Below is a selection of recent research on the ongoing coronavirus (Covid-19) crisis. For resources and guidance to help health professionals continue to provide care for babies, their mothers and families during the outbreak, visit our response to Covid-19 page.
The impact of pandemic restrictive visiting policies on infant wellbeing in a NICU
Given the countrywide lockdown in the first pandemic period and the respective Hospital restrictive policies, this retrospective cohort study aimed to investigate if the SARS-COV-2 pandemic was associated to a reduced parental presence in the NICU and in which form this had an impact on infant wellbeing. The study assessed altered NICUs parental presence (measured by number of visits and kangaroo care time) due to pandemic restrictive policies and its impact on infant wellbeing (measured through The Neonatal Pain Agitation and Sedation scale and nurses’ descriptive documentation). Data collected through the pandemic confirm the importance of parental presence for infants’ wellbeing in a NICU setting.
Giordano V, Fuiko R, Witting A, Unterasinger L, Steinbauer P, Bajer J, Farr A, Hoehl S, Deindl P, Olischar M, Berger A, Klebermass-Schrehof K. The impact of pandemic restrictive visiting policies on infant wellbeing in a NICU. Pediatr Res. 2023 Mar 23:1–6. doi: 10.1038/s41390-023-02562-w. Epub ahead of print. PMID: 36959317; PMCID: PMC10034238.
Breastfeeding in the pandemic: A qualitative analysis of breastfeeding experiences among mothers from Canada and the United Kingdom
Breastfeeding in a COVID-19 world
This secondary analysis of an observational study on clinical and epidemiological characteristics of pediatric COVID-19 in Majorca determined a higher prevalence of positive SARS-CoV-2 RT-PCR test results among children who visited emergency services with symptoms of potential COVID-19 who were exclusively formula fed compared with those who were ever breastfed. Conclusions suggest that ever breastfeeding reduces the risk of COVID-19 among children, as documented for other infections.
Verd, S., Ramakers, J., Vinuela, I. et al. Does breastfeeding protect children from COVID-19? An observational study from pediatric services in Majorca, Spain. Int Breastfeed J 16, 83 (2021). https://doi.org/10.1186/s13006-021-00430-z
Effects of COVID-19 pandemic on breastfeeding rates in a neonatal intensive care unit
Comparative profiles of SARS-CoV-2 Spike-specific milk antibodies elicited by COVID-19 vaccines currently authorized in the USA
This report presents a comparative assessment of the milk Ab response elicited by the Pfizer, Moderna, and Johnson & Johnson vaccines, with results indicating that 49% – 63% fewer Johnson & Johnson vaccine recipient milk samples were positive for Spike-specific IgG compared to mRNA vaccine recipients, with positive samples exhibiting significantly lower mean IgG titers. Note: This article is a preprint and has not been peer-reviewed. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.
SARS-CoV-2 Antibodies in Breast Milk After Vaccination
From 2 February 2021 to 4 April 2021 a prospective cohort single institution study was carried out on breastfeeding women receiving their Covid-19 vaccination. Analysis of blood and milk samples on day 14 after the participants’ second dose indicated an association between Covid-19 vaccination and specific immunoglobulin concentrations in human milk which was more pronounced when lactation periods exceeded 23 months. The influence of the lactation period on immunoglobulins was specific and independent of other variables.
This is a pre-publication version of an article that has undergone peer review and been accepted for publication but is not the final version of record. The journal is providing an early version of this article to expedite access to this information.
Locked out: the impact of Covid-19 on neonatal care
Research from Bliss shows that parents are 70% more likely to say they found it difficult to bond with their baby if Covid-19 restrictions resulted in time limitations on the neonatal unit. The report includes results of a survey of over 500 parents of neonatal babies born between March 2020 to February 2021 and findings from a survey of 70 NHS England Trusts. Results indicate that whilst Covid-19 restrictions have begun to ease, there are ongoing challenges faced by parents of neonatal babies with regards to spending time with their infant in their critical first days and weeks of life, which have had an effect on bonding, attachment, and parental mental health. An overview of the study can be found here.
VON SONPM COVID-19 Impact Audit
At the beginning of the coronavirus pandemic, the Vermont Oxford Network and American Academy of Pediatrics Section on Neonatal-Perinatal Medicine conducted an audit to assess the quality of care provided to pregnant women, infants, and families in hospital. A total of 1,031 completed audits were collected from 28 countries and 47 states or territories. Results indicated that the pandemic had a large effect on hospitals’ abilities to provide quality care for infants and their families, with increased demands for testing, PPE, and nursing. Significant disruption to families was also reported, with policies separating mothers from infants and/or restrictions on family visitation, which was said to have a “drastic deviation from the core concepts of patient- and family-centred care.”
High Levels of Interferon-Alpha Expressing Macrophages in Human Breast Milk During SARS-CoV-2 Infection: A Case Report
Researchers observed an increase in interferon alpha (IFNα) milk leukocytes and an increased percentage of macrophages expressing IFNα in samples of expressed breastmilk obtained from a lactating mother before and during Covid-19 infection. Findings indicate that breastfeeding infants may benefit from this natural antiviral agent, which may contribute protection from Covid-19 infection or symptomatic Covid-19 infection. A study on Covid-19 specific antibodies in breastmilk following vaccination can be found here.
Should Infants Be Separated from Mothers with COVID-19? First, Do No Harm
This articles addresses the benefits and risks of temporary separation of mothers and infants in the context of the Covid-19 pandemic. With the health and wellbeing of the mother and infant in the months following birth being the primary goal, the following six factors are provided for additional consideration:
- Separation may not prevent infection
- Interruption of skin-to-skin care disrupts newborn physiology
- Separation stresses mothers
- Separation interferes with provision of maternal milk to the infant, disrupting innate and specific immune protection
- Separation isolation doubles the burden on the health system
- Early separation disrupts breastfeeding, and not breastfeeding increases the risk of infant hospitalization for pneumonia.
This study found robust secretion of SARS-CoV-2 specific IgA and IgG antibodies in breast milk for 6 weeks after vaccination. Antibodies found in breast milk of these women showed strong neutralizing effects, suggesting a potential protective effect against infection in the infant.
Perl SH, Uzan-Yulzari A, Klainer H, et al. SARS-CoV-2–Specific Antibodies in Breast Milk After COVID-19 Vaccination of Breastfeeding Women. JAMA. Published online April 12, 2021. doi:10.1001/jama.2021.5782
Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis
This study aims to assess the collective evidence on the effects of maternal, fetal, and neonatal outcomes of the pandemic by conducting a systematic review and meta-analysis of related studies. The authors conducted searches across MEDLINE and Embase from 1 January 2020, to 8 January 2021, for case-control studies, cohort studies and brief reports comparing maternal and perinatal mortality, maternal morbidity, pregnancy complications and intrapartum and neonatal outcomes before and during the pandemic. The search identified 3592 citations, of which 40 studies were included. Interpretation of findings included that global maternal and fetal outcomes worsened during the pandemic, with an increase in maternal deaths, stillbirth, ruptured ectopic pregnancies, and instances of maternal depression. Authors noted that there was considerable disparity between high-resource and low-resource settings.
B. Chmielewska, et al. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis, The Lancet Global Health, 2021,ISSN 2214-109X, https://doi.org/10.1016/S2214-109X(21)00079-6.
Maintaining human milk bank services throughout the COVID-19 pandemic: A global response
This study explores how milk banking services are highly vulnerable to new infectious pathogens. In the COVID-19 pandemic, a Virtual Communication Network was established to collect data and experiences from milk banks across 35 countries. Data collected estimates over 800,000 infants worldwide receive donor human milk yearly, with ~500,000 infants born <32 weeks lacking access. Seven pandemic-related vulnerabilities in service provision were identified, including maintaining sufficient donors, transport logistics, safe handling, and contingency planning. Mitigations are proposed. The VCN now seeks to build upon this work to inform and improve future responses as the Global Alliance of Milk Banks and Associations.
Evidence on the safety of maintaining family integrated care practices and the effects of restricting parental participation in neonatal care during the SARS-CoV-2 pandemic is reviewed in this study, with findings confirming that the pandemic-related hospital restrictions had adverse effects on care delivery and outcomes for neonates, families and staff. Authors explore this and discuss recommendations for restoring essential family integrated care practices.
van Veenendaal NR, Deierl A, Bacchini F, O’Brien K, Franck LS; International Steering Committee for Family Integrated Care. Supporting parents as essential care partners in neonatal units during the SARS-CoV-2 pandemic. Acta Paediatr. 2021 Mar 26. doi: 10.1111/apa.15857. Epub ahead of print. PMID: 33772861.
