Human Milk Banking and SARS CoV-2 update. 12 March 2021
Prof Anna Coutsoudis & Dr Penny Reimers

COVID-19: Breastfeeding and human milk banking

Please note: This information is accurate as of today but new information about COVID-19 transmission is emerging daily. Please consult resources such as the CDC and the WHO for the most recent guidance.

Breastfeeding

Breast milk is the optimum source of nutrition for babies, yet the emergence of COVID-19, caused by the novel coronavirus SARS has raised questions both about the safety of breastfeeding and human milk banking.

Although there is much unknown about COVID-19, the recommendations below, sourced from the Center for Disease Control and Preventions (CDC) in the USA,  The World Health Organisation, UNICEF, the Human Milk Banking Association of North America (HMBANA), the European Milk Bank Association and the Academy of Breastfeeding Medicine (AMB) all agree breastfeeding should be continued.

According to the CDC, to date the virus has not been isolated in the breastmilk of infected women. Neither is there evidence at this stage, that the virus can be transmitted through breastmilk. Although the virus was not found in the breastmilk of infected women, antibodies against SARS-CoV were detected in one sample.(Center for Disease Control and Prevention [CDC], 2020)

Given low rates of transmission of respiratory viruses through breast milk, the World Health Organization states that mothers with COVID-19 can breastfeed. UNICEF too are encouraging mothers infected with COVID-19 to continue breastfeeding while taking precautions which include wearing a mask when feeding or near the baby, frequent hand washing before and after handling the baby and disinfecting all surfaces. These practice careful  practices should continue for at least 5-7 days until cough and respiratory secretions are dramatically improved.Should the mother be too ill to breastfeed, expressed breastmilk can be fed to the baby. (UNICEF,2020).

No evidence of the virus was found in breastmilk, cord blood, amniotic fluid or throat swabs of newborns whose mothers had tested positive for the virus (Chen et al., 2020).

Editor-in-Chief of Breastfeeding MedicineArthur Eidelmanstates: “Given the reality that mothers infected with coronavirus have probably already colonized their nursing infant, continued breastfeeding has the potential of transmitting protective maternal antibodies to the infant via the breast milk. Thus, breastfeeding should be continued with the mother carefully practicing handwashing and wearing a mask while nursing, to minimize additional viral exposure to the infant” (Liebert, 2020).

https://www.bfmed.org/abm-statement-coronavirus

ACADEMY OF BREASTFEEDING MEDICINE STATEMENT ON CORONAVIRUS 2019 (COVID-19)

IN HOSPITAL

The choice to breastfeed is the mother’s and families.

If the mother is well and has only been exposed or is a PUI with mild symptoms, breastfeeding is a very reasonable choice and diminishing the risk of exposing the infant to maternal respiratory secretions with use of a mask, gown and careful handwashing is relatively easy.

If the mother has COVD-19, there may be more worry, but it is still reasonable to choose to breastfeed and provide expressed milk for her infant. Limiting the infant’s exposure via respiratory secretions may require more careful adherence to the recommendations depending on the mother’s illness.

There are several choices in the hospital concerning housing for a breastfeeding mother and her infant.

  1. Rooming-in (mother and baby stay in the same room without any other patients in that room) with the infant kept in a bassinet 6 feet from the mother’s bed and taking precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, for direct contact with the infant and while feeding at the breast. Ideally, there should be another well adult who cares for the infant in the room.
  2. Temporary separation – primarily because the mother is sick with the COVID-19 infection and needs medical care for herself in the hospital. Mothers who intend to breastfeed / continue breastfeeding should be encouraged to express their breast milk to establish and maintain milk supply. If possible, a dedicated breast pump should be provided. Prior to expressing breast milk, mothers should practice hand hygiene. After each pumping session, all parts that come into contact with breast milk should be thoroughly washed and the entire pump should be appropriately disinfected per the manufacturer’s instructions. This expressed breast milk should be fed to the newborn by a healthy caregiver.

Mothers and families may need additional guidance and support to continue breastfeeding, to utilize expressed breast milk, to maintain her milk production and to store milk for later use while the mother is sick with COVID-19.

Human Milk Banking

Human Milk Banks have numerous safety measures in place which ensure that every bottle of donor milk is safe. These included careful screening of potential donors as well as proven pasteurisation methods, which kill viruses and bacteria and microbiology testing of the milk.

Despite the fact that COVID-19 is a new virus and there is limited data about it, the similarities with SARS and MERS are pertinent and can be applied to milk banking namely, that these viruses are inactivated by Holder pasteurisation (62.5° C for 30 minutes.

Notwithstanding this HMBASA proposes additional screening questions be added to the current lifestyle/health questionnaire:

  • Have you travelled through or stayed in a high-risk area during the past 14 days?
  • Have you been in close contact with any confirmed or suspected case of Covid-19?
  • Have you attended a facility where a positive case of Covid-19 has been confirmed?

If any responses are positive, these donors should be suspended for 14 days. Should any donor mothers become ill with signs of a respiratory infection the milk banks should be notified immediately (EMBA,2020).

