Initial recommendations

The U.S. Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) initially issued fairly conservative recommendations. Despite the general encouragement of breastfeeding and the lack of evidence of SARS-CoV-2 transmission (the virus causing COVID-19) through breast milk, they recommended that the mother and the newborn be separated, citing the risk of transmission of the virus through the mother's respiratory secretions. The basis for such strict recommendations (by the way, diametrically opposed to those usually given by these institutions), were, of course, not some irrefutable facts confirmed by the studies, but the unknown: how high is the risk of infection with COVID-19 during the newborn?How severe can the disease be for infants?

At the same time, the CDC and AAP emphasized in their recommendations that breast milk is a potentially important source of antibodies for the infant and, given all the advantages of breastfeeding, should be encouraged to express the mother's contaminated breast milk with further use of it in fresh form (without pasteurization) for feeding a healthy baby to a caregiver.

Before expressing, mothers should observe the hygiene of hands and chest, wear a mask. After pumping, all parts that come into contact with breast milk should be thoroughly washed, and the entire breast pump should be disinfected in accordance with the manufacturer's instructions.

Recommendations of individual health systems

In addition to national recommendations, recommendations from individual health systems can also be found. For example, the New York University health system at Langone (NYULH) was initially guided by the recommendations of THE AAP and cdc (in the first edition), issued a preliminary internal guide recommending that mothers-to-be be split at birth by a mother with COVID-19 (Stephanie Popofsky et al., 2020). It was also recommended to feed the baby with expressed milk appointed persons providing care.

However, six weeks after the original local guidelines were published, they were changed. Asymptomatic mothers with positive results of the SARS-CoV-2 test were allowed to stay in the room with their infants and breastfeed them directly while observing hand hygiene and wearing masks.

Change in recommendations

As new data on the risk of infection and outcomes for infants born to mothers with SARS-CoV-2 infection emerged, the CDC and AAP recommendations were also gradually revised to an increasingly loyal perspective (closer to who's position), allowing not only expressed milk, but also direct breastfeeding with cohabitation.

In their recommendations for health care providers caring for newborns at risk of COVID-19 infection, including recommendations for testing, prevention and control of infections (with changes from 03.08.2020; further – Recommendations on newborns) the CDC concludes that the incidence of SARS-CoV-2 infection in newborns does not appear to be affected by the method of delivery, the method of feeding, or the presence/in general contact with the mother who is suspected or confirmed to have COVID-19 infection. In particular, current data show that there is no difference in the risk of infection for the newborn, regardless of whether it is in a separate room or remains in the mother's room. At the same time, early and close contact between mother and newborn has a lot of well-known advantages.

As for skin-to-skin contact, the CDC's Newborn Guidelines note that there is currently insufficient data to limit such contact to prevent the transmission of SARS-CoV-2 to a newborn.

In the CDC's Interim Guide to Breastfeeding and Breastfeeding in the context of COVID-19 (with changes from 09.06.2020; further, the Guide to Nursing Women), the CDC reports that breast milk is the best food source for infants. However, limited evidence suggests that the transmission of SARS-CoV-2 through breast milk to a mother infected with COVID-19 is unlikely.

Current evidence also suggests that SARS-CoV-2 infection in newborns is rare and, if found, is in most cases asymptomatic or mild, in which respiratory support is not required. Cases of severe disease in newborns (when artificial ventilation was required) have been reported, but this is a rarity. In addition, it is sometimes difficult to determine the extent of the effect of a particular infection on symptoms, as other causes (e.g. temporary tachipnoe in newborns, respiratory distress syndrome of newborns) are possible. In newborns with comorbidities and premature babies (with gestational age <37 недель) риск тяжелого течения COVID-19 может быть выше.

Decision on cohabitation and type of breastfeeding

The CDC's Newborn Guidelines state that ideally, every mother with suspected or confirmed COVID-19 infection should be given the right to choose whether the infant will be in the same room with her or should be isolated from her for the duration of her illness.

The CDC also provides mothers, in collaboration with the newborn's family and health care providers, to decide whether or not to start or continue breastfeeding, and in what form (breastfeeding or expressed milk).

In order for the decision to be as balanced as possible, the mother should discuss these issues with the health care providers during antenatal care and continue the discussion during childbirth. It should be taken into account that mothers with suspected or confirmed COVID-19 infection may feel uncomfortable because of the potential risk of infection of the baby, and medical professionals should respect any decision made by the mother.

When deciding whether to share/separate a newborn from a mother who is suspected or confirmed to have a COVID-19 infection, as well as the type of feeding it, the following points should be taken into account:

– Mothers who are close to their babies learn to recognize the signals about feeding, feed the baby faster, and react to them more quickly, which helps to establish breastfeeding.

Breastfeeding reduces morbidity and mortality for both mothers and infants.

– If the mother is breastfeeding, she should take appropriate measures (including wearing a mask and washing her hands) to minimize the risk of transmission of the virus during feeding.

– The bond between mother and baby is formed faster and easier if the newborn is near the mother.

Cohabitation promotes family-oriented care. In the future, the mother may educate other family members on the care of the newborn, as well as on measures to prevent and control infections.

– Mothers with suspected or confirmed SARS-CoV-2 infection should not be considered to pose a potential risk of transmission of the virus to their newborns if they meet the criteria for ending isolation (and must be a set of all three criteria) and may continue to take precautions. These criteria include:

It has been at least 10 days since the first symptoms of the disease (up to 20 days if the mother has a severe illness or severely weakened immunity), and

At least 24 hours have passed since the last fever without taking antipyretic drugs or other means of reducing body temperature, and

other symptoms of the disease have decreased.

Mothers who do not meet these criteria may be temporarily separated from their newborn children in order to reduce the risk of transmission of the virus. However, if they are unable to maintain separation from the child after discharge until they meet the above criteria, the effectiveness of this separation is questionable.

– Separation may be necessary for mothers who are too sick to take care of their baby.

– Separation may be necessary for newborns with an increased risk of severe disease (e.g. premature babies, infants with comorbidities).

– Separation is not required if the newborn has a positive result on SARS-CoV-2.

Measures to minimize the risk of COVID-19 transmission

If the newborn remains in the ward of the mother with a suspected or confirmed COVID-19, she should take appropriate measures to minimize the risk of transmission of the virus. Among these measures, the CDC's Nursing Care Guide:

– Wash your hands with soap and water before touching the baby. This is especially true in cases where the hands are clearly contaminated with the mother's respiratory secretions. If soap and water are not available, the mother should use a hand sanitizer with an alcohol content of at least 60%.

– Wearing a cloth mask while breastfeeding.

The CDC also reports that there is currently no evidence to support the effectiveness of breast cleansing before feeding or pumping, as well as the effectiveness of disinfecting the outer surfaces of milk collection items (e.g. bottles, milk packets).

The CDC's Newborn Guidelines further recommend maintaining a distance of 6 feet or more (approximately 2 meters) between a suspected/confirmed COVID-19 mother and a newborn, or placing the baby in an incubator if possible.

The CDC also clarifies in the CDC's Newborn Guidelines that it is necessary to wear a mask during any contact with a newborn (i.e. when the baby is 6 feet away or less from the mother with a suspected/confirmed COVID-19). Plastic face masks are not recommended, nor should you wear masks on children under the age of 2.

The CDC suggests that there is a potential risk of TRANSMITTing SARS-CoV-2 to a newborn from a mother (or other contact person) infected with COVID-19, including even before the onset of infection symptoms. Thus, the CDC concludes that all caregivers (even if they are not suspected or confirmed to have a COVID-19 infection) should apply prevention measures (wearing a mask and wash their hands) before and during the care of newborns.

Feeding expressed and donor milk

In the event that the mother for some reason has decided (or is forced) to feed expressed milk, she needs to wash her hands before expressing (as above), before touching any parts of a breast pump or bottle (or breast, if expressing by hand), and put on a cloth mask on the face. If the mother expresses milk with a breast pump, she also needs to follow the recommendations for proper cleansing and disinfection of its parts.

If possible, to feed the child expressed milk should a healthy person, not at high risk of COVID-19 disease in severe form.

If it is impossible to breastfeed a newborn or expressed milk, the CDC recommends feeding donor milk. At the same time, if hospitals have difficulty obtaining donor milk, priority should be given to preterm infants for whom breast-feeding is particularly important.

Thus, with the new data, the recommendations of the CDC and AAP regarding breastfeeding and co-host are gradually being relaxed. Currently, much depends on the decision of the mother, who, if desired and physical opportunity, can now breastfeed directly and even practice skin-to-skin contact with her newborn baby.