WHO urges healthworkers to allow lifesaving mother-baby contact
This article highlights two studies cited by the World Health Organization (WHO), which found that thousands of neonatal healthcare workers are not allowing mothers with confirmed or suspected COVID-19 infections to have skin-to-skin contact with their newborns, and nearly a quarter of those surveyed are not allowing breastfeeding. The WHO says mothers should continue to share a room with their babies from birth and be able to breastfeed and have skin-to-skin contact – even when COVID-19 is suspected or confirmed.
A public health approach for deciding policy on infant feeding and mother–infant contact in the context of COVID-19
New research discussing the rising concerns of mother–infant transmission of SARS-CoV-2 through breastfeeding and close contact has been published, citing how insufficient available evidence has contributed to differing guidelines and recommendations from public health agencies and national health authorities. The study concludes that deaths among infants affected by a policy of separation and non-breastfeeding would be at least 67 times greater than mortality potentially attributable to COVID-19.
N. Rollins, et al. (2021). A public health approach for deciding policy on infant feeding and mother–infant contact in the context of COVID-19, The Lancet Global Health, ISSN 2214-109X, https://doi.org/10.1016/S2214-109X(20)30538-6.
Old Tricks, New Opportunities: How Companies Violate the International Code of Marketing of Breast-Milk Substitutes and Undermine Maternal and Child Health during the COVID-19 Pandemic
This study addresses how inappropriate marketing of breastmilk substitutes (BMS), feeding bottles, and teats threatens the enabling environment of breastfeeding, and exacerbates child mortality, morbidity, and malnutrition, especially in the context of COVID-19. The authors identify marketing tactics of BMS companies since the start of the COVID-19 pandemic by reviewing promotional materials and activities from 9 companies in 14 countries, and the official Code reporting data from the Philippines. Eight qualitative themes emerged that indicate companies are capitalizing on fear related to COVID-19 by using health claims and misinformation about breastfeeding. Other promotional tactics such as donations and services were used to harness the public sentiment of hope and solidarity. The authors propose both immediate actions and longer-term solutions as part of their key findings.
C. Constance, et al. 2021. “Old Tricks, New Opportunities: How Companies Violate the International Code of Marketing of Breast-Milk Substitutes and Undermine Maternal and Child Health during the COVID-19 Pandemic” Int. J. Environ. Res. Public Health 18, no. 5: 2381. https://doi.org/10.3390/ijerph18052381
Characterization of SARS-CoV-2 RNA, Antibodies, and Neutralizing Capacity in Milk Produced by Women with COVID-19
Using RT-qPCR, the authors of this study confirm that they did not detect SARS-CoV-2 RNA in any milk sample (n = 37) collected from 18 women following COVID-19 diagnosis. Further findings confirm that whilst evidence of viral RNA was found on 8 out of 70 breast skin swabs, only one was considered a conclusive positive result. A total of 76% of the milk samples collected from women with COVID-19 contained SARS-CoV-2-specific IgA, and 80% had SARS-CoV-2-specific IgG. In addition, 62% of the milk samples were able to neutralize SARS-CoV-2 infectivity in vitro, whereas milk samples collected prior to the COVID-19 pandemic were unable to do so. The authors conclude that the data does not support mother-to-infant transmission of SARS-CoV-2 via milk, and that milk produced by infected mothers is a beneficial source of antiSARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity.
The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review
A scoping review was conducted to assess the impact on reproductive and perinatal health as a result of the Covid-19 pandemic, both due to the infection itself as well as changes in health care, social policy, or social and economic circumstances. The authors found that the guidelines for labour, delivery, and breastfeeding for COVID-19 positive patients vary, which could create uncertainty and unnecessary harm. The authors assessed this across low and high income countries, finding that many reported higher frequencies of maternal mental health problems, such as clinically relevant anxiety and depression, during the epidemic. Authors conclude with key recommendations for moving forward in the scope of the pandemic.
Kotlar, B., Gerson, E., Petrillo, S. et al. The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review. Reprod Health 18, 10 (2021). https://doi.org/10.1186/s12978-021-01070-6
Breastfeed or be vaccinated—an unreasonable default recommendation
The authors of this article discuss their fear that, “many clinicians will recommend against taking the vaccine when breastfeeding, as is the default in the absence of data, as though breastfeeding is a neutral health decision,” despite the fact that the UK has reversed its stand and now advises offering the vaccine to breastfeeding women. The authors affirm that milk contains antibodies that could potentially protect the breastfed baby from COVID-19 and that antibodies generated in response to the vaccine should protect the breastfeeding women and the breastfed infants.
