COVID-19 and Safety of Breast Milk and/or Breastfeeding -Please send all your questions

Dear colleagues

Gradually I am getting more questions on the safety of breast milk, breastfeeding etc. in the context of COVID-19.

I know that you as health/nutrition practitioners get many questions and perhaps you have a few yourselves.

I am trying to compile the ones you/we are all struggling with so we have an idea what are the most pertinent ones. In this way, we can see how and where we can flag these.

Please feel free to send any important questions you have to me (mververs@jhu.edu) when you have a few minutes or put them on this forum here. The questions can be science-related, programmatic/operational, etc. Note: you can send your questions anonymously on this forum as well. 

Warm regards and stay safe! Mija

Thanks everybody for sending questions to me both through this forum and via my email. Keep on sending the questions and I will categorize and list them this weekend and put them back here on this forum and share via IFE CoreGroup. As for now, we are assessing what the main questions as a first step. Thanks, Mija 

Assessment of questions on Infant Feeding in the context of COVID-19

21 March 2020 3 pm USA EST Mija Ververs

Dear colleagues

Here the first list of all questions that were submitted to me on Infant Feeding and COVID-19 over the last 48 hours. I want to express appreciation to those that submitted questions. I took the liberty to rephrase some of the questions in order to combine a few together. The questions are categorized under some provisionary headings. The questions come from all over the world: from refugee settings, (NGO) health workers working in Europe, the Americas and Asia, to staff from hospitals in the USA, etcetera.

A.Transmission of the virus

1. As most people will not have access to face masks, is there a recommendation around ‘home made’ protective versions that would provide the best protection from mother-infant transmission. In other words: what alternative materials (second-best options) can be used and how to clean these?
2. Can the virus be transmitted through milk sharing, through containers and supplies and then might infect an infant or the infant’s family?
3. If women do not wish or cannot breastfeed (and they are a  suspected or confirmed case), is there guidance on whether they should have skin-to-skin with their infants after birth?
4. Is there a protocol to "disinfect" mother's skin prior to skin-to-skin contact with her infant?
5. What are the precautions to be followed by lactating women, is it different from normal situations?
6. Can the COVID-19  virus be transmitted through breast milk? Or only through naso-oral transmission?
7. Can the infant become infected by the mother?
8. What measures need to be taken if the virus will be proven to be transmitted through breast milk?
9. If the virus is not transmitted through breast milk but through naso-oral transmission, can the mother express the milk with a  breast pump instead of having direct contact with her infant?

B. Destruction of the virus

1. Is the virus destroyed by freezing (how long need to be the exposure and to what temperatures)?
2. What temperature is needed to destroy the virus in breastmilk?
3. How should mothers/family members effectively clean face masks (if in use)? Is soap and water enough, is hot water above a certain temp’ recommended, or are there other recommendations?

C. Recommendations from normative organisations

1. It seems there are discrepancies between guidance from CDC and from WHO, is that true? Can that be solved?  Mija Ververs: NOTE that guidance issued by CDC and WHO do not necessarily aim for the same audience, CDC’s guidance provided on breastmilk and breastfeeding on its website targets a domestic USA audience with a different context.
2. Some hospitals are using the perception of the disagreement on guidance from WHO and CDC as a rationale for separating all infants from mothers  when COVID-19 is suspected or confirmed. How can we avoid this?
3. What are the most important key messages that our organization should be sharing now? The CDC and WHO pages are too difficult for families to read.
4. What does the science tell us currently on breastmilk, breastfeeding and COVID-19  – is there some kind of factsheet that is referenced with peer-reviewed journal articles?
5. Some of the guidance from normative organizations state to use masks, PPE[1] and implement good IPC[2]. How is that possible if all these materials are not available and what are the alternatives?

D. Recommendations from health workers

1. In various European countries mothers who contract COVID-19 are being told not to breastfeed or feed their infants their expressed breastmilk. Some mothers are advised to top up breastmilk with infant formula after one month. How can we best reach on international scale physicians, in particular, so they provide appropriate advice? (e.g., major physician blog, Lancet)

E. Mechanisms of the provision of technical assistance and materials

1. Is there a mechanism at CDC/USA Government for creating a Help Desk where questions can be addressed.
2. Have countries set up specific Help Desks/Helplines and are there experiences and lessons learned to be shared?
3. We are working in a refugee setting and intend to increase awareness on breastfeeding in the context of COVID. We are looking for visuals and brochures to go with our promotion. Do these materials already exist? And if so, can they be shared?

