key: cord-0764859-hzwy4nwp
authors: Martins-Filho, Paulo Ricardo; Santos, Victor Santana; Santos, Hudson P.
title: To breastfeed or not to breastfeed? Lack of evidence on the presence of SARS-CoV-2 in breastmilk of pregnant women with COVID-19
date: 2020-04-27
journal: Rev Panam Salud Publica
DOI: 10.26633/rpsp.2020.59
sha: 07dbdd6b9ad63534ffd6bb195c39af45426f21c9
doc_id: 764859
cord_uid: hzwy4nwp

A rapid systematic review was carried out to evaluate the current evidence related to the presence of SARS-CoV-2 in breast milk from pregnant women with COVID-19. Eight studies analyzing the presence of SARS-CoV-2 RNA in the breast milk of 24 pregnant women with COVID-19 during the third trimester of pregnancy were found. All patients had fever and/or symptoms of acute respiratory illness and chest computed tomography images indicative of COVID-19 pneumonia. Most pregnant women had cesarean delivery (91.7%) and two neonates had low birthweight (< 2 500 g). Biological samples collected immediately after birth from upper respiratory tract (throat or nasopharyngeal) of neonates and placental tissues showed negative results for the presence SARS-CoV-2 by RT-PCR test. No breast milk samples were positive for SARS-CoV-2 and, to date, there is no evidence on the presence of SARS-CoV-2 in breast milk of pregnant women with COVID-19. However, data are still limited and breastfeeding of women with COVID-19 remains a controversial issue. There are no restrictions on the use of milk from a human breast milk bank.

SARS-CoV-2 is a novel emerged positive-strand RNA virus associated with an acute respiratory distress disease known as COVID-19. Studies have suggested that transmission of SARS-CoV-2 is primarily from person to person through respiratory droplets (1, 2) . In addition, there is emergent evidence that the virus could be detected in biological fluids including bronchoalveolar lavage fluid specimens (3), blood (3, 4) and saliva (5) , but substantial knowledge gaps remain regarding the presence of SARS-CoV-2 in the breast milk. Recently, a report in Science discussed the wrenching choices of pregnant women with COVID-19 after childbirth including whether or not they should breastfeed their children (6) .

We performed a rapid systematic review to evaluate the current evidence related to the presence of SARS-CoV-2 in breast milk from pregnant women with COVID-19. The study was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines (7), but given emergency-need for this review, PROSPERO registration was not sought. 

We found eight studies (8) (9) (10) (11) (12) (13) (14) (15) analyzing the presence of SARS-CoV-2 RNA in the breast milk of 24 pregnant women with COVID-19 during the third trimester of pregnancy (Table 1) . All patients had fever and/or symptoms of acute respiratory illness and chest computed tomography (CT) images indicative of COVID-19 pneumonia. Most pregnant women had cesarean delivery (91.7%) and two neonates had low birthweight (< 2,500 g). Biological samples collected immediately after birth from upper respiratory tract (throat or nasopharyngeal) of neonates and placental tissues showed negative results for the presence SARS-CoV-2 by RT-PCR test. In addition, no breast milk samples were positive for SARS-CoV-2. In three studies (10, 12, 13) there was a clear recommendation for mother's to not breastfeed their children despite the lack of evidence on the potential viral transmission via breast milk.