Early life factors and COVID-19 infection in England: A prospective analysis of UK Biobank participants
This study aims to examine whether maternal smoking, birth weight, birth month and breastfeeding are associated with COVID-19 infection and hospitalisation. Conclusions found that maternal smoking was positively associated with COVID-19 infection, while breastfeeding was negatively associated with COVID-19 infection. The odds of being hospitalised due to COVID-19 were higher among those who had lower birthweight and mothers who were smoking during pregnancy.
COVID-19 Vaccine in Pregnancy and Breastfeeding
This US paper addresses how pregnant and/or breastfeeding women have not been included in studies to determine how well COVID-19 vaccines work or how safe they are. The authors believe the risk and benefit of the vaccine should be compared to each mother’s individual risk for getting COVID-19 as well as how well she is expected to tolerate the disease.
Breastmilk Harbors Antibodies to SARS-CoV-2
This article discusses the abundance of immunoglobulin antibodies, and a paucity of viral RNA, in breastmilk which offer evidence that women can safely continue breastfeeding during the pandemic.
Marketing of breastmilk substitutes during the COVID-19 pandemic
This article addresses how the infant formula industry has been actively exploiting concerns about COVID-19 to increase sales, in violation of the WHO International Code of Marketing of Breastmilk Substitutes and national law across the globe. These infant formula companies and large manufacturers of breastmilk substitutes have inappropriately positioned themselves as sources of public health expertise, and suggested various unnecessary hygiene measures, the use of expressed breastmilk, and the separation of mothers from their babies. Such recommendations undermine breastfeeding and thus increase the risk of infant death. Baby Milk Action and the International Baby Food Action Network have documented numerous infringements of both the Code and laws associated with COVID-19.
van Tulleken C, Wright C, Brown A, McCoy D, Costello A. Marketing of breastmilk substitutes during the COVID-19 pandemic [published online ahead of print, 2020 Oct 8]. Lancet. 2020;396(10259):e58. doi:10.1016/S0140-6736(20)32119-X
Breastfeeding support during Covid-19
This article addresses the removal of breastfeeding support services and the rise of misinformation related to breastfeeding safety during the coronavirus pandemic. To ascertain families’ experiences of breastfeeding, the authors of this article surveyed women who were breastfeeding their baby when lockdown changes started to occur in the UK about their experiences of breastfeeding support at this time. A total of 1360 mothers completed the survey between May and June 2020, with key findings including that the most common reasons for stopping breastfeeding were insufficient professional support, physical issues such as difficulties with latch, exhaustion, insufficient milk and pain. Seventy per cent of respondents said a lack of face to face support led to their decision to stop breastfeeding and 21% had been worried about the safety of breastfeeding during the pandemic. A further 4% had been told by a health professional that breastfeeding may not be safe during COVID-19.
NGOs defend breastfeeding as COVID-19 misinformation rages
This article discusses recent announcements by NGOs that the misinformation about the safety of breastfeeding during the coronavirus pandemic has led to decreases in the practice by women who fear it could harm babies.
Experiences of breastfeeding during COVID‐19: Lessons for future practical and emotional support
This article explores the effects of the Covid-19 pandemic on women’s breastfeeding experiences in the UK. An online survey of 1219 breastfeeding mothers in the UK with a baby 0-12 months old showed varying results: 41.8% of mothers felt that breastfeeding was protected due to lockdown, however 27.0% of mothers struggled to get support and had numerous barriers stemming from lockdown, with some stopping breastfeeding before they were ready. Mothers reported certain challenges, including lack of support, feelings of isolation and being confined to home. Additionally, mothers with a lower education, with more challenging living circumstances and from Black and minority ethnic backgrounds were more likely to find the impact of lockdown challenging and stop breastfeeding.
Mistakes from the HIV pandemic should inform the COVID-19 response for maternal and newborn care
Researchers discuss efforts by governments, professional organisations, and health facilities to institute policies that isolate newborns from their mothers which prevent breastfeeding in order to prevent infants being infected with Covid-19. Policy makers and practitioners are urged to learn from the mistakes of the HIV pandemic and not undermine breastfeeding; it is clear that in order to maximise infant health and wellbeing, COVID-19 policies should support skin-to-skin contact, maternal proximity, and breastfeeding.
Gribble, K., Mathisen, R., Ververs, M. et al. Mistakes from the HIV pandemic should inform the COVID-19 response for maternal and newborn care. Int Breastfeed J 15, 67 (2020). https://doi.org/10.1186/s13006-020-00306-8
Visitation restrictions: is it right and how do we support families in the NICU during COVID-19?