F. Provision of milk

1. Should organizations respond to the infant formula shortages in our community and how should that be done?
2. Is there guidance for milk banks to scale up their work in emergency response to COVID-19?
3. Should we encourage the use of breast milk substitutes or this is violation of The Code (WHO’s International Code of Marketing Breastmilk Substitutes)?

G. Testing on COVID-19 of breast milk

1. Are there currently any laboratories that have the capacity to test for COVID-19 virus in milk samples of mothers with COVID-19?
2. Does CDC or WHO have an insight to which laboratories are doing this or planning to do so?
3. Are there tests available for human milk banks?
4. Without testing, should milk sharing be stopped?
5. Are there tests being used to identify COVID-19 in human milk or antibodies in human milk?

H. Miscellaneous

1. Are there certain precautions (IPC, messaging) we need to take during food distributions targeted for pregnant and lactating women?

[1]PPE = Personal Protective Equipment

[2]IPC =  Infection Prevention Control

Assessment of questions on Infant Feeding in the context of COVID-19

21 March 2020 3 pm USA EST Mija Ververs

UPDATE 24 March 8 pm USA EST Mija Ververs

Dear colleagues

Here the second list of all questions that were submitted to me on Infant Feeding and COVID-19 over the 4 days. This is an UPDATE and the more recent questions are marked in italics. Again,  I want to express appreciation to those that submitted questions. I took the liberty to rephrase some of the questions in order to combine a few together. The questions are categorized under some provisionary headings. The questions come from all over the world: from refugee settings, (NGO) health workers working in Europe, the Americas, Africa and Asia, to staff from hospitals in the USA and many other countries, etcetera.

A. Transmission of the virus

1. As most people will not have access to face masks, is there a recommendation around ‘home made’ protective versions that would provide the best protection from mother-infant transmission. In other words: what alternative materials (second-best options) can be used and how to clean these?
2. Can the virus be transmitted through milk sharing, through containers and supplies and then might infect an infant or the infant’s family?
3. If women do not wish or cannot breastfeed (and they are a  suspected or confirmed case), is there guidance on whether they should have skin-to-skin with their infants after birth?
4. Is there a protocol to "disinfect" mother's skin prior to skin-to-skin contact with her infant?
5. What are the precautions to be followed by lactating women, is it different from normal situations?
6. Can the COVID-19  virus be transmitted through breast milk? Or only through naso-oral transmission?
7. Can the infant become infected by the mother?
8. What measures need to be taken if the virus will be proven to be transmitted through breast milk?
9. If the virus is not transmitted through breast milk but through naso-oral transmission, can the mother express the milk with a  breast pump instead of having direct contact with her infant?
10. We are told that some people remain asymptomatic then the body naturally fights the virus until they get cured but during the period they can still infect somebody. What are the risk factors of such people to the children whom they breast/ have direct contact?
11. In case breastfeeding has been discontinued and COVID 19 infected mother has been treated and discharged cured, how soon after can the child be breastfed again?
12. Is there official guidance on whether infected women, who are planning not to breastfeed, should have skin-to-skin with their infants after birth?
13. Can the mother still breastfeed if she is infected by COVID-19? If yes, how can that be done concretely?
14. What measures do we need to consider for a breastfeeding/infant formula feeding mother that has COVID-19 symptoms?
15. Has there been any evidence that breastfeeding puts the woman at higher risk of Covid 19, or other complications?
16. Is there any evidence based milk storage guidelines for patients postpartum with suspected or confirmed cases of COVID-19?

B. Destruction of the virus

1. Is the virus destroyed by freezing (how long need to be the exposure and to what temperatures)?
2. What temperature is needed to destroy the virus in breastmilk?
3. How should mothers/family members effectively clean face masks (if in use)? Is soap and water enough, is hot water above a certain temp’ recommended, or are there other recommendations?