As the coronavirus pandemic takes hold, pregnant women infected with SARS-CoV-2 experience fear and uncertainties regarding the care of their child. Making decisions without a robust evidence base may influence mother-child interactions and lead to poor outcomes. Furthermore, there is a lack of consensus among health agencies regarding breastfeeding for women with COVID-19. In February 2020, the National Health Commission of China recommended that neonates of pregnant women with suspected or confirmed COVID-19 should be isolated in a designated unit for at least 14 days and should not be breastfeed due to the high risk of infection (16) . Although this expert working group has suggested breastfeeding only in cases of negative tests for SARS-CoV-2, this warning may contribute to reducing breastfeeding by women with no exposure to the virus which may lead to infant poor health outcomes. On the other hand, interim guidance provided by the Centers for Disease Control and Prevention (CDC) (17) and the World Health Organization (WHO) (18) advises that breastfeeding should be determined by the mother in coordination with her family and healthcare providers, and all possible prevention measures to avoid spreading the virus to the infant must be taken including wearing a mask and washing hands and breasts with soap and water before breastfeeding. If the woman opts to express breast milk, all recommendations for cleaning the breast pumps and utensils after each use must be rigorously followed. Consideration should be given to the possibility of someone healthy providing breast milk to the infant using a cup or spoon. This person must receive training from a qualified professional before starting procedures. If there is no production of breast milk by the mother, a human milk bank should be contacted. There are no restrictions on the use of milk from a human breast milk bank (19, 20) . The possibility of drug excretion into breast milk with potential adverse effects in breastfeed neonates should also be analyzed (21) . To date, there is no evidence on the presence of SARS-CoV-2 in breast milk of pregnant women with COVID-19. Data provided on current literature are still limited and breastfeeding of women with COVID-19 remains a controversial issue. Further studies with large samples are needed to confirm these results particularly given the importance of breastfeeding in preventing other childhood illnesses. Lactancia materna en mujeres con COVID-19: falta de evidencia sobre la presencia de SARS-CoV-2 en la leche materna RESUMEN Se llevó a cabo una revisión sistemática rápida para evaluar la evidencia disponible sobre la presencia de SARS-CoV-2 en la leche materna de mujeres embarazadas afectadas con COVID-19. Se encontraron ocho estudios que analizaron la presencia de ARN de SARS-CoV-2 en la leche materna de 24 mujeres embarazadas con COVID-19 durante el tercer trimestre del embarazo. Todas las pacientes tenían fiebre o síntomas de enfermedad respiratoria aguda e imágenes de tomografía computarizada de tórax indicativas de neumonía por COVID-19. La mayoría de las mujeres embarazadas (91,7%) tuvieron un parto por cesárea y dos neonatos presentaron bajo peso al nacer (< 2 500 g). Las muestras biológicas recogidas inmediatamente después del parto de las vías respiratorias superiores (faringe o nasofaringe) de los neonatos y los tejidos placentarios mostraron resultados negativos para SARS-CoV-2 mediante RT-PCR. Ninguna muestra de leche materna fue positiva para SARS-CoV-2 y, hasta la fecha, no hay evidencia de la presencia de SARS-CoV-2 en la leche materna de las mujeres embarazadas con COVID-19. Sin embargo, los datos disponibles todavía son limitados y la lactancia materna en las mujeres con COVID-19 sigue siendo un tema controvertido. No hay restricciones para el uso de leche materna de banco.

Infecciones por coronavirus; virosis; pandemias; virus del SRAS; lactancia materna.

A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster

First known person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the USA

Detection of SARS-CoV-2 in Different Types of Clinical Specimens

Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore

Consistent detection of 2019 novel coronavirus in saliva

New coronavirus leaves pregnant women with wrenching choices-but little data to guide them

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records

Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn

Perinatal Transmission of COVID-19 Associated SARS-CoV-2: Should We Worry? Clin Infect Dis

Lack of Vertical Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, China. Emerg Infect Dis

Coronavirus disease 2019 (COVID-19) during pregnancy: a case series

A case report of neonatal COVID-19 infection in China

Vaginal Delivery Report of a Healthy Neonate Born to a Convalescent Mother with COVID-19

Clinical characteristics of 19 neonates born to mothers with COVID-19

Chinese expert consensus on the perinatal and neonatal management for the prevention and control of the 2019 novel coronavirus infection

World Health Organization. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts. Interim guidance

Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings

Coronavirus (COVID-19) Infection in Pregnancy. Information for healthcare professionals. Version 1: Published Monday

Breastfeeding and Respiratory Antivirals: Coronavirus and Influenza

As amostras biológicas coletadas imediatamente após o nascimento do trato respiratório superior (faringe ou nasofaringe) de neonatos e tecidos placentários apresentaram resultados negativos para a presença do SARS-CoV-2 pelo teste RT-PCR. Nenhuma amostra de leite materno foi positiva para o SARS-CoV-2 e, até à data, não há evidências da presença do SARS-CoV-2 no leite materno de mulheres grávidas com COVID-19. No entanto, os dados ainda são limitados e a amamentação de mulheres com COVID-19 continua a ser uma questão controversa

Infecções por coronavirus; viroses; pandemias; vírus da SARS

Author contributions. All authors conceived the original idea and contributed to the analysis and interpretation of the results. All authors reviewed and approved the final version.Disclaimer. Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH or the Pan American Health Organization (PAHO).