It’s no secret that the best food for a newborn is his mother’s breast milk. And even if a mother is suspected or confirmed to have COVID-19, her milk, according to the World Health Organization (WHO) and many other organizations, will still be the best food for her baby, since no available research has demonstrated the presence of the virus in breast milk .

However, the mother may not always breastfeed directly due to the severity of the disease or other circumstances. In this situation, most of the guidelines and recommendations available urge mothers to express breast milk in a prophylactic manner so that a healthy caregiver or nursing staff can feed the baby. Thus, the baby will be able to receive antibodies to the virus and other benefits of breastfeeding, and the mother will maintain a sufficient level of lactation .

COVID-19 Preventive Measures to Take When Expressing

In the Russian Federation, the Methodological Recommendations adopted in May 2020 are currently in force, «Organization of medical care for pregnant women, women in labor, postpartum women and newborns with a new coronavirus infection COVID-19» (hereinafter referred to as the Methodological Recommendations of the Russian Federation), in clause 8 of Art. … 8.6 which lists the rules that mothers with suspected / confirmed COVID-19 should carefully follow when expressing milk:

● Expression of milk is performed by the mother in her room using an individual clinical breast pump.

It is strange that manual pumping is not supposed to be possible. At the same time, WHO in the interim guidance «Clinical Management of Severe Acute Respiratory Infection in Suspected Coronavirus Infection COVID-19» dated March 13, 2020 (WHO / 2019-nCoV / clinical / 2020.5), (hereinafter referred to as the Interim Guidance) and in the material for health workers “Frequently asked questions: COVID-19 and breastfeeding” (WHO / 2019-nCoV / FAQ / Breast_feeding / 2020.1) (hereinafter referred to as the FAQ) says that you can express milk by hand or using a breast pump — both methods can be equally effective. The choice of a particular method of expressing depends on the preference of the particular mother, the availability of equipment, hygiene conditions, and cost.

By the way, in the first days, as a rule, only a few milliliters of colostrum is expressed from the mother. This is a very valuable food for a child, which he simply needs. Nevertheless, if we try to express it with a breast pump into a bottle, then these few drops will simply smear on the walls and will not reach the addressee. It is much more productive in this case to express with your hands, collecting a valuable resource in a syringe, from which you can later feed the child. In our case, this option is not provided.

The Royal College of Obstetricians and Gynecologists (RCOG) also talks about the possibility of expressing milk by hand or with a breast pump (Infection in Pregnancy. Information for Healthcare Professionals. Version 11 Published Friday 24 July 2020).

The CDC also reviews hand expression option. In this case, the use of a special (individual) clinical breast pump is considered ideal.

Some guidelines suggest that a dedicated breast pump is desirable, but with proper disinfection, a generic one can be. It’s more of a security issue.

● Milk is collected in sterile bottles that are sealed to the breast pump.

WHO also notes that it is important to ensure that all parts of the pump, milk storage containers and utensils are properly cleaned from the previous expression before expressing. Moreover, compliance with this rule is necessary, even if the mother does not have a suspected or confirmed infection with COVID-19.

● Breasts should be washed with soap before expressing.

This recommendation is found in only a few guides. Most agree that the breasts should only be washed when the mother’s respiratory secretions may have been exposed to it (for example, the mother sneezed on it). More details on this item here.

● In between pumping, the breast should be closed to avoid the passage of saliva and mucus from the respiratory tract onto the breast.

● Before expressing milk, the woman washes her hands and changes the surgical mask to a new one.

The WHO FAQ also states that the mother and anyone who helps her should wash their hands before expressing breast milk or touching any part of the pump or bottle.

The CDC Care Guidelines, among other things, state that a mother should always wash her hands with soap and water for at least 20 seconds before expressing, whether she has COVID-19 or not. If soap and water are not available, hand sanitizer with at least 60% alcohol should be used. In the case of COVID-19, you must also wear a mask before expressing. Read more about applying masks and washing your hands here.

● Spreads an antiseptic on the surface where the breast milk collection bottle will be placed before and after expressing.

● Seals a sterile bottle to the breast pump, then pumps the milk into it.

● When finished, detaches the bottle from the pump and quickly replaces the cap.

● Treats the bottle with the cap with an antiseptic and places the bottle in a clean plastic bag, then closes the bag.