C.Recommendations from normative organisations

1. It seems there are discrepancies between guidance from CDC and from WHO, is that true? Can that be solved?  Mija Ververs: NOTE that guidance issued by CDC and WHO do not necessarily aim for the same audience, CDC’s guidance provided on breastmilk and breastfeeding on its website targets a domestic USA audience with a different context.
2. Some hospitals are using the perception of the disagreement on guidance from WHO and CDC as a rationale for separating all infants from mothers when COVID-19 is suspected or confirmed. How can we avoid this?
3. What are the most important key messages that our organization should be sharing now? The CDC and WHO pages are too difficult for families to read.
4. What does the science tell us currently on breastmilk, breastfeeding and COVID-19  – is there some kind of factsheet that is referenced with peer-reviewed journal articles?
5. Some of the guidance from normative organizations state to use masks, PPE[1] and implement good IPC[2]. How is that possible if all these materials are not available and what are the alternatives

D. Recommendations from health workers

1. In various European countries mothers who contract COVID-19 are being told not to breastfeed or feed their infants their expressed breastmilk. Some mothers are advised to top up breastmilk with infant formula after one month. How can we best reach on international scale physicians, in particular, so they provide appropriate advice? (e.g., major physician blog, Lancet)
2. Some neonatologists state that skin to skin can cause the infant to catch COVID-19. With so limited evidence, is that correct advice?
3. Some hospitals are apparently implementing a protocol to "disinfect" mother's skin prior to skin-to-skin after birth for COVID-19. Where is this practice coming from and how do we address it?

E. Mechanisms of the provision of technical assistance and materials

1. Is there a mechanism at CDC/USA Government for creating a Help Desk where questions can be addressed.
2. Have countries set up specific Help Desks/Helplines and are there experiences and lessons learned to be shared?
3. We are working in a refugee setting and intend to increase awareness on breastfeeding in the context of COVID. We are looking for visuals and brochures to go with our promotion. Do these materials already exist? And if so, can they be shared?

F. Provision of milk

1. Should organizations respond to the infant formula shortages in our community and how should that be done?
2. Is there guidance for milk banks to scale up their work in emergency response to COVID-19?
3. Should we encourage the use of breast milk substitutes or this is violation of The Code (WHO’s International Code of Marketing Breastmilk Substitutes)?

G. Testing on COVID-19 of breast milk

1. Are there currently any laboratories that have the capacity to test for COVID-19 virus in milk samples of mothers with COVID-19?
2. Does CDC or WHO have an insight to which laboratories are doing this or planning to do so?
3. Are there tests available for human milk banks?
4. Without testing, should milk sharing be stopped?
5. Are there tests being used to identify COVID-19 in human milk or antibodies in human milk?

H. IYCF Programmes in humanitarian context

1. Are there certain precautions (IPC, messaging) we need to take during food distributions targeted for pregnant and lactating women?
2. What community approach (without gathering) should we take to continue services in mother-baby or IYCF corners as the mothers may need these services more than ever in the face of panic/fear of infection?
3. How can group counselling sessions on breastfeeding be conducted given the fact that group setups are abolished?

I. Miscellaneous

1. Are the benefits and harms of the many recommendations that circulate and that consider separation mother from infant adequately mapped out with respect to the following:
   • Impact of separation on breastfeeding initiation and maintenance for short and long term & impacts on overall morbidity and mortality
   • Consequences of insufficient breastfeeding for an immune response to SARSCoV2
   • Impact of lack of skin to skin contact on breastfeeding as well as on maternal & infant health (including mental health)
   • Impacts of no physical contact between mother and baby for 14 days in the newborn period 
   • Implementation in real-world of separation post discharge in home setting (and likelihood of exposure there)
   • Likely exposures of baby to the virus by being handled by multiple HCWs who have high likelihood of exposure, with many who lack sufficient PPE
   • Implementation of these guidelines in the middle of a surge where hospital capacity is exceeded multiple-fold
   • Potential disruptions in the infant formula supply chain
   • Lactation difficulties postpartum leading to lactation failure in context of shortages
   • Impact of the above on vulnerable populations already at higher risk for insufficient breastfeeding 
2. What is the evidence base for the recommendation for separation for PUI[3]/confirmed infected mothers?
3. Are PUI/infected mothers provided with the opportunity to participate in informed decision making about their own and their infant's care especially when evidence is quite limited?

[1]PPE = Personal Protective Equipment

[2]IPC =  Infection Prevention Control

[3] PUI = Person Under Investigation