REVIEW ARTICLE

Guidance on breastfeeding during the Covid-19

pandemic

Valdenise Martins Laurindo Tuma Calil1

Vera Lucia Jornada Krebs2
Werther Brunow de Carvalho3

1. Doutora em Medicina pela Faculdade de Medicina da Universidade de São Paulo (FMUSP), médica pediatra e neonatologista
do Instituto da Criança do Hospital das Clínicas da FMUSP, São Paulo, SP, Brasil.
2. Professora livre-docente em Pediatria pela FMUSP, médica pediatra e neonatologista
do Instituto da Criança do Hospital das Clínicas da FMUSP, São Paulo, SP, Brasil.
3. Professor Titular do Departamento de Pediatria da FMUSP, área de Neonatologia/Terapia Intensiva, São Paulo, SP, Brasil.

http://dx.doi.org/10.1590/1806-9282.66.4.541

SUMMARY
OBJECTIVE: These recommendations aim to provide guidance on breastfeeding for mothers with suspected or confirmed Covid-19.

METHODS: We performed a review of the recent medical literature on breastfeeding mothers with suspected or confirmed Covid-19,
focusing on the neonatal period.
RESULTS: We analyzed 20 recent publications on breastfeeding, Covid-19, and its transmission through breastmilk. We presented possible
options for breastfeeding and their consequences for the mother and the child.
CONCLUSION: All maternal decisions in relation to breastfeeding are justifiable since the infection by Covid-19 is still poorly known. How-
ever, puerperal women and their families must be very well informed to make a conscious choice based on the information available
in the literature so far.
KEYWORDS: Infant, newborn. Breastfeeding. Neonatology. Coronavirus. COVID-19.

INTRODUCTION

The impact of infections by the new coronavirus the H1N1 virus, the effect in pregnant women is simi-
(Covid-19) has been increasing rapidly as the pan- lar to that of adults of the same age group1-3. There is
demic spreads and the number of patients affected no evidence of greater clinical severity during preg-
grows exponentially. nancy, nor of a higher prevalence of obstetric com-
The repercussions of this infection for pregnant plications in patients infected by Covid-193-5. A study
women and newborns (NB) are still not well known, that included nine patients with pneumonia caused
with sparse scientific evidence about its behavior in by Covid-19 did not find the presence of the virus in
mothers and children. Reports and case series from samples of six patients, collected from amniotic liq-
the first epicenter of the epidemic, China, suggest that, uid, blood from the umbilical cord, breastmilk, and
unlike other infections caused by coronaviruses and oropharynx swab of the NB3. Thus, the existing data

DATE OF SUBMISSION: 14-Apr-2020

DATE OF ACCEPTANCE: 15-Apr-2020
CORRESPONDING AUTHOR: Werther Brunow de Carvalho
Av. Dr. Enéas de Carvalho Aguiar, 647, São Paulo, SP, Brasil - 05403-000
E-mail: werther.brunow@hc.fm.usp.br

