169; quiz 170.
3. Sriraman NK. The Nuts and Bolts of Breastfeeding: Anatomy and Physiology of Lactation. Curr Probl Pediatr Adolesc Health Care. 2017;47(12):305-310.
4. https://www.aap.org/en-us/advocacy-and-policy/aap-health initiatives/Breastfeeding/Documents/tenstepsposter.pdf.
5. Centers for Disease Control and prevention. Pregnancy and Breastfeeding. Information about Coronavirus Disease 2019. Last reviewed on March 17, 2020. Accessed March 21, 2020.
6. ABM Statement on Coronavirus 2019 (COVID-19). Academy of Breastfeeding Medicine. Published March 10, 2020. Accessed March 21, 2020.
7. Bergmann Renate L, Bergmann Karl E, von Weizsäcker K, Berns M, Henrich W, Dudenhausen Joachim W. Breastfeeding is natural but not always easy: intervention for common medical problems of breastfeeding mothers – a review of the scientific evidence. In. Journal of Perinatal Medicine. Vol 422014:9.