Breastfeeding is one of the most effective ways to foster an infant’s health and survival. The World Health Organization (WHO) recommends starting breastfeeding within one hour of birth and continuing it for the first six months of life.12 However, during emergencies, unsolicited breast milk substitutes could undermine breastfeeding.8,13
Main findings
Our study showed that breastfeeding was less practiced in NICU during the COVID-19 pandemic in China. More importantly, we found no SARS-CoV-2 RNA in the breast milk samples in our study. Based on all the evidence on SARS-CoV-2 and human milk now14, it seems there was low possibility of SARS-CoV-2 presence in human milk. Our results provide evidence in support of breastfeeding during COVID-19 pandemic; therefore, encouraging promotion of breastfeeding practices worldwide.
Strengths and limitations
The survey targeted member hospitals of the CNA that had an NICU. Therefore, the results may be a good representation of the current state of breastfeeding in China.
One possible limitation could be the small sample size of mothers whose breastmilk could be tested for the presence of SARS-CoV-2.
Interpretation
A national survey of the factors influencing breastfeeding conducted by the China Development Research Foundation in February 2019 showed that 73.2% newborns in China were successfully breastfed during the first 24 hours after birth.15 Recently, the WHO released guidelines for mothers with COVID-19 who choose to breastfeed regarding proper measures that should be adhered to, in order to ensure safe breastfeeding.16 In our study, 96.51% of the hospitals supported breastfeeding as usual in the obstetrics ward, and more than 80% of these hospitals developed special guidelines on safe breastfeeding during the pandemic. Given that approximately 40% of severe COVID-19 cases occur in hospitals,17these regulations are necessary to prevent cross infection when the mother and newborn infant stay at the hospital after delivery. These findings also support continuation of breastfeeding during the COVID-19 pandemic, which may alleviate stress in lactating women during their hospital stay and thereby facilitate successful breastfeedingtherefore contributing to successful breastfeeding.13
However, we also found that only 44.48% of the included hospitals received breast milk in their milk banks, and only 10.47% centers opened their milk banks to receive donated milk, indicating that breastfeeding was undermined in NICUs. The WHO recommends that if a mother with COVID-19 is too unwell to breastfeed, she could be supported to safely provide her baby with breast milk in other ways, such as through milk expression, relactation, and using donated milk.16 The shutdown of milk banks due to the pandemic further inhibits early, exclusive breastfeeding.
Regarding neonatologists’ opinions on mothers with COVID-19 breastfeeding, most of them expressed concerns about the presence of SARS-CoV-2 in human milk or possible cross contamination. Another avenue to address these concerns is to reduce close contact in hospitals during breast milk feeding sessions.
In China, breastfeeding is not recommended for mothers with COVID-19 until they were released from isolation.9 In our study, milk banks at eight Level III hospitals received human milk from COVID-19 mothers to feed their babies. These hospitals did not conduct SARS-CoV-2 PCR tests in human milk, but none of the babies were infected according to the throat swab PCR tests. Another eight Level III hospitals tested the presence of SARS-CoV-2 in the breast milk of 15 lactating women who were COVID-19 positive, using the SARS-CoV-2 PCR kit. The results showed no presence of SARS-CoV-2 in human milk. None of their infants were breastfed. Although four neonates were confirmed to have SARS-CoV-2 infection, transmission through breastfeeding as the cause of illness was ruled out in these cases.
SARS-CoV-2 is a beta coronavirus in the coronavirus family and is 60–140 nanometers in diameter. It is similar to two other WHO Blueprint priority coronaviruses, SARS-CoV and MERS-CoV.18 To date, there have been no reports of SARS-CoV and MERS-CoV being detected in the breast milk of infected mothers.19–22 Among all the available reports, SARS-CoV-2 RNA was only detected in one human milk sample, and no evidence on the transmission of the virus to infants through breastfeeding was found.2,7,10,11