541 REV ASSOC MED BRAS 2020; 66(4):541-546

Guidance on breastfeeding during the Covid-19 pandemic

so far, although not very solid from a scientific point Recently, Eidelman A. made a contribution along
of view, suggest that the main route of transmission of the same line, stating that: “given the fact that moth-
Covid-19 to neonates is by infected droplets from care- ers infected with the coronavirus have probably already
givers or, secondarily, through contact with contam- colonized their babies, and ongoing breastfeeding has
inated biological material. The vertical mother-fetus the potential to transmit protective maternal antibodies
transmission seems to be possible but is not docu- to infants through breastmilk. Therefore, breastfeeding
mented, neither seems to be frequent. Zeng et al.6 should continue with the mother carefully washing her
reported 33 newborns of mothers infected by Covid-19 hands and wearing a mask during the procedure in
who showed mild to moderate signs and symptoms of order to minimize the NB’s additional viral exposure”9.
early neonatal infection. Three of these NB presented Based on the evidence available and the recommen-
molecular tests positive for Covid-19, and the authors dations listed above, the Brazilian Federation of the
questioned the existence of possible vertical transmis- Gynecology and Obstetrics Associations (Febrasgo)
sion of the virus since all measures recommended for published a note highlighting that the benefits of
infection control were adopted. However, the samples breastfeeding outweigh any potential risks of virus
of amniotic fluid, umbilical cord blood, and breastmilk transmission through breast milk10. Therefore, they
did not show the presence of the virus. recommended that women infected by Covid-19 who
In the face of the existing evidence so far, the con- wish to breastfeed should be encouraged to do so10.
cerns regarding the care of newborns whose mother The World Health Organization (WHO)11, the Min-
have a suspected or proven infection by Covid-19 is istry of Health12.13, the Secretary of Health of the State
focused on two aspects: 1) avoiding the infection of of São Paulo14, the Brazilian and Global Network of
NB after birth, and 2) avoiding the infection of health Human Milk Banks15, the Pediatrics Society of São
professionals present in the delivery room and neo- Paulo16.17, the Brazilian Society of Pediatrics1.2, and the
natal unit1.2. American Academy of Pediatrics18, considering that
On the other hand, the Chinese consensus is con- mothers infected with the new coronavirus have prob-
trary to the evidence available; they have affirmed ably already colonized their children, the benefits of
the possibility of vertical transmission of the new breastfeeding for the health of the child and women19,
coronavirus and through breastmilk; for this reason, and the absence of scientific evidence on the trans-
they recommend separating the mother and child and mission of Covid-193 and other respiratory viruses7
interrupting breastfeeding, even in suspected cases. through breastfeeding, recommend that breastfeeding
In their publications, they advise that breastfeeding is maintained with the necessary precautions in case
and/or extraction of breast milk are allowed only in the of infection by Covid-19; this guidance is valid only if
case of a negative PCR test for Covid-19 in the mother the mother wishes to breastfeed her child and is in
and breastmilk4. Thus, if these tests are not negative, clinical conditions to do so. Skin-to-skin contact in the
the NB should be fed with breastmilk from a donor delivery room and breastfeeding within the first hour
and/or formula. of life should be suspended. Puerperal women and
their NBs can stay in the same room, provided they are
asymptomatic, there is a distance of 2 meters between
PROTOCOLS AVAILABLE FOR GUIDANCE
the maternal bed and the NB cradle, and all the safety
ON BREASTFEEDING FOR MOTHERS WITH
precautions described below are observed12-14. If the
SUSPECTED OR CONFIRMED COVID-19
woman does not feel safe to breastfeed while infected,
Two reviews, one by the North-American Centers it is recommended that their milk is extracted and
for Disease Control and Prevention7 and another by offered to the child.
the Royal College of Obstetricians and Gynaecol- It is recommended, therefore, that the precautions
ogists, London8, concluded that if the mother is ahead are followed since an infected mother can pass
willing and in clinical conditions to breastfeed her the virus through respiratory droplets when in contact
child, she must be well-informed and agree with the with the child, including during breastfeeding:7,12-15
preventive measures necessary. The initiation and
continuation of breastfeeding must be determined • Washing hands for at least 20 seconds before
by the puerperal woman, along with their families touching the baby or extracting breastmilk (man-
and health professionals. ual extraction or by pump).

