In COVID-19

newborn breastfeeding

The short answer to “Can you safely breastfeed if you test positive for COVID-19” is “Yes.” But let’s look at what underpins it. Let’s see what official guidelines have to say and why they say it, and let’s review the research. As usual, I’ll follow the discussion with a “Take Away” section giving you practical tips and ideas and “Taking a Deeper Dive,” which will look closer at the research.

What do the guidelines say about breastfeeding with COVID-19?

“Based on the available evidence, [the World Health Organization’s] advice is that the benefits of breastfeeding outweigh any potential risks of transmission of COVID-19. Mothers with suspected or confirmed COVID-19 should be encouraged to initiate and continue breastfeeding and not be separated from their infants, unless the mother is too unwell.”WHO 2020a

All health organization and professional guidelines I could find agree that women suspected or known to have COVID-19 infections should be able to hold, care for, and breastfeed their babies if they wish and feel able to do so with, of course, proper precautions and hygiene, including the American Academy of Pediatrics, the American College of Obstetricians & Gynecologists, the U.S. Centers for Disease Control, the International Federation of Gynecologists & Obstetricians (FIGO), the International Confederation of Midwives, the U.S. National Institutes of Health, the U.K. Royal College of Obstetricians & Gynaecologists, the Society of Obstetricians & Gynaecologists of Canada, and the World Health Organization.

Several guidelines add that women planning to breastfeed who prefer not to put the baby to breast or who don’t feel able to do so or who have babies who are ill or premature and must remain in the nursery should be helped to express milk or pump their breasts and that the milk should be fed to their baby.

What precautions do guidelines recommend for preventing infection transmission from mother to child?

No guideline recommends separating babies from their mothers if the baby is able to be with the mother, and the mother is well enough to care for her infant, although a couple of them suggest that the baby’s crib be kept 6 feet away from the mother’s bed and behind a physical barrier such as a curtain (ACOG 2020; FIGO 2020).

As you would expect, guidelines recommend handwashing and wearing a mask while breastfeeding. As you would also expect, they recommend careful cleaning of breast pumps if the mother is pumping, having a pump that only she uses, and disinfecting the surface of breastmilk containers.

What does the research say about the possibility of transmitting infection to the baby through breastfeeding?

The research has taken a two-pronged approach: Some studies have examined the likelihood of the coronavirus getting into the milk of an infected mother while others have looked at the likelihood that breastfed infants whose mothers test positive will become infected.

As regards finding the virus in breastmilk, we have little data, but what we have doesn’t find that the virus is readily passed into breastmilk. In the studies overall, among 60 women having their milk tested for the presence of the virus’ RNA, only 3 tested positive, and 2 of the 3 tested positive only intermittently, that is, samples taken on other days tested negative. Furthermore, finding bits of viral RNA isn’t the same as finding live virus capable of reproducing itself. One study that cultured samples didn’t find any live virus, including in a sample that tested positive for viral RNA.

With respect to likelihood of infection through breastfeeding, again, we don’t have much data, but what evidence we have is reassuring. Among 200 breastfeeding mothers, 7 infants, or less than 4%, tested positive for the virus compared with 5% of formula fed babies, which means feeding method didn’t make a difference. Among those 7 infants, only one had symptoms that might have been related to an infection. That baby developed low blood sugar and was having difficulty feeding. The baby was admitted to neonatal intensive care for treatment and recovered.

Could breastmilk protect against COVID-19 infection?

There is another side of the coin: one of the advantages of breastfeeding is that women transmit antibodies to illnesses they contract to the baby via breastmilk. A small study found that this was true for women with COVID-19.

The Take-Away

Based on the information above, if you are planning (or considering planning) to have your baby at a particular hospital, here are some questions you may wish to ask about hospital policies for women with the coronavirus.

Hopefully, they will never apply to you. Even so, knowing what they are serves a couple of useful purposes: For one thing, it tells you whether the hospital bases its COVID-19 policies on the best evidence, and that’s important. You would be wise to look elsewhere if the hospital doesn’t. For another, until the test administered at hospital admission comes back negative, hospitals are likely to treat women as “persons under investigation” and apply the same restrictions as they do to women who have tested positive. Getting test results back may take hours, which means your baby could be born in the interim.

If I have COVID-19 . . .

  • Would I be able to have my baby with me if my baby is well, and I feel able to care for my baby?
  • Under what circumstances would my baby be separated from me?
  • Would I be able to breastfeed my baby if I wished to do so?
  • Are there any circumstances where I wouldn’t be permitted to breastfeed my baby?
  • If circumstances made it necessary to separate me from my baby, would arrangements be made to collect colostrum (the substance that precedes breast milk) and breast milk to be fed to my baby?
  • Do you have lactation specialists who could advise and help me with feeding my baby or pumping my milk?

Taking a Deeper Dive

Coronavirus RNA particles are rarely found in breastmilk, and even when they are, they may only be fragments and not infectious virus.

Among 60 unique* women who tested positive for COVID-19, 3 of them had at least one breastmilk sample that tested positive for the virus (Chambers 2020; Gross 2020; Lackey 2020; Lang 2020; Martins-Filho 2020; Tam 2020; Yang 2020). Two of the three women, however, tested positive only intermittently, that is, samples taken on different days tested negative. The authors of the report of one of the cases testing positive intermittently note that the woman hand expressed the samples and didn’t wear a mask, which means the milk could have been contaminated with the virus after it left the breast (Tam 2020).

Furthermore, testing positive for viral RNA doesn’t equate with finding infectious virus. One study cultured milk samples from 18 COVID-19-positive women, among whom 1 had a sample that tested positive (Chambers 2020). No sample contained replication-competent virus, including the sample that tested positive for viral RNA.

*Some studies were reviews pooling data from multiple studies, and the studies they included overlapped.

Breastmilk appears to be a rare route of transmission to babies and infrequently results in symptomatic illness in babies testing positive.

A systematic review (a study of studies on a particular topic) attempted to determine the effectiveness of policies intended to prevent COVID-19 transmission between infected mothers and their newborns, one of which was formula feeding (Walker 2020). Among women for whom infant feeding method was known, 148 women fed their babies at the breast, five women had their breastmilk fed to their babies, and 56 babies were formula fed. Six breastfed babies and one fed expressed milk tested positive for the virus for an overall rate of 5% of the 153 babies who were either breastfed or fed breastmilk. Three of the 56 babies fed formula likewise tested positive for an identical rate of 5%, which means that formula feeding was not protective. A different study contributed an additional 47 breastfed babies, none of whom tested positive for the virus (Salvatore 2020). This increases the total number of babies breastfed or fed breastmilk to 200 and reduces the infection rate associated with breastfeeding and breastmilk to less than 4%.

Moreover, most babies who tested positive didn’t develop symptoms of illness. Only one of the seven developed symptoms that might have been related to an infection. That baby developed low blood sugar (hypoglycemia) and was having difficulty feeding. The baby was admitted to neonatal intensive care for treatment and recovered.

Breastmilk transfers COVID-19 antibodies from mother to child.

A study has confirmed that, as for so many other illnesses, women recovering from COVID-19 produce protective antibodies (immunoglobulins) that are transmitted through breastmilk to their babies (Fox 2020). Among 15 recovering women whose milk was analyzed for the presence of immunoglobulin A (IgA), 12 tested positive. (Unlike the more commonly measured immunoglobulin G and immunoglobulin M, which are found in blood and other bodily fluids, IgA is common in breastmilk and is particular to the lining of the respiratory and digestive tracts.)

###

References

Chambers C, Krogstad P, Bertrand K, et al. Evaluation for SARS-CoV-2 in Breast Milk From 18 Infected Women. JAMA 2020.

Fox A, Marino J, Amanat F, et al. Evidence of a significant secretory-IgA-dominant SARS-CoV-2 immune response in human milk following recovery from COVID-19. MedRxiv May 8, 2020.

Gross R, Conzelmann C, Muller JA, et al. Detection of SARS-CoV-2 in human breastmilk. Lancet 2020;395(10239):1757-8.

Lackey KA, Pace RM, Williams JE, et al. SARS-CoV-2 and human milk: What is the evidence? Matern Child Nutr 2020:e13032.

Lang GJ, Zhao H. Can SARS-CoV-2-infected women breastfeed after viral clearance? J Zhejiang Univ Sci B 2020;21(5):405-7.

Martins-Filho PR, Santos VS, Santos HP, Jr. To breastfeed or not to breastfeed? Lack of evidence on the presence of SARS-CoV-2 in breastmilk of pregnant women with COVID-19. Rev Panam Salud Publica 2020;44:e59.

Salvatore CM, Han JY, Acker KP, et al. Neonatal management and outcomes during the COVID-19 pandemic: an observation cohort study. Lancet Child Adolesc Health 2020.

Tam PCK, Ly KM, Kernich ML, et al. Detectable severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in human breast milk of a mildly symptomatic patient with coronavirus disease 2019 (COVID-19). Clin Infect Dis 2020.

Yang N, Che S, Zhang J, et al. Breastfeeding of infants born to mothers with COVID-19: a rapid review. Ann Transl Med 2020;8(10):618.

Walker KF, O’Donoghue K, Grace N, et al. Maternal transmission of SARS-COV-2 to the neonate, and possible routes for such transmission: A systematic review and critical analysis. BJOG 2020.

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