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Table 1 Suggested guidelines for breastfeeding during COVID-19 pandemic with supporting evidence

From: Breastfeeding during the COVID-19 pandemic – a literature review for clinical practice

Category Suggested guideline Rationale/remarks
All infants Avoiding separation of mother-infant dyads, including infection control precautions. Separation of a mother and her infant may have potential detrimental effects on feeding and bonding [18, 38, 40, 43,44,45].
Infant from healthy or non-symptomatic mother Initiate and continue breastfeeding. Breastfeeding is the optimal source of nutrition and protection for infants [46, 47].
Infant of mother with suspected COVID-19 (potentially exposed and/or symptomatic, but well enough to breastfeed) Continue breastfeeding while applying infection control protocols with specific attention to droplet protection. Mechanisms of breastmilk protect the infant [40, 43,44,45].
Respiratory viruses are not transmitted in breastmilk [1, 5, 38].
Direct transfer of antibodies into breastmilk [43].
Anti-infective factors transfer to breastmilk [43].
Immunological competence and memory in breastmilk [43].
  Continue breastfeeding. The virus is not transmitted via breastmilk [1, 5, 15, 38, 43, 44].
  All laboratory confirmed cases are isolated and cared for in a health care facility. Isolate mother-infant dyad together. Avoid person-to-person transmission of the virus [35, 40].
  Wear a mask during feeding. To avoid coughing or sneezing on the baby while feeding at the breast [38, 43, 44, 47, 48].
Infant of mother who test positive for COVID-19 (mother well enough to breastfeed) Continue breastfeeding. No virus detected in amniotic fluid [5, 15].
No virus detected in cord blood [5, 15].
No virus detected in neonatal throat swabs [5, 15].
No virus detected in breastmilk after first breastfeeding [5, 15].
Positive mother with mild symptoms Isolate mother-infant dyad at home. Avoid person-to-person transmission of the virus [35].
  Wear a mask during feeding. To avoid coughing or sneezing on the infant while feeding at the breast [38, 43, 44, 47, 48].
Positive mother with severe symptoms (can breastfeed) Hospitalize mother-infant dyad. All laboratory confirmed cases are isolated and cared for in a health care facility [35, 40].
  Isolate mother-infant dyad together in hospital. Avoid person-to-person transmission of the virus [35, 40].
  Conduct a risk/benefits discussion between neonatologists and families to individualise infant care in the case of infants requiring neonatal care. Admission to the neonatal unit may be required in infants that are born to COVID-19 positive mothers and/or have symptoms. This may require close observation and may lead to separation, however, not necessarily to discontinuation of breastfeeding [38].
   Temporary separation may be needed in case of mothers who need medical care in hospital -continue to express milk [40, 47].
Infant of mother who test positive for COVID-19 (mother too ill to breastfeed) Express milk and feed with clean cup or spoon. Prevent accidental transmission of pathogens via surface areas [35, 44].
  *Practical note: Mother can decant milk from her container into a clean container held by a healthy person to prevent transmission via the containers surface.
  Wear a mask during expressing. Prevent accidental transmission of pathogens via air [35, 44, 47].
  Ask a healthy person to feed the baby expressed milk. Prevent accidental transmission of pathogens via person-to-person contact or air [38, 47].
  In case of separation, ensure appropriately trained mental health and psychosocial support for parents. The prevalence of common mental disorders in the antenatal and postpartum period is high [43].
Expressing breastmilk: Assumption: COVID-19 is not found in breastmilk, therefore general expressing guidelines apply.
  Apply all general infection prevention measures. Prevent accidental transmission of pathogens [35, 38, 47]
  PUI and positive mothers should express in the area where they are isolated. Prevent potential infection of non-infected areas and persons.
  Do not share equipment for breastmilk expressing. Milk particles can be left within any parts of the equipment and transferred to the next person. Any pathogens surviving on surfaces can be transferred via equipment [38, 49].
  Rinse all expressing equipment in clean, cold running water before sterilising. Prevent proteins in milk to coagulate due to heat, cold water removes milk residue [38].
  Decant expressed milk into a clean container held by a healthy person wearing protective clothing. Prevent transmission of the virus via container surface area potentially infected by positive mother via surfaces [42}.
  Wipe down bottles with a viricidal agent of 1:10 diluted bleach. Kill pathogens on surfaces, such as bottles handles by infected person [37].
  Wash expressing equipment with hot soapy water with domestic detergent, rinse under running water and dry with a paper towel. Kill pathogens [38, 47].
  Sterilise equipment after each use [42]. Kill pathogens [38].
General infection control measures
 Personal hygiene Washing hands often for 20 s with soap and water or using alcohol-based hand rub (based on 80% ethanol or 75% 2-propanol). Prevent accidental transmission of pathogens via person-to-person contact [4, 47, 50].
 Personal hygiene Cover mouth and nose with a disposable tissue or elbow when coughing and sneezing. Prevent accidental transmission of pathogens via air [4, 14].
 Personal hygiene Wash hands before and after contact with the infant. Prevent accidental transmission of pathogens via person-to-person contact [38, 43, 44, 47, 48].
 Environment Thoroughly cook meat and eggs. Prevent accidental transmission of pathogens in food sources [4].
 Environment Clean/disinfect contaminated surfaces immediately. Prevent accidental transmission of pathogens via surfaces [43, 44, 49].
  Surface disinfection with 0.1% sodium hypochlorite or 71% ethanol reduces coronavirus infectivity on surfaces within 1-min exposure time. Human coronaviruses can remain infectious on surfaces for up to 9 days [49].
 Social distance Keep mother and baby together and practice safe skin-to-skin contact and rooming-in. Immediately after birth, during establishment of breastfeeding and whether mother or infant have suspected, probable, or confirmed COVID-19, 24 h/day [18, 43, 51].
 Social distance Avoid close contact with anyone who is coughing and/or sneezing. Prevent accidental transmission of pathogens via air [4].
 Social distance Avoid crowds of people such as church gatherings, shopping malls and large events. Prevent accidental transmission of pathogens via person-to-person contact or air [4].
 Social distance Do not allow anyone to kiss the infant and ask them to disinfect their hands when they come into the house or plan to touch the infant. Prevent accidental transmission of pathogens via person-to-person contact [4].
 Social distance Do not allow anyone who is ill to visit the mother and infant. Prevent accidental transmission of pathogens via person-to-person contact or air [4].
Mental health of mothers during COVID-19 pandemic No need for alarm. Children (aged 1–16 years) accounted for roughly 5% of total patients with COVID-19 in China, but frequently do not have a notable disease and no transfer via breastmilk has been confirmed [1, 5, 7, 13, 52].
  Use self-isolation time to bond with infant at home. Bonding improves relationships and mental health and overall wellbeing [51].