REVISIÓN DE LA LITERATURA
BREASTFEEDING IN CHILDREN WITH MOTHERS SUFFERING
FROM COVID-19. RISK OR BENEFIT?
Arévalo Zabala Carina1*, Chalco Navas Jorge2.
The Covid-19 pandemic has led to multiple health problems. At the beginning
lack of knowledge about the risk of transmission of the virus through
breastfeeding has triggered the suspension of breastfeeding and early
postpartum attachment in several areas of the world, over the benets that
these behaviors bring to the mother and the newborn.
Objective:
Carry out a search and analysis of the available scientic literature on
breastfeeding and its risk of transmission to the newborn, as well as the risk of
transmission during childbirth and early attachment.
Methods:
A systematic search was conducted in PUBMED, LILACS, MEDLINE and SCIELO
with the search terms: Breastfeeding and Covid-19, vertical transmission, and
Covid-19, it was veried that the articles have a description of the type of
delivery, type of study performed to conrm the presence of the virus in the
mother, newborn, and breast milk. English and Spanish studies were included.
Conclusions:
Up to now, there is scientic evidence showing that there is neither risk of
virus transmission through breastfeeding, nor vertical transmission or early
attachment to be a risk factor for the transmission of the virus to newborns.
La Pandemia por Covid-19 ha llevado a que existan múltiples complicaciones
en el área de la salud. A sus inicios la falta de conocimiento sobre el riesgo
de transmisión del virus por la lactancia materna desencadenó que en varias
zonas del mundo se proceda a suspender la lactancia y el apego precoz
posterior al parto, por sobre los benecios que trae estas conductas a la
madre y al recién nacido.
Objetivo:
Realizar una búsqueda y análisis de la literatura cientíca disponible sobre
lactancia materna y su riesgo de transmisión al recién nacido, además el
riesgo de transmisión durante el parto y apego precoz.
Métodos:
Se realizó una búsqueda sistemática en PUBMED, LILACS, MEDLINE y SCIELO
con los términos de búsqueda: Lactancia Materna y Covid-19, transmisión
vertical y Covid-19, se verico que los artículos cuenten con descripción del
tipo de parto, tipo de estudio realizado para conrmar la presencia del virus
en la madre, el recién nacido y la leche materna. Se incluyeron estudios en
inglés y español.
Conclusiones:
Al momento existe evidencia cientíca que demuestra que no existe riesgo de
transmisión del virus por la lactancia materna, tampoco se ha comprobado
la transmisión vertical o que el apego precoz sea un factor de riesgo para la
transmisión del virus a los recién nacidos.
Revista Médica Vozandes
Volumen 32, Número 2, 2021
Resumen
LACTANCIA MATERNA EN HIJOS DE MADRES CON
COVID-19. ¿RIESGO O BENEFICIO?
49
Abstract
Palabras clave: lactancia materna, conducta en la lactancia, leche humana, sustitutos de la leche, Infección
por Covid-19, Virus del SARS CoV2.
Forma de citar este artículo: Arévalo
ZC, Chalco NJ. BREASTFEEDING
IN CHILDREN WITH MOTHERS
SUFFERING FROM COVID-19. RISK OR
BENEFIT?. Rev Med Vozandes. 2021; 32
(2): 49 - 53
1 Universidad Central del Ecuador, Facultad de Cien-
cias Médicas, Posgrado de Pediatría. Quito - Ecuador
2 Hospital General IESS San Francisco. Médico del
servicio de Pediatría. Quito - Ecuador.
ORCID ID:
Arévalo Zabala Carina
orcid.org/0000-0001-6536-0064
Chalco Navas Jorge
orcid.org/0000-0002-1590-5844
Este artículo está bajo una
licencia de Creative Com-
mons de tipo Reconocimien-
to – No comercial – Sin obras
derivadas 4.0 International.
DOI: 10.48018/rmv.v32.i2.7
*Corresponding author: Arévalo Zabala Carina
E-mail: caribel159@hotmail.com
Received: 27 – Sep – 2021
Accepted: 22 – Nov – 2021
Publish: 20 – Dic – 2021
Article history
Conflict of interest: The authors declare no conict
of interest.
Financial disclosure: The authors have no nancial
relationships relevant to this article to disclose
Authors’ contribution: Carina Arévalo concep-
tualized and compiled articles of high impact scientic
evidence, analyzed and interpreted the results and then
wrote the article in a critical way.
Jorge Chalco conducted a critical review of the article.
Keywords: breastfeeding, breastfeeding behavior, human milk, Covid-19 infection, SARS virus CoV2.
50 Revista Médica Vozandes
Volumen 32, Número 2, 2021
BACKGROUND
The severe pulmonary disease of unknown etiology was rst
described in December 2019 in China. In January 2020 it was
identied as part of the coronavirus family being named by
the World Health Organization (WHO) as coronavirus of 2019
(Covid-19)1.
The disease caused major public health devastation and
spread rapidly to other countries. On January 30 the Covid-19
epidemic is declared by WHO “a public health emergency of
international concern”. Gradually the virus became a public
health emergency as it spread rapidly to other continents and
on March 11, Dr. Tedros Adhanom Ghebreyesus, head of WHO,
announced Covid-19 as pandemic2.
In the 2009 AH1N1 inuenza pandemic, pregