The COVID-19 pandemic has affected all aspects of human life since the first moments after birth. In an attempt to reduce the incidence of COVID-19, some countries are taking tough measures to isolate infants from mothers not only with a confirmed disease, but even with suspected COVID-19 to reduce the risk of mother-to-child transmission. At the same time, other countries offer skin-to-skin contact and breastfeeding, including to reduce the effects of the pandemic.

With few exceptions (indeed, there are a couple of viruses that can penetrate breast milk), mothers are allowed and even recommended to breastfeed when they are diagnosed with a viral infection, because breast milk contains immunoglobulins and other biologically active compounds that protect breast milk itself from the virus and facilitate the baby's receipt of antibodies to the virus. However, if the mother has a positive result on SARS-CoV-2 (the virus that causes coVID-19), the recommendations for breastfeeding become contradictory, although the possibility of penetration of active (i.e. able to infect the baby) SARS-CoV-2 in breast milk is still in doubt, and the benefits of breastfeeding are not in doubt.

Unsurprisingly, in the current situation, pregnant women infected with SARS-CoV-2 (and even unfected) feel insecure and even fearful about the choice of proper care for their child and the best way to feed it, because even among health institutions there is no consensus on this issue.

Ideally, guidelines and recommendations should be based on reliable, evidence-based evidence, including well-planned randomized controlled trials.It takes time, often years, to obtain such evidence, but it is not possible in a rapidly evolving situation such as the COVID-19 pandemic. This is the reason for this difference in the approaches of different countries to the care of infants and, in particular, to the choice of the optimal type of feeding.

On 13 March 2020, the World Health Organization (WHO) published a detailed guide to the care of babies born to women who have confirmed or suspected COVID-19. This guide recommends immediate postpartum skin-to-skin contact, stay in the same room of mother and newborn, breast-feeding while taking precautions in the form of wearing a mask and washing your hands before every contact with the baby. Many international organizations, governments and health authorities from different countries have issued their guidelines based on who's recommendations (College Perinatale zorg (Netherlands), Public Health Agency Canada, Clinical Recommendations of Australia,R
oyal College of Obstetricians and Gynecologists (RCOG, UK) and many others).

However, in China, where COVID-19 originated, it was initially recommended that mothers and infants be separated immediately after delivery, and babies to be fed breast milk substitutes (L. Wang, Shi, et al., 2020). A number of other countries have followed China's path and have also recommended that infants and their mothers should be separated as soon as possible, in the event that the latter is found or suspected of COVID 19. There were not many such countries: India (Chawla et al., 2020), Philippines (Philippine Society of Obstetricians and Gynecologists), Thailand (Royal College of Obstetricians and Gynecologists of Thailand), Indonesia (Pemerintah Kabupaten Kulon Progo), Japan (Japanese Society for Neonatal Health and Development), Malaysia (Malaysian Ministry of Health), originally the United States (Centers for Disease Control and Prevention).

However, in most countries, despite the recommendation of separation, it was still allowed to feed babies expressed breast milk (for example, in the U.S., Japan). Rarely and expressed milk was banned (e.g. in Malaysia) (Cec'lia Tomori et al., 2020).

In July 2020, a study by Kee Thai Yeo et al. was published to critically assess the applicability of guidelines and guidelines for the management of newborns born to mothers with suspected and confirmed COVID-19, which were published between December 31, 2019 and May 25, 2020.

A total of 20 guidelines and recommendations were evaluated from 17 countries (China, Japan, Singapore, South Korea, Italy, Australia, Brazil, Canada (national recommendations, as well as regional recommendations of Toronto and Edmonton), France, India, Saudi Arabia, South Africa, Spain, Sweden, Switzerland, THE United Kingdom and the United States (CDC and AAP).) At the time of the review, at least nine guidelines and recommendations have been revised at least twice (!).

The study found that 17 guidelines and recommendations support the use of expressed breast milk to feed infants from asymptomatic but infected mothers, and 15 of them also recommend direct breastfeeding (Japan and Saudi Arabia recommended only feeding expressed breast milk). Singapore and South Korea have not recommended breastfeeding, regardless of whether or not symptoms are symptoms, expressed milk is also not applicable. China has allowed the use of pasteurized expressed milk.

Thus, an analysis of the guidelines and recommendations of international organizations, governments and health authorities of different countries on breastfeeding has identified three main models:

1. The toughest option is when any interaction between mother and child is limited. The baby is isolated from the mother immediately after birth, fed with donor milk (if available) or mixture. The mother can express the milk and pour it until it ceases to be considered contagious in accordance with the guidance that has adopted this option. Such measures are aimed at maximizing the risk of COVID-19 transmission, but do not take into account the consequences of limiting the relationship between mother and child, as well as the lack of breast milk. Similar measures were initially taken in China.

2. The most loyal option is when direct breastfeeding and even skin-to-skin contact is allowed for asymptomatic mothers or mothers with mild symptoms when certain precautions are taken (usually hand washing before and after feeding or care, wearing a mask during contact with the baby). It takes into account all the benefits of breastfeeding, skin-to-skin contact, and generally establishing a relationship between mother and child. The risk of COVID-19 transmission is reduced by taking precautions. In some cases, if the mother and child are asymptomatic, they are discharged home with further examination only if the child has symptoms. WHO and UNICEF were the first to recommend this option.

3. Something in between when it is recommended to express the mother's milk. At the same time, a healthy family member or nurse feeds their child in a fresh, not pasteurized form. The mother also observes precautions in the form of hand washing, wearing a mask, as well as washing and sterilizing the parts of the breast pump after each use. It is sometimes allowed to place the mother and child in the same room, but at least 6 feet (or 2 meters), ideally with a partition between them. This option was originally recommended by the U.S. Centers for Disease Control and Prevention (CDC).

It is worth noting that the available studies do not support the recommendation to abstain from breastfeeding in the absence of evidence regarding the presence of a viable virus in breast milk. There is also insufficient evidence to recommend the separation of mothers and their newborns (Pablo Duran et al., 2020).

In contrast, in April 2020, Ferrazzi et al. reported a series of cases of breastfeeding of 11 newborns from mothers with COVID-19. At the same time, all newborns had an favorable outcome. Over time, such research becomes more and more.

However, it is difficult to unequivocally name the best strategy for managing infected mothers with their babies in the postnatal period, as research is still underway, COVID-19 continues to be studied. In this regard, any maternal decision regarding breastfeeding is justified. However, in order to make informed choices, mothers and their family members must be very aware of the pros and cons of different approaches based on the latest research-based information.

At the same time, in practice, even if direct breastfeeding is permitted, it may not be given priority, not adequate support, especially when the default recommendation is separation (respectively, the young mother may not be informed that there are other options, and she does not always dare to ask a question). Also, adequate support for breast milk pumping during separation is not always provided (and the possibility of breastfeeding in general, and not only during the separation period) (Cec'julia Tomori et al., 2020). In addition, if the mother is afraid to breastfeed and does not want to take risks, it is possible to offer her to feed the expressed milk fresh or after pasteurization (at the discretion of the mother) until the risk of transmission disappears. This also needs to be discussed.

So, today, international guidelines recommend continued breastfeeding regardless of whether the nursing mother has a SARS-CoV-2 infection or not, with appropriate precautions. Recommendations to limit direct breastfeeding continue to exist in one form or another, but a total ban on breast milk in any form is virtually gone anywhere in the world. In addition, as new data, guidelines and recommendations emerge, guidelines and recommendations are periodically revised in a more loyal direction.