World Health Organization (WHO)

WHO's position on breastfeeding and infant care during the pandemic is enshrined in interim guidance, published on 13 March 2020 under the headline "Clinical management of severe acute respiratory infection in suspected coronavirus infection COVID-19" (WHO/2019-nCoV/clinical/2020.5), which was subsequently updated (last edition of May 27, 2020) (next by text – Interim Guide).

In addition to this document, on May 12, 2020, a paper was released for health care workers, "Frequently asked questions: COVID-19 and Breastfeeding" (WHO/2019-nCoV/FA/Breast_feeding/2020.1) (more by text – FA).

On 23 June 2020, a brief scientific review entitled "Breastfeeding and COVID-19" (WHO/2019-nCoV/Sci_Brief/Breastfeeding/2020.1) was also published on who's official website, in which WHO confirms previously published recommendations, complementing them with new research (further by text- Scientific Review).

In its recommendations for the care and feeding of infants whose mothers have a suspected or confirmed COVID-19 infection, WHO focuses on finding and maintaining balance, as the recommendations should take into account not only the risks of COVID-19 infection, but also the risks of serious morbidity and mortality associated with breastfeeding or improper use of breast milk substitutes, as well as the protective effects of skin contact with the mother's body.

In particular, WHO reports in its interim manual that relatively few confirmed cases of COVID-19 have been reported in infants, with mild illness occurring. In support of its words, WHO cites a review of 17 articles describing 115 "mother-child" couples where mothers had confirmed COVID-19 infection. At the same time, COVID-19 was detected only in 13 children: 4 of them were breastfed, 5 – received a mixture, 2 – were mixed-feeding, the diet of the other two was not specified.

At the same time, breastfeeding protects against the morbidity and death of children in the post-neonatal period, as well as at an older age. Protective action is particularly effective against infectious diseases, which are prevented both by direct transmission of antibodies, and by other anti-infective factors and by prolonged transmission of immunological competence and memory (see WHO publication Essential Newborn Care and Breastfeeding). There are many other proven positive aspects of breastfeeding, both for the infant and for the mother (in particular, breastfeeding reduces the risk of breast and ovarian cancer for the mother, etc.).

Who also notes that active COVID-19 has not been found in breast milk by any mother with confirmed/suspected COVID-19, and so far there is no evidence that the virus is transmitted through breastfeeding.

Close physical contact ("skin to skin") optimizes the thermoregulation and other physiological functions of the infant, significantly reduces mortality and morbidity, and promotes the development of an emotional connection between mother and child.

At the same time, newborns and infants have a low risk of developing COVID-19 infection. Among the few confirmed cases of COVID-19 in young children, the majority was accompanied by asymptomatic or mild current. WHO thus considers coVID-19 to pose a lower risk to infants and older children than other infections and adverse factors that protect breastfeeding. This protection is particularly important in the face of severe overload of the health and other public services.

In light of the evidence available, WHO has concluded that mothers with suspected or confirmed COVID-19 infection should not be isolated from their infants. Health care providers are also advised to actively advise such mothers to start/continue breastfeeding with appropriate precautions. Referring to the available evidence, mothers should explain that the benefits of breastfeeding far outweigh the potential risks of transmission.

Who notes that the results of COVID-19 testing do not necessarily change the way a child is fed. However, confirmation of coVID-19 means that mothers need to take appropriate measures to prevent infections before symptoms disappear or within 14 days of their occurrence, depending on how long longer.

Thus, mothers and infants should be able to stay together at all times, practice skin-to-skin contact (including kangaroo method), breastfeed (in particular, the baby should be attached to the breast no later than an hour after birth), regardless of the presence of suspected or confirmed COVID-19 infection in the mother or infant. This also applies to babies born prematurely or with low body weight. If the baby is ill and needs special care, every possible measure should be taken to ensure that the mother has free access to the ward where her baby is located, as well as to promote the early start of breastfeeding. In all of these cases, it is important to apply appropriate preventive measures.

Measures to prevent and control infections

In its interim guide, WHO, among other things, lists the practical techniques that a mother who is suspected or confirmed to have a COVID-19 infection should use in the care process:

Washing your hands. It is recommended often, especially before contact with the child, to carry out hygienic treatment of hands by washing with soap or using alcohol-containing disinfectant.

– Respiratory hygiene. When coughing and sneezing should cover the mouth and nose with a disposable handkerchief or napkin, which should then be immediately thrown away. After that, it is also important to carry out hand hygienic treatment using alcohol-containing disinfectant or to wash them with soap;

Cleaning surfaces. It is important to clean and disinfect all surfaces indoors on a regular and regular, especially those with which the mother is in contact;

Wearing a mask. It is recommended to wear a medical mask until symptoms disappear and to meet the criteria for ending isolation. Who notes, however, that in the absence of a mask, breastfeeding should still be recommended, as other preventive measures outweigh the potential risks of transmission of the virus.

WHO's FAJ notes that the effectiveness of non-medical masks (e.g. made independently or made of fabric) has not been studied, so it is not possible to provide recommendations to support or oppose their use.

It is important to follow the rules of using a medical mask. In particular, you should change the mask as soon as it becomes wet. It should be removed by the rubber band at the back, you can not touch the front of the mask. The mask must be disposed of as soon as it is used.

Washing your breasts. If coughing or sneezing on the breast could get drops of saliva nursing mother with a suspected or confirmed infection COVID-19, should also wash the breast with soap before feeding, gently rinsing it with warm water for 20 seconds or longer. There is no need to wash the breast before each feeding of the child or expressing milk.

When is separation justified?

In its Interim Guide, WHO notes that the mother should not be separated from her baby unless she is unable to care for the child for health reasons (in this situation, another family member should be identified to perform this function).

