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Breast milk and vaccinations during a pandemic:

rationalising the risks

Can COVID-19 be passed from mother to infant through breast milk? Should mothers who test positive for the
virus avoid contact with their child? Is it safe for recently vaccinated women to breastfeed a newborn infant?
Jennifer Fuerte Almalbis answers these questions in light of the latest research and guidance.

Jennifer Fuerte Almalbis1,2

Why is breastfeeding important?
Breastfeeding has long been recommended as the best option for infant feeding. There are
Author details can be found
at the end of this article many benefits to both mother and child; not only does breast milk contain all the necessary
nutrients, vitamins and minerals required by the baby, it is also shown to reduce the risk of
Correspondence to: various illnesses, including infection and sudden infant death syndrome (Hauck et al, 2011).
Jennifer Fuerte Almalbis;
jennifer.almalbis@gstt.nhs.uk Breast milk contains many beneficial components, including immunoglobins, antiviral factors,
cytokines and leukocytes, all of which help to destroy harmful pathogens and support the
baby’s immune system. This makes it particularly important for babies born prematurely
or with congenital conditions. Breast milk also helps the baby’s gut to mature and develop,
leading to easier feeding later on (Centers for Disease Control and Prevention, 2020).
Evidence also suggests that breastfeeding can reduce the mother’s risk of developing
conditions such as breast cancer, osteoporosis and cardiovascular disease, as well as
promoting a strong bond between the mother and child, which can reduce the risk of
maternal postnatal depression (NHS, 2020).
A report by UNICEF UK (2019) argued that promoting breastfeeding could lead to
significant cost savings for the NHS, as the subsequent prevention of infant illnesses would
likely reduce the number of hospital admissions and GP consultations required. Similarly,
the World Health Organization (2009) stated that effective breastfeeding of infants under the
age of 2 years is the most important intervention to promote child survival worldwide, with
the potential to prevent 1.4 million deaths among children aged under 5 years.
However, the ongoing COVID-19 pandemic has led to a number of challenges to
promoting effective breastfeeding. This article discusses these challenges, as well as the
potential implications for the vaccination of breastfeeding mothers.

Can COVID-19 be transmitted via breastmilk?

A number of studies have investigated the risk of COVID-19 transmission between mother and
child in the antenatal and perinatal period. Fenizia et al (2020) found evidence of the COVID-
19 genome in the umbilical cord blood and vaginal mucosa of a pregnant woman, and in the
placenta. They also found evidence of two types of COVID-19 antibodies (IgM and IgG) in
the umbilical cord. This suggests that COVID-19 transmission from mother to child during the
antenatal stage is possible, although the researchers noted that reported cases of this are rare.
Fenizia et al (2020) also found evidence of COVID-19 RNA in breast milk, which
may have implications for breastfeeding promotion on maternity and neonatal wards.
However, a systematic review by the World Health Organization (2020) concluded that
the risk of transmission of COVID-19 to infants from breastfeeding is low. Furthermore,
How to cite this article: epidemiological evidence for the benefits of breast milk to infants suggests that the potential
© 2021 MA Healthcare Ltd

Almalbis JF. Breast milk risks of avoiding breastfeeding outweigh the risk of virus transmission, particularly for
and vaccinations during babies born prematurely or with congenital conditions. It should also be noted that Fenizia
a pandemic: rationalising et al’s (2020) study had a small sample size and concluded that more research was needed
the risks. British Journal of
Healthcare Management.
before a conclusion could be drawn.
2021. https://doi. Given this limited evidence, and the immune-boosting effects of breast milk for infants,
org/10.12968/bjhc.2021.0018 UNICEF UK (2020) has emphasised the importance of continuing to promote and support

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parents to breastfeed their child, especially if that child is premature or has any other
condition. There is also ongoing study regarding the potential protective factor of COVID‑19
antibodies in breast milk for the infant, but no conclusive evidence as of yet.

Should a positive COVID-19 test affect breastfeeding?