REV ASSOC MED BRAS 2020; 66(4):541-546 542

 CALIL, V. M. L. T. ET AL

• Wearing a face mask (completely covering the the mother because she is not able to share her hap-
nose and mouth) and avoiding talking or cough- piness and worries with other family members.
ing during breastfeeding. Breastfeeding protects against morbidity and mor-
• Immediately changing masks in case of coughing tality in the neonatal and post-neonatal periods, as
or sneezing, or at every feeding. well as throughout childhood. Its benefits extend also
• In the case of manual or mechanical extraction to adolescence and adulthood and include the preven-
of human milk, strictly observe the guidelines tion of dental malocclusion, overweight and obesity,
available in the document: http://bvsms.saude. allergic and chronic diseases. It also favors the bond
gov.br/bvs/publicacoes/cartilha_mulher_tra- between mother and child, provides higher intellectual
balhadoraamamenta.pdf. If possible, ask for coefficients, and greater professional success, with
help from a trained professional of the Human higher monthly incomes in the future11,18-20.
Milk Bank. Regarding immunological protection, its effect
• Strictly follow the recommendations for clean- is particularly important against infectious diseases
ing the pumps for milk extraction after each use that benefit from the direct transfer of antibodies and
according to the manufacturer’s specifications. other anti-infectious factors, favoring also the lasting
• Consider the possibility of asking for help from transfer of immunologic competence and memory11.19.
someone who is healthy to feed the newborn We must not forget, also, of the protection con-
with the breastmilk using a cup or spoon. ferred by breastfeeding to the maternal health, provid-
• It is necessary that the person who will feed the ing less postpartum bleeding, aiding in the reduction
NB with breastmilk learns how to do this with of weight gained during the pregnancy, reducing the
the help of a healthcare professional. risk of breast and ovarian cancer, diabetes type 2, and
postpartum depression. Exclusive breastfeeding also
provides a contraceptive effect which assists in the
CONSEQUENCES OF MATERNAL CHOICES IN
spacing between pregnancies, even when no other
RELATION TO BREASTFEEDING
method is used for such purposes19.20.
As described above, mothers with suspected or The contact between mother and child during
confirmed Covid-19 may, after receiving all necessary breastfeeding will certainly benefit her from an emo-
information, choose to breastfeed their NBs, extract tional point of view, providing the necessary support
the breast milk and ask a professional or healthy com- to cope with this difficult period of quarantine and
panion to feed it to the NB, or even not to feed the social isolation. The mother should be well-informed
child breastmilk. Whatever the choice, it should be about the absence of data, so far, that proves vertical
respected without reprimands. Puerperal women are transmission and infection through breast milk3.6. On
often going through a very difficult time, fragile, afraid the other hand, there are reports of cases in which the
of their diagnosis, and the consequences it might NB contracted the disease, usually with a not severe
ensue. They will always choose what they think is presentation, through respiratory droplets from the
best for their child. Thus, their choice reflects their mother or health professionals; hence the importance
state of mind and should be heeded, whatever it is. of, at all times, complying with the protection prac-
tices during the period of viral transmissibility3-6.
A. Option for starting and maintaining breast-
feeding B. Option for not breastfeeding and extracting
This is a WHO recommendation11, which must be breastmilk
respected provided the mother and NB are in good Women who are not in good clinical conditions or
clinical conditions. The mother should be encouraged who do not feel safe to maintain direct contact with
to breastfeed her child, always complying with the their child should opt for the extraction of breastmilk
protection standards described above; it is essential and get help from a trained professional to feed the NB
she receives all the support and guidance necessary using a cup or spoon or instruct a healthy companion
from the multi-professional team, including regarding on how to do so. The extraction of milk should also
mental health, in this particularly difficult time. The be an option when the NB is premature, or even when
presence of a healthy companion is allowed, but must they are not in clinical conditions that allow sharing
not of visitors; this tends to be a cause of sorrow for the same room.