The WHO FAI notes that at the moment there is no evidence that breastfeeding can somehow change the clinical course of COVID-19 in a mother. However, if a mother with a suspected or confirmed COVID-19 infection is unable to breastfeed directly due to the severity of the disease (or some other disease), it should be recommended that she express the milk and use it to feed the infant with appropriate infection prevention measures. In addition, pumping (even if it will not be milk, and drops of colossus) is very important for the maintenance of lactation, so that after recovery the mother can establish breast-feeding.

How to feed the child, in case of separation from the mother?

Expressed milk. In both the Interim Manual and the FAJ, WHO calls it the best alternative to breastfeeding with expressed milk. You can express milk with your hands or using a breast pump – both methods can be equally effective. The choice of a specific method of pumping depends on the mother's preferences, availability of equipment, hygiene conditions and cost.

When feeding expressed breast milk, it is preferable to use a cup and/or spoon (they are easier to keep clean) by a person who has no signs or symptoms of the disease, and with whom the child feels comfortable. Before feeding the child, the mother or guardian must wash her hands with soap. By the way, the WHO mask is not mentioned in this place, but probably if the mother with suspected or confirmed COVID-19 infection is fed expressed milk, it makes sense to apply the same preventive measures as when breastfeeding.

Who cites the rules that must be followed when expressing milk. In particular, the mother and anyone who helps her should wash their hands before expressing breast milk or touching any part of the breast pump or bottle.

It is also important to make sure that all parts of the breast pump, milk storage containers and utensils have been properly cleaned after the previous pumping. WHO notes that compliance with this rule is necessary, even if the mother does not have a suspected or confirmed COVID-19 infection.

Proper cleaning is considered to be washing parts of a breast pump/container after each use with liquid soap (e.g. dishwashing liquid) with warm water. Then it is necessary to rinse with hot water for 10-15 seconds. Some parts of the breast pumps can be put in the upper rack of the dishwasher (if there is one). However, you should study the instructions before doing so.

Donor milk. If the mother's condition does not allow breast milk to be expressed, WHO recommends the use of donor milk in its Interim Guide. With limited supplies of donor milk (which is relevant during the current pandemic for many countries), WHO recommends that it be used primarily for preterm and low-birth infants.

Nursing services or breast milk substitutes. The Interim Guide proposes that in the absence of donor milk, consider the use of nursing services (when the baby is breast-feeding another woman who is not its mother) or feeding the baby with breast milk substitutes, taking into account the practical feasibility, safety, long-term stability of the supply of mixtures, cultural context, acceptability for the mother and the availability of appropriate services. In this case, first of all it is recommended to involve the nurses for feeding the youngest children.

WHO also notes that testing of potential nurses on COVID-19 is not required. However, where HIV prevalence rates are high, future nurses should be consulted on HIV and, if possible, tested quickly.

When can I feed if there was separation?

According to the WHO Interim Guidelines, mothers who have not been able to start breastfeeding within the first hour after delivery should be helped to breastfeed as soon as conditions are more favourable. It should be assisted in the restoration of lactation and continued breastfeeding after recovery.

Who clarifies that there is no specific waiting period for pre-breastfeeding or resumption of breastfeeding if there is a suspected or confirmed diagnosis of COVID-19. The mother can start breastfeeding as soon as she feels good enough to do so.

The WHO Scientific Review concludes:

There is currently insufficient evidence to conclude that COVID-19 is vertically transmitted when breastfeeding;

The risk of contracting COVID-19 infection in infants is low, mainly in asymptomatic or mild form, with no consequences;

– AT the moment, coVID-19 appears to pose a much lower threat to survival and health than other infections that protect breastfeeding;

The benefits of breastfeeding and the close interaction of the child and the mother to prevent infection, promote health and development are particularly important at a time when health and other public services are themselves inaccessible or limited;

– Maternal compliance with suspected/confirmed COVID-19 infection prevention and control measures is very important to prevent contact transmission of the virus from mother to baby.

In general, WHO's breastfeeding recommendations reflect recommendations in situations where the mother is sick with the flu: breastfeeding is encouraged, but mothers need to take infection control measures.

It is worth noting that the WHO Interim Guide is based on decades of work in maternal and child health. The general principles enshrined on 13 March 2020 remain unchanged. Further additions to the Interim Manual itself, as well as other explanatory documents, only reinforce the initial recommendations and provide additional information to the public as well as medical professionals (Cec'lia Tomori et al., 2020).

Many international organizations, governments and health authorities in different countries, in setting up their own guidelines, have based on the recommendations of WHO (College Perinatale zorg (Netherlands), Public Health Agency of Canada, Clinical Recommendations of australia ,Australia), the Royal College of Obstetricians and Gynecologists (RCOG, UK) and many others).

United Nations Children's Fund (UNICEF)

UNICEF fully supports WHO recommendations and believes that mothers with suspected/confirmed COVID-19 infection should be advised to breastfeed with precautionary measures (which are fully consistent with those recommended by WHO) and to practice skin-to-skin contact.

On 28 May 2020, Mandy Rich's article "Safe Breastfeeding during the COVID-19 Pandemic: How to Feed your Child in accordance with current expert recommendations" (last updated 08.09.2020) was published on the official UNICEF website, which answers the most frequent questions about breastfeeding during the pandemic.

This article notes that breast milk contains antibodies and bioactive factors that protect infants from many infections, including, can fight COVID-19 infection if the child is exposed to it.

And it is especially important to breastfeed if the child is sick (regardless of whether he has contracted COVID-19 or other disease), because breastfeeding strengthens the immune system of the baby, and antibodies transmitted with breast milk help fight infections.