The pandemic has created challenges for everyone, and this is especially true for new parents.
This is particularly the case if one or both parents have tested positive for COVID‑19. As
well as concerns about breastfeeding, allowing parents with a positive test result into the
maternity ward or neonatal intensive care unit puts other patients and parents, as well as
staff, at risk. How, then, can neonatal units continue to provide support for parents, promote
breastfeeding and prevent outbreaks of COVID-19 on their wards?
A number of organisations have issued guidance on best practice for maternity and neonatal
wards during the pandemic. The British Association of Perinatal Medicine (2020) stated that
mothers with confirmed COVID-19 should still be given support to establish and continue
breastfeeding or provide breast milk for their babies in the neonatal unit. Similarly, the
American Academy of Paediatrics (2020) recommends the continuation of both breastfeeding
and ‘rooming-in’, where the mother and infant stay together in the same room for 24 hours
a day following the birth. However, to minimise the risk of COVID-19 transmission, great
care must be taken on the ward by both staff and parents, including the maintaining of hand
hygiene and the donning of personal protective equipment where necessary.
It is important for clinicians to discuss both the advantages of breastfeeding and the
potential risk of COVID-19 transmission, both from breast milk and physical proximity,
with parents of babies admitted to the neonatal intensive care unit. A joint decision should
be made about whether the infant should be fed directly from the breast, with expressed
breast milk (taken from the mother via a pump or cup and given to the infant) or with donor
milk. This decision should take into account the baby’s gestational age, clinical status,
availability of donor milk and parental choice.
For mother who choose to feed their child with expressed milk, clinicians should ensure
that breast milk from mothers with suspected or confirmed COVID-19 are stored in a separate
fridge or freezer. If it has been agreed that breastfeeding will temporarily not be possible
because of confirmed or suspected COVID-19, the mother should still be encouraged to
express milk to maintain lactation until she is no longer carrying the infection.

What are the implications for vaccinations in mothers?

The approval of several COVID-19 vaccines is a great source of hope for an eventual return
to normal functioning on the neonatal unit. Although clinical trials were not conducted
with pregnant women, none of the COVID-19 vaccines approved for use in the UK contain
organisms that can multiply in the body, thus they cannot infect the foetus in the womb
(Public Health England, 2021). The Joint Committee on Vaccination and Immunisation
has recognised that vaccination may be particularly important for some pregnant women,
including those who are clinically at risk of severe COVID-19 or those who are at higher
risk of catching the virus, such as key workers.
Thus far, there is not data regarding the safety of COVID-19 vaccinations for breastfeeding
mothers or their infants. However, it is very unlikely that the vaccine lipid would reach
the breast tissue and even less likely that it would then transfer to the breast milk. Even
if the mRNA of the vaccine were present in the breast milk, it would be expected to be
digested by the infant and have no biological effects (Academy of Breastfeeding Medicine,
2020). In fact, although there is little plausible risk to the child, there may be a biologically
plausible benefit of vaccinating breastfeeding mothers. There is evidence that antibodies
© 2021 MA Healthcare Ltd

from vaccinations against other viruses can be transferred into breast milk and remain
detectable for 5–7 days; therefore, it is possible that antibodies from a mother who had
recently received a COVID-19 vaccine may transfer to the infant through breastfeeding
(Halperin et al, 2011; Academy of Breastfeeding Medicine, 2020).
In light of this, and because the benefits of breastfeeding to the infant’s and mother’s health
are known to be significant, the Joint Committee on Vaccination and Immunisation (2020)

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Key points
■ Breastfeeding has ample benefits for both the mother and child, including reduced
risk of sudden infant death and maternal postnatal depression.
■ Research suggests that the risks associated with not breastfeeding outweigh the risk
of COVID-19 transmission to the infant, thus breast milk should still be encouraged as
the gold standard of infant feeding where possible.
■ Clinicians working on maternity and neonatal wards must continue to minimise the
risk of COVID-19 transmission through proximity.
■ There is very little plausible risk of harm to the infant from receiving breast milk from a
mother who has been vaccinated against COVID-19.

recommends that eligible individuals should be vaccinated even if they are breastfeeding,
as long as they are informed of the absence of safety data for their specific COVID-19
vaccine. This is in line with recommendations for vaccination of breastfeeding mothers
from the World Health Organization (2021a, b).

Conclusions
The COVID-19 pandemic has created and exacerbated challenges across all aspects of
healthcare service delivery, and neonatal care is no exception. It is unsurprising that
concerns have arisen regarding the possibility of passing the virus on to the infant through
breastfeeding, especially if that infant is already unwell or premature. However, the evidence
suggests that this risk is outweighed by the risks associated with missing out on the benefits
of breastfeeding for both the mother and child. Similarly, although empirical evidence for the
COVID-19 vaccines specifically is lacking, it is very unlikely that vaccinating breastfeeding
mothers could have any adverse effect on the infant. Therefore, it is the author’s view
that clinicians working on maternity or neonatal wards should continue to encourage and
support breastfeeding, while maintaining the necessary precautions to minimise the risk
of COVID-19 transmission through proximity on the ward.

Author details
1Centre for the Developing Brain, Kings College London, London, UK
1Neonatal Intensive Care Unit, Guy’s and St Thomas’ Hospital, London, UK

Conflicts of interest
The author declares that there are no conflicts of interest.

References
Academy of Breastfeeding Medicine. ABM statement: considerations for COVID-19 vaccination in
lactation. 2020. https://www.bfmed.org/abm-statement-considerations-for-covid-19-vaccination-in-lac
tation?fbclid=IwAR1qG7rS66IyTDyDlxGIOrwQsoSqDRuXWMWnjgBXwhOJuSofk13veeT3jl8
(accessed 22 February 2021)
American Academy of Paediatrics. FAQs: management of infants born to mothers with suspected or
confirmed COVID-19. 2020. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-
infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/ (accessed 2
February 2021)
British Association of Perinatal Medicine. Human milk and SARS-CoV-2: a summary of knowledge
© 2021 MA Healthcare Ltd

to date Compiled for the British Association of Perinatal Medicine. 2020. https://hubble-live-assets.
s3.amazonaws.com/bapm/redactor2_assets/files/562/Human_milk_and_SARS-CoV-2_-_A_summary_
of_knowledge_to_date.pdf (accessed 2 February 2021)
Centers for Disease Control and Prevention. About breastfeeding: why it matters. 2020. https://www.cdc.
gov/breastfeeding/about-breastfeeding/why-it-matters.html (accessed 22 February 2021)
Fenizia C, Biasin M, Cetin I et al. Analysis of SARS-CoV-2 vertical transmission during pregnancy. Nat
Commun. 2020;11(1):5128. https://doi.org/10.1038/s41467-020-18933-4

3 British Journal of Healthcare Management  | 2021  |  https://doi.org/10.12968/

Downloaded from magonlinelibrary.com by 180.248.122.142 on March 28, 2021.

 Comment

Halperin BA, Morris A, Mackinnon-Cameron D et al. Kinetics of the antibody response to tetanus-
diptheria-acellular pertussis vaccine in women of childbearing age and postpartum women. Clin Infect
Dis. 2011;53(9):885–92. https://doi.org/10.1093/cid/cir538
Hauck FR, Thompson JMD, Tanabe KO et al. Breastfeeding and reduced risk of sudden infant death
syndrome: a meta-analysis. Pediatrics. 2011;128(1):103–110. https://doi.org/10.1542/peds.2010-3000
Joint Committee on Vaccination and Immunisation. Joint Committee on Vaccination and Immunisation:
advice on priority groups for COVID-19 vaccination. 2020. https://assets.publishing.service.gov.uk/
government/uploads/system/uploads/attachment_data/file/950113/jcvi-advice-on-priority-groups-for-
covid-19-vaccination-30-dec-2020-revised.pdf (accessed 1 March 2021)
NHS. Benefits of breastfeeding. 2020. https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-
feeding/breastfeeding/benefits/ (accessed 2 February 2021)
Public Health England. COVID-19 vaccination: a guide for women of childbearing age, pregnant or
breastfeeding. 2021. https://www.gov.uk/government/publications/covid-19-vaccination-women-of-
childbearing-age-currently-pregnant-planning-a-pregnancy-or-breastfeeding/covid-19-vaccination-a-
guide-for-women-of-childbearing-age-pregnant-planning-a-pregnancy-or-breastfeeding (accessed 22
February 2021)
UNICEF-UK. Benefits of breastfeeding. 2019. https://www.unicef.org.uk/babyfriendly/about/benefits-of-
breastfeeding/ (accessed 2 February 2021)
UNICEF UK. Statement on infant feeding during the coronvirus (COVID-190) outbreak. 2020. https://
www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2020/04/Unicef-UK-Baby-Friendly-
Initiative-statement-on-infant-feeding-during-the-Covid-19-outbreak.pdf (accessed 2 February 2021)
World Health Organization. Infant and young child feeding: model chapter textbooks for medical
students and allied health professionals. 2009. https://www.who.int/nutrition/publications/
infantfeeding/9789241597494.pdf (accessed 2 February 2021)
World Health Organization. Breastfeeding and COVID-19. 2020. https://www.who.int/news-room/
commentaries/detail/breastfeeding-and-covid-19 (accessed 1 March 2021)
World Health Organization. Who can take the Pfizer-BioNTech COVID-19 vaccine? 2021a. https://
www.who.int/news-room/feature-stories/detail/who-can-take-the-pfizer-biontech-covid-19--vaccine
(accessed 1 March 2021)
World Health Organization. The Moderna COVID-19 (mRNA-1273) vaccine: what you need to know.
2021b. https://www.who.int/news-room/feature-stories/detail/the-moderna-covid-19-mrna-1273-
vaccine-what-you-need-to-know (accessed 1 March 2021)

© 2021 MA Healthcare Ltd

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