543 REV ASSOC MED BRAS 2020; 66(4):541-546

Guidance on breastfeeding during the Covid-19 pandemic

The raw milk must be extracted in an isolated tube is used in premature NBs (with gestational age
room, preferably with the aid of a trained professional less than 34 weeks) or with respiratory insufficiency.
of the Human Milk Bank (HMB), and can be stored for It is known that the donor milk can only be offered
up to 12 hours in the refrigerator. The milk extracted to the NB after pasteurization; although this process
from mothers with a suspected or confirmed Covid- maintains the nutritional value of the milk, it reduces
19 infection should not be kept inside the HMB; the its immunological properties by about 30% to 40%.
fridge must be located outside and exclusive, although Regarding its nutritional components, only lipase and
there is no evidence of viral excretion in breast milk. some thermolabile vitamins are inactivated in pas-
It is important that mothers are aware of the teurized milk15.18.
importance of providing their milk to the NB, and We must highlight here the importance of Human
professionals should inform them of all the benefits Milk Banks. In Brasil, there are approximately 225
listed above. It is also recommended that the mother Human Milk Banks and 212 Units of Human Milk
be informed of the frequency of extraction, i.e., four to Collection, which provide donor milk for NBs who
six times a day or more, to maintain milk production do not receive milk from their own mothers. These
until the end of isolation12-15. numbers are growing because the Brazilian Network,
which served as a basis for the implementation of
the Global Network of Human Milk Banks, is very
OPTION FOR NOT BREASTFEEDING AND
active and recognized at a world level (https://rblh.
NOT EXTRACTING BREASTMILK
fiocruz.br)15. We are in the final stage of implement-
Women may fear transmitting the virus to the NB, ing a Human Milk Bank in the Neonatal Center of the
both by contact and through breastmilk; they also Children’s Institute of Hospital das Clínicas and the
may not yet be in clinical conditions to breastfeed or Faculty of Medicine of the University of São Paulo,
extract their milk. In this situation, they will be sep- which is likely to become a reference in Brasil and
arated from their child, who will not be offered their abroad. The project should be completed shortly, by
milk during the period of isolation. Such an option, if the end of 2020.
maintained after clarification by professionals, should The offer of the pasteurized donor milk is a valid
be respected. option in the situations mentioned above, much bet-
As reported above, the Chinese consensus is to ter than the administration of formula. This features
separate the mother from the child and interrupt nutritional elements that are not always suitable for
breastfeeding, even in suspect cases. Breastfeeding the nutrition of NB, proteins that form bigger curds
and/or the extraction of breast milk are allowed only of difficult digestion and provide immunological fac-
in the case of negative PCR tests for Covid-19 in the tors19. There is also the possibility of, after a single
mother and breastmilk4. Thus, if these tests are not ingestion of formula, the NB developing cow’s milk
negative, the NB should be fed with breastmilk from protein allergy. We also have to consider the cost of
a donor and/or formula. In Brasil, according to the the product, often inaccessible for Brazilians with low
protocols described above, the recommendation is dif- purchasing power and difficulty to work in the current
ferent, but the will of the mother is paramount and scenario we are going through20.
must be accepted. There is the possibility of weaning if the pre-
Once again it is recommended to inform the cautions mentioned above are not taken. Milk pro-
mother on the frequency of at least four to six daily duction may decrease gradually if the frequency of
extractions to maintain the milk production until the extraction is not maintained; the NB may become
cure of the infectious process; this milk will, unfortu- accustomed to the bottle nipple and, thus, refuse the
nately, be discarded15. mother’s breast when breastfeeding is attempted.
The NB will be separated from the mother and, Walters et al.20, in 2019, published an article that
during the period recommended, will be preferably describes the billionaire costs of not breastfeeding.
supplied with breast milk from a healthy donor. A The research was conducted for six years, in more
bottle should not be used for the administration of than 100 countries. The absence of breastfeeding and
milk, if possible, so that there is the possibility of the interruption of exclusive breastfeeding in the first
resuming breastfeeding after the isolation period; the six months led to, according to their calculations, the
use of a cup or spoon is recommended. A nasogastric loss of 341.3 billion dollars annually due to childhood

REV ASSOC MED BRAS 2020; 66(4):541-546 544

 CALIL, V. M. L. T. ET AL

diseases and deaths, loss of productivity by early Considering everything that has been exposed, it
mortality, cognitive loss in children who were not can be concluded that all the options regarding breast-
breastfed, maternal deaths due to diabetes, breast feeding are justifiable since the infection by Covid-19
cancer, and ovarian cancer. We should also include is still very new and little known. However, puerperal
the thousands of cases of childhood obesity, which women and their families must be very well informed
also increase morbidity and mortality. The authors to make a conscious choice based on the information
completed the study by stating that “the human available in the literature so far.
and financial costs of not breastfeeding highlight
the importance of fostering a culture that supports Author contributions
breastfeeding at a global scale.” All authors contributed equally to this study.

RESUMO
OBJETIVO: Estas recomendações têm como objetivo orientar o aleitamento materno de mães com Covid-19 suspeita ou confirmada.

MÉTODO: Foi realizada revisão da literatura médica recente sobre aleitamento materno de mães com Covid-19 suspeita ou confirmada,
focando o período neonatal.
RESULTADOS: Foram analisadas 20 publicações recentes sobre aleitamento materno, Covid-19 e sua transmissão pelo leite. Foram
apresentadas as possíveis opções maternas em relação ao aleitamento e suas consequências para o binômio mãe-filho.
CONCLUSÃO: Todas as opções maternas em relação à amamentação são justificáveis, porque a infecção por Covid-19 ainda é pouco
conhecida. Porém, as puérperas e seus familiares devem ser muito bem orientados, realizando uma opção consciente e baseada nas
informações disponíveis na literatura até o momento.
PALAVRAS-CHAVE: Recém-nascido. Aleitamento materno. Coronavírus. Neonatologia. Covid-19.

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