This article addresses how the Covid-19 pandemic has affected levels of care provided in hospitals and neonatal intensive care units around the globe and discusses the various new methods of supporting families both in-hospital and at home. The authors explore the ethical dilemma of separating parents and infants, particularly in regard to severely limited family visitation privileges.
Murray, P.D., Swanson, J.R. Visitation restrictions: is it right and how do we support families in the NICU during COVID-19?. J Perinatol 40, 1576–1581 (2020). https://doi.org/10.1038/s41372-020-00781-1
Breastfeeding link to COVID-19 is negligible, says World Health Organization
The World Health Organization (WHO) announced in August 2020 that the risk of Covid-19 infection from breastfeeding is negligible and has never been documented, and that the benefits of exclusive breastfeeding for six months for the infant and mother far outweigh any risk from Coronavirus. The organisation notes that not using mother’s own milk is linked to 820,000 child deaths a year and a cost of $300 billion to the global economy.
Implications of the COVID-19 Pandemic Response for Breastfeeding, Maternal Caregiving Capacity and Infant Mental Health
This article discusses the variable support for breastfeeding and the mother–infant dyad in policies and guidance developed in response to the coronavirus pandemic. Authors outline the benefits of breastfeeding during the pandemic, the current scientific understanding of any relationship between coronavirus and infants/human milk, and the current national guidance for newborn care in this context. Policies that are causing separation of mothers and babies and parallels to the HIV pandemic are also described.
Gribble, K., Marinelli, K., et al. (2020). Implications of the COVID-19 Pandemic Response for Breastfeeding, Maternal Caregiving Capacity and Infant Mental Health. https://doi.org/10.1177/0890334420949514
Covid-19 and maternal and infant health: Are we getting the balance right? A rapid scoping review
The purpose of this study was to summarise the evidence of the clinical and psychological impacts of Covid-19 on perinatal women and their infants. Results of the study found that despite the lack of evidence, many maternity services have been imposing severe restrictions on aspects of maternity care previously acknowledged as vital to optimum health (including birth companionship, breastfeeding, and contact between mother and baby).
Optimising mother-baby contact and infant feeding in a pandemic
Unicef UK Baby Friendly were delighted to be involved in a rapid analytic review by the RCM advisory group. The review offers evidence-based recommendations for midwives and maternity teams on optimising mother-baby contact and infant feeding during Covid-19 and explores the implications of the pandemic on breastfeeding and infant health, including the wearing of face masks.
When Separation is not the Answer: Breastfeeding Mothers and Infants affected by COVID‐19
This article discusses separation of mothers and babies affected by Covid-19, saying that separation causes cumulative harms and disrupts breastfeeding, thus preventing the ability to pass on protection against infectious disease. Authors also discuss the risk of “replaceability of breastfeeding” that is caused by separation of mothers and babies and therefore minimised rates of breastfeeding. According to the authors, separation does not ensure lower viral exposure and instead increases the burden on strained healthcare services. Health services are called to consider the short‐and‐long‐term impacts of separating mothers and infants in their policies.
Navigating pregnancy during the coronavirus disease (COVID-19) pandemic
This helpful article addresses the fear, uncertainty and anxiety that expectant mothers may be facing during the outbreak of the coronavirus disease (COVID-19). Unicef spoke with Franka Cadée, President of the International Confederation of Midwives to discuss common questions women may be having, including whether prenatal checkups are considered safe, if Covid-19 can be passed to the baby and whether giving birth in a hospital or healthcare clinic is still considered a good option. The interview covers a range of additional topics, including whether expecting mothers can have a partner or family member nearby during birth, how to protect a newborn from Covid-19 and more.
Maintaining safety and service provision in human milk banking: a call to action in response to the COVID-19 pandemic
This article calls on global policy leaders and funding agencies to recognise and prioritise the need to address four high-impact areas: (1) ensuring neonatal nutrition is an essential focus during emergencies; (2) funding research to optimise human milk bank systems in response to new infectious threats; (3) investing in innovation across all aspects of milk banking processes to improve the responsivity, access, and quality of donor milk provision; and (4) supporting the integration of learnings and innovations by the global milk bank community during COVID-19 into newborn, nutrition, and emergency response planning for future emergencies. The author notes that this is the best chance to keep infants healthy is to promote breastfeeding and a human milk diet and it is vital to avoid further straining the health system during the COVID-19 pandemic.