Indeed, some guidelines consider every bottle received from a mother with a suspected or confirmed COVID-19 as a potential vector.

There is a proposal for the mother to express milk into a bottle and then transfer it to a clean container held by a healthy person with appropriate protective clothing, including a mask and gloves. Accordingly, in such a new container, milk can be stored in a common refrigerator without fear of contamination of other containers.

Kathleen A. Marinelli, Robert M Lawrence, 2020 recommend wiping bottles with antiviral wipes or diluted (1:10) bleaching solution (sodium hypochlorite [NaOCl] 0.5%) and then leaving on a clean surface to air dry. Once dried, these bottles can be placed in shared hospital refrigerators in separate patient containers.

In response to this recommendation, Katrina B. Mitchell, Sarah R. Weinstein, 2020 published an article in the Journal of Human Lactation. In particular, they draw attention to the CDC’s statement that there is currently no evidence to support the effectiveness (in terms of reducing the risk of COVID-19 transmission) of disinfecting the external surfaces of milk collection items (e.g. bottles, milk bags). They make it clear that the virus spreads through direct person-to-person contact through respiratory secretions. The CDC emphasizes that the virus does not spread primarily through surfaces. Katrina B. Mitchell, Sarah R. Weinstein believe that donor milk cans have strict bottle handling guidelines that prevent the transmission of pathogens by donor milk recipients. And these standard measures for cleaning bottles are quite enough. In addition to the lack of evidence of the effectiveness of enhanced bottle disinfection, such recommendations could cause undue concern about the safety of breast milk, which could save lives, which could cause unnecessary long-term harm to mothers and babies.

● After that, all parts of the breast pump are processed in accordance with the current recommendations for the processing of breast pumps. Upon completion of all actions, you must wash your hands.

WHO considers it proper cleaning to wash breast pump parts / containers after each use with liquid soap (such as dishwashing liquid) and warm water. Then rinse with hot water for 10-15 seconds. Some breast pump parts can be placed in the top rack of the dishwasher (if available). However, you should read the instructions before doing this.

How often to express

In their Guidelines for Care, the CDC recommends expressing milk every 2-3 hours (at least 8-10 times a day, including at night), especially in the first few days. In addition to allowing the baby to feed expressed milk, this frequency signals the breast to produce milk and also prevents milk duct blockages and breast infections. More about maintaining lactation here.

Should expressed milk be pasteurized?

With a few exceptions, guidelines and recommendations from different countries (including the Methodological Recommendations of the Russian Federation) recommend feeding babies with native (fresh, without pasteurization) expressed milk, since it is not considered a carrier of infection. In addition, pasteurization reduces the immunological value of breast milk by about 30-40%. As for the nutritional components, only lipase and some heat-sensitive vitamins are inactivated in pasteurized milk. However, if mom is too anxious, pasteurized milk will be much healthier than formula. At the same time, it has already been proven that pasteurization kills even a virus specially placed in breast milk. More on this here.

How to feed expressed milk

WHO reminds that when feeding expressed breast milk, it is preferable to use a cup and / or spoon (they are easier to keep clean, ideally these feeding methods are trained by medical personnel) by a person who does not have signs or symptoms of illness and with whom the baby feels comfortable … The mother or caregiver should wash their hands with soap and water before feeding a baby. By the way, WHO does not mention the mask in this place. At the same time, the CDC says that any person caring for a child must wear a mask. If this person comes into contact with an infected mother, then the mask is worn for the entire period of isolation of the mother and for another two weeks after the mother has completed isolation.

A nasogastric tube is used to feed premature babies (less than 34 weeks of gestational age) or for respiratory failure.

Drug compatibility

In each case, the compatibility of the medicines used by the mother with breastfeeding should also be assessed. It should be noted that most of the drugs used in the treatment of COVID-19 are compatible with breastfeeding.

If you can’t get enough pumping

In cases where the mother is unable to independently express breast milk or she is forced to stop breastfeeding due to poor health, it makes sense to seek help from a lactation support specialist, to learn about relaxation.

When to switch to breastfeeding

In the FAQ, WHO clarifies that there is no specific waiting period before starting or resuming breastfeeding in the presence of a suspected or confirmed diagnosis of COVID-19. The mother can start breastfeeding as soon as she feels good enough to do so.