key: cord-0966287-1yvypblr authors: Williams, Julianne; Namazova-Baranova, Leyla; Weber, Martin; Vural, Mehmet; Mestrovic, Julije; Carrasco-Sanz, Angel; Breda, Joao; Berdzuli, Nino; Pettoello-Mantovani, Massimo title: The importance of continuing breastfeeding during COVID-19: in support to the WHO statement on breastfeeding during the pandemic date: 2020-05-11 journal: J Pediatr DOI: 10.1016/j.jpeds.2020.05.009 sha: 4d158d5a63a301bdb71c86508e1fdae82c0eeded doc_id: 966287 cord_uid: 1yvypblr nan There are many questions and concerns about the coronavirus disease (COVID-19) 1 , including its implications for breastfeeding. This commentary draws upon a statement and recommendations recently issued by the Regional Office for Europe of the World Health Organization with the contribution of the European Pediatric Association-Union of National European Pediatric Societies and Associations (EPA-UNEPSA) and other main European pediatric organizations 1 , Our aim is to disseminate provide pediatricians with further guidance on breastfeeding and related safety measures during COVID- 19, particularly in instances where a mother has or may have COVID-19. The coronavirus 2019 epidemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 2 increasing over time 6, 7 , but questions remain, including questions about breastfeeding, particularly in instances when a mother may be infected with COVID 19. The protection, promotion and support of breastfeeding are a priority for public health 8 and WHO has been continuously compiling evidence on the effect of COVID on mothers and children 3, 9 Breastfeeding during the COVID-19 pandemic According to the WHO, mothers with COVID-19 (or suspected COVID-19) can breastfeed their babies as long as they take appropriate precautions 9, 10 . Breast milk encloses various antimicrobial substances, anti-inflammatory components and factors that promote the development of immune system and reduce the occurrence of respiratory tract infections 11 . The WHO statement 9 emphasizes again that breast milk contains all the nutriments in appropriate proportions essential for the healthy growth of infants, who can benefit from breastfeeding also from mothers with COVID-19 infection confirmed or suspected. Breastfeeding guarantees many health benefits for both the mother and infant and it is recognized as the ideal food for children in the first six months of life, constituting a primary form of promoting the child's health and development 7 . Breast milk is perfectly adjusted to the infant's nutrition requirements and growth, as it contains all the nutrients an infant needs, as well as various antimicrobial substances, antiinflammatory components and factors that promote immune development 12 . It enhances the immature immune system of the infant and strengthens defense mechanisms against infectious and other agents throughout the breastfeeding period 12 . Several studies demonstrated that continued, frequent breastfeeding is associated with greater linear growth and further protects child health by delaying maternal fertility postpartum and reducing the child's risk of morbidity and mortality 13 . 15 . A case study from Australia, described a mother with COVID-19 not separated from her infant; breast feeding appears possible and safe when viral precautions are observed 20 . Further studies are needed to confirm these results. Even if virus is transmitted occasionally, risks and benefits would have to be balanced, and the long term risks of not breastfeeding would need to enter the equation. As the data currently available show that clinical feature of COVID-19 in children and infants is generally mild and risks for viral transmission from mother to child are likely to be directly related to a COVID-19 infection affecting the respiratory tract of mothers 14 , the potential risks for newborns seem to be minimal. Women with confirmed or suspected COVID-19 infection are encouraged to breastfeed in absence of other limitations. However, precautions should be taken to minimize potential problems (Table) . Roomsharing and uninterrupted mother-infant proximity is recommended as an important factor for establishing good breastfeeding also for mothers with COVID-19, providing that specific and appropriate respiratory and skin hygiene measures are taken (Table) . If mothers are unable to breastfeed due to severe health conditions caused by COVID-19, they should receive support from competent health care professionals. They may be advised to provide breast milk to their infants via safe alternative methods, such as the provision of expressed milk or relactation (the process of restarting breastfeeding after a gap or very little breastfeeding). If that is not possible other alternatives can be considered, such as the use of certified donor milk bank services, designed to protect the incoming milk supply by rigorous screening criteria for milk donors 21, 22 . Current WHO recommendations indicate that mothers should provide exclusive breastfeeding to their babies during the first six months of life 24 . After the addition of solid food, mothers are advised to continue breastfeeding for at least six additional months and, if possible, to continue this practice up to the age of two years and beyond. Therefore, COVID-19 affected or suspected mothers should be informed about the importance to continue providing their infants breast milk, and that this goal can be achieved by adopting appropriate hygiene and safety practices. The document on COVID-19 and breastfeeding developed by the WHO Regional Office for Europe, strongly supports the continuation of this practice during COVID-19, which is key for ensuring the health of children. EPA-UNEPSA, on behalf of its National European pediatric societies and associations, strongly and actively collaborates with the WHO regional office in promoting the position that breast milk is the ideal food for infants, as it is safe, clean and provides all the energy and nutrients that the infant needs for the first months of life. Breast milk contains antibodies, which help protect children against many common childhood illnesses, and breastfeeding confers many short-and long-term health benefits for both the mother and child. Efforts should be made to properly advise and support mothers with breastfeeding, even in instances when the mother has confirmed or suspected COVID-19 infection. • If clinical conditions prevent to breastfeed or express breastmilk, explore the possibility to practice relactation (restarting breastfeeding after a gap), or using donor human milk though certified donor milk banking. (The adopted approach will depend on cultural context, patients acceptability and availability of services) Advised measures for staff working in maternity and newborn services • Breastmilk substitutes, feeding bottles, teats, pacifiers or dummies should not be promoted by staffs providing maternity and newborn services • Mothers and infants should be enabled to remain together, practice skin-to-skin contact and room-in throughout the day and night, whether or not the mother or child has suspected, probable, or confirmed COVID-19. Especially straight after birth during establishment of breastfeeding European Pediatric Association/Union Of National European Pediatric Societies And Associations (EPA/UNEPSA) Covid-19 -Navigating the Uncharted COVID-19) outbreak. Coronavirus disease (COVID-19) outbreak Pediatric Patients With 2019 Coronavirus Disease in China Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention Report of the WHO-China Joint Mission on Coronavirus Disease United Nations Children's Fund. Innocenti declaration on the protection, promotion and support of breastfeeding. New York: unicef's Nutrition Cluster Coronavirus disease (COVID-19) technical guidance: Infection prevention and control Corona Virus Breastfeeding durationand exclusivity associated with infants' health and growth: data from a prospective cohort study in Bavaria Breast-feeding: A commentary by the ESPGHAN Committee on Nutrition World Health Organization. WHO. e-Library of Evidence for Nutrition Actions (eLENA) Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia Lack of vertical transmission of severe acute respiratory syndrome coronavirus 2, China. Emerg Infect Dis Analysis of the pregnancy outcomes in pregnant women with COVID-19 in Hubei Province What are the risks of COVID-19 infection in pregnant women? COVID-19 vaginal delivery-a case report International Perspectives Concerning Donor Milk Banking During the SARS-CoV-2 (COVID-19) Pandemic European Milk Banking Association Milk banking and COVID-19 Exclusive breastfeeding for six months best for babies everywhere