Regardless of the importance of breastfeeding, the guidelines evaluated do not ensure and protect breastfeeding practices.
The possibility of maternal-fetal virus transmission leading to infection in the neonatal period was observed in other respiratory diseases before the current pandemic 24. However, the literature on COVID-19 is still limited, and the available data has not observed significant infection rates among neonates born from mothers who tested positive for COVID-19; when it occurred, clinical manifestations were generally mild 2–4, 8–10.
Despite the evidence on transmission during breastfeeding and due to the major concern about SARS-CoV-2 dissemination, the guidelines recommend restrictive measures related to breastfeeding, discrediting the benefits 11–20.
Breastfeeding and its socio-economic impact
Undoubtedly, breastfeeding has an impact not only in maternal-infant health, but socio-economically. The WHO highlights the need for public policies for breastfeeding maintenance, as it can prevent 82,300 infant deaths per year worldwide. Nevertheless, even with intense campaigns and publications on the benefits of breastfeeding, only approximately 37% of the children are breastfed until 6 months of age worldwide, showing the need for investments in this area 25–26.
The absence of breastfeeding has a negative impact in countries worldwide. In developing societies, which are even more impoverished by the economic crisis triggered by the pandemic, with rising unemployment and falling Gross Domestic Product (GDP); this impact is likely to be greater 27 . Adding to that, total annual global economic losses related to non-breastfeeding are estimated to be between US $ 257 billion and US $ 341 billion, or between 0.37% and 0.70% of the global GDP 6 .
Despite the data related to breastfeeding, strategies for protecting this valuable practice during the pandemic have not been adequately developed 11–20. Although the currently available guidelines discuss prevention of mother-to-child transmission, they do not consider the possibility of weaning the baby and do not foresee actions to minimize the discontinuity of breastfeeding. Countries have prepared themselves to prevent the spread of COVID-19, however the principle of “first do no harm,” as mentioned by Alison Stuebe in a recent editorial, was not taken seriously 28.
We emphasize that, since COVID-19 is unlike other viral diseases, such as AIDS, in which breastfeeding is contraindicated due to the chronic condition of the disease, actions to prevent the transmission of SARS-CoV-2 must be performed within 14 days after birth. However, lack of support during this period combined with maternal anxiety about the disease may cause irreversible consequences on the success of breastfeeding 29, 30.
This study evaluated at least one referral hospital in each Brazilian region committed to promoting breastfeeding, and 50% of the services evaluated have a BFHI certification. The vast majority developed their own guidelines (75%) and this is probably because Brazil is a continental country with different cultures, requiring adaptation of the recommendations available in the medical literature to their own reality.
By evaluating the recommendations of the protocols for the delivery room, we noticed that most hospitals did not recommend measures to promote breastfeeding for exposed dyads, with a high rate of non-recommendation of skin-to-skin contact (79.1%) and breastfeeding in the first hour after birth (87.5%).
These recommendations in the delivery room may lead to dyad detachment, with possible impairment of breastfeeding and consequent intense maternal stress, directly related to weaning. It also causes the baby’s stress, with a possible worsening of the adaptation performance for extrauterine life 31. The concern regarding contamination in the delivery room is related to the active phase of normal delivery, where the mother can disperse droplets. However, pregnant women wear masks according to the guidelines, reducing the spread of particles 32.
We also consider the prohibition of labor companionship as a questionable measure, possibly attributed to prevent crowding in the delivery room. However, the maternal anxiety of being without a partner can be much more harmful, since several publications reinforce the relevance of the father or the presence of a companion in the entire process, from birth to breastfeeding 33.
There are few guidelines on bathing the neonate, as recommended for other viral conditions. The SARS-CoV-2 may be transmitted through feces and this measure should be considered, although bathing is associated to neonatal stress. Only SBP recommends individualizing the bathing after birth, a desirable recommendation 34.
In rooming-in, only one hospital did not allow breastfeeding and separated the dyad. This is not recommended, since separation can compromise support, increase maternal stress, discourage breastfeeding, and increase the consumption of PPE 29, 30.
Hand washing (95.8%) and the use of a surgical mask for breastfeeding (95.8%) was widely recommended in our sample, as well as maintaining a 2-meter distance between mother and child (95.8%), possibly making the immediate postpartum period more exhausting, especially when the woman is likely to be in pain.
However, even with restrictions that require more effort from the puerperal woman, most services did not allow a companion room (95.8%), and a family member could be a facilitator of breastfeeding. Responsive feeding, changing diapers, and bathing demand constant hygiene from the puerperal women and being alone would probably make the correct execution of the protection measures more unlikely and, again, contribute to maternal tiredness and anxiety. Mental health during the pandemic is already a concern of health agencies, and services must plan measures to prevent worsening of mental health 35.
Additionally, the permission of a companion for the dyad could facilitate the health education of a member of the family support network, who would be adequately trained to provide help during the period of isolation at home, avoiding contamination and encouraging breastfeeding, since the support is fundamental to its success 36.
Shared decision about breastfeeding with the family was adopted in 75% of the hospitals, however the protocols were not individualized. When adopting the same recommendation for all mothers, they did not consider the role of breastfeeding in that family and did not assess the dyad’s socio-economic situation.
The dyad’s assessment considering a bio-psycho-social approach would possibly avoid the implementation of useless measures in a hospital environment, since these recommendations cannot be followed in the home environment, especially in developing countries where several people inhabit places with insufficient hygiene conditions 37.
Another interesting aspect is related to surface cleaning. Mothers with COVID-19, due to the common symptoms—coughing, sneezing, and scratching their faces—can increase the chance of having their face, clothes, and breasts potentially contaminated. However, there are no specific recommendations for cleaning these surfaces.
Breastfeeding support and guidance on breastfeeding with COVID-19 were offered in most of the services evaluated; however, in 79.1% of Brazilian hospitals, discharge took place between 24 and 48 hours, a period when breastfeeding is often not yet well established, mainly in primiparous mothers or those with breastfeeding-related anxieties. Additionally, guidance for mothers and family members were more specific to prevent infection than to promote and support breastfeeding. 11–20
Regarding the home environment, the guidelines are standardized: all of them allow breastfeeding with hygiene measures. However, the recommendations are vague on how to proceed when the newborn is crying, with only 45.8% of the evaluated guidelines guiding how the mother should manage the crying of the newborn during the isolation period. The guidance on how to console the neonate should be seriously considered since crying is referred to as one of the leading causes of early weaning, and adequate management can alleviate maternal-fetal stress 29, 30, 38.
The prescription of artificial milk and guidance for neonatal care to be executed by other people was performed in approximately 20% of the evaluated hospitals, measures that can lead to weaning, and the lack of bond between child and mother. Concerning siblings, 62.5% of services recommended that children be separated from the dyad, a situation that probably would not be possible in socially vulnerable families, and possibly contribute to maternal anxiety 29, 30, 35, 37.
Another significant difficulty observed is the support from the primary care health service. Home visits were conducted by only 16.6% of the services; telemedicine was used by 45.8% and psychological care by telemedicine, was only used 37.5%. The lack of recommendations for adequate home support is worrying, since this type of measure would be fundamental for the promotion of breastfeeding 36.
Despite the recommendations to avoid follow-up in primary care units, 79% of participating hospitals did not offer the possibility to return to the referral health service if necessary, recommending the primary care unit if there is a problem with the dyad.
In an attempt to contribute to the dyad isolation, 45.8% of hospitals performed the neonatal screening in a hospital environment. Probably, when this possibility is not offered, there will be possible delays in the diagnosis of neonatal diseases.
Breast Pumping and Human Milk Donation
Regarding the handling and donation of human milk, we noticed guidance for breast pumping in a hospital environment (87.5%), although these mothers cannot be milk donors during the isolation period, probably due to the concerns of contamination 39.
Most hospitals recommended that raw milk must be offered to the newborn (87.5%), preferably by the cup (75%). Only 8.3% of hospitals allowed relactation, possibly not providing the stimulus to lactation through neonatal suction during the complementary feeding practices 40.
Concerning limitations of the study, we evaluated only a sample of Brazilian hospitals; therefore, it perhaps cannot represent the Brazilian reality. We also analyzed the guidelines on the COVID-19 outbreak, and it does not mean the measures are executed in these participating hospitals.
Lack of breastfeeding knowledge is significant, and so are the concerns regarding the impact of the pandemic on breastfeeding. Among the international protocols evaluated (WHO, CDC, UNICEF, RCGO, UENPS, and ABM) and those of national agencies (SBP and rBLH), we observed that the recommendations with the highest agreement between them are those related to avoiding contamination of the newborn. Nevertheless, there is no guidance on how to support and promote breastfeeding in pandemic situations, or how to continue implementing the actions recommended by breastfeeding protection policies 11–20.
Therefore, to investigate the management of breastfeeding in the dyads exposed to SARS-CoV-2, we prepared a prospective multicenter study, with the 24 Brazilian hospitals evaluated in this study (BRACOVID Project). The purposes are to assess the impact of the COVID-19 guidelines on breastfeeding rates, evaluate maternal mental health, analyze the feasibility of implementing the proposed hygiene measures in the home environment, and the clinical evolution of breastfed neonate born of mothers with COVID-19. A part of this study is still being carried out at the moment, and the final data collection will be completed by September 2020.