References:

  1. Center for Disease Control and Prevention (CDC). (2020). Interim guidance on breastfeeding for a mother confirmed or under investigation for COVID-19. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-guidancebreastfeeding.html
  2. UNICEF. Coronavirus disease: What parents should know. Available at: https://www.unicef.org/stories/novel-coronavirus-outbreak-what-parents-should-know
  3. Chen, H., Guo, J., Wang, C., Luo, F. L., Yu, X., Zhang, W., Li, W, et al. (2020) Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records. The Lancet. Advanced online publication. DOI:10.1016/S0140-6736(20)30360-3
  4. Liebert, M.L. Coronavirus treatment and risk to breastfeeding women. Available at: https://eurekalert.org/pub_releases/2020-03/mali-cta030420.php
  5. European Human Milk Banking Association Covid-19: EMBA position statement. Available at : https://europeanmilkbanking.com/covid-19-emba-position-statement/
  6. Academy of Breastfeeding Medicine. ABM statement on corona virus 2019 (COVID-19). Available at :https://www.bfmed.org/abm-statement-coronavirus

Guidance on breastfeeding for mothers with confirmed COVID-19 or under investigation for COVID-19

Breast milk is the best source of nutrition for most infants. However, much is unknown about COVID-19. Whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and healthcare providers.  A mother with confirmed COVID-19 or who is a symptomatic PUI should take all possible precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, if possible, while feeding at the breast.  If expressing breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is well feed the expressed breast milk to the infant.

Considering the benefits of breastfeeding and the insignificant role of breastmilk in the transmission of other respiratory viruses, the mother can continue breastfeeding, while applying all the necessary precautions.

For symptomatic mothers well enough to breastfeed, this includes wearing a mask when near a child (including during feeding), washing hands before and after contact with the child (including feeding), and cleaning/disinfecting contaminated surfaces – as should be done in all cases where anyone with confirmed or suspected COVID-19 interacts with others, including children.  

If a mother is too ill, she should be encouraged to express milk and give it to the child via a clean cup and/or spoon – all while following the same infection prevention methods.

The virus spreads mainly from person to person by close contact (0-2 meters) and it is transmitted via respiratory droplets produced when an infected person sneezes or coughs. It may be possible that a person can get COVID-19 by touching a surface or object contaminated by infected respiratory secretions and then touching his or her own mouth, nose, or eyes, but, so far, this is not thought to be the main way the virus spreads. Infected people are thought to be most contagious when they are most symptomatic. However, as with other respiratory infections, some spread might be possible before symptoms appear.

This justifies all the precautions which are recommended by the health authorities in order to limit the transmission of the virus (http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19).

Regarding human milk donation:

Human milk is essential for premature infants, as it significantly reduces the risk of serious complications related to prematurity, in the short and long term.

Human milk donation is organized and supported by EMBA according to the common rules concerning the selection of donors based on a health questionnaire and on blood sampling as well as the handling and treatment of milk by pasteurisation, in accordance with the EMBA documents1,2.

Regarding breastmilk and SARS CoV-2:

It is not yet known whether SARS CoV-2 can be found in human milk, and if found, it could be contagious.

Other coronaviruses are destroyed by thermal inactivation3. In particular, MERS-coronavirus is inactivated in camel, goat and cow’s milk at 63°C for 30 min4. However, it should be pointed out that the few available studies simulated pasteurisation in small aliquots, a procedure that does not follow human milk bank protocols. Based on the available data on other coronaviruses it is likely that, even if SARS CoV-2 is present in breastmilk, it could also be destroyed by pasteurisation, but solid data is needed.

Taking into account the available information, EMBA recommends to add to the health questionnaires utilised to screen human milk donors, specific questions concerning the risk of being a suspected or probable case (refer to the “Case” definition on the World Health Organization website: https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov)).

For example:

  • Having stayed or transited in a risk zone during the previous 14 days
  • Close contact with a confirmed or probable case of SARS CoV-2 infection during its symptomatic phase
  • Person who worked in or attended a health care facility in which a case of SARS CoV-2 infection has been confirmed.

This makes it possible to temporarily suspend the recruitment of these mothers for 2 weeks, in order to ensure that they do not become ill during this period of time.

If an already established donor develops signs of possible SARS-CoV2 infection (severe acute respiratory infection: cough, fever, sore throat etc.) with no other etiology that fully explains the clinical presentation, and/or reports a risk exposure in the 14 days preceding the milk donation,  a rhinopharyngeal swab is recommended. Donation should be temporary discontinued until the result of the swab. If the culture is positive for SARS CoV-2, donation should be interrupted until a negative culture is found. If the culture is negative for SARS CoV-2, donation can be continued.

Regarding hygiene in human milk banks

EMBA recommends strict observation of the hygienic rules regarding collection, storage and handling of donated human milk1.

References

  1. Weaver G et al. Recommendations for the Establishment and Operation of Human Milk Banks in Europe: A Consensus Statement From the European Milk Bank Association (EMBA). Front. Pediatr. 7:53 (2019).
  2. Moro GE et al. Processing of Donor Human Milk: Update and Recommendations From the European Milk Bank Association (EMBA). Front. Pediatr. 7:49 (2019).
  3. Duan SM et al. Stability of SARS coronavirus in human specimens and environment and its sensitivity to heating and UV irradiation. Biomed Environ Sci. 16(3):246-55 (2003).

van Doremalen N et al. Stability of Middle East Respiratory Syndrome Coronavirus in Milk. Emerg Infect Dis. 20(7):1263-1264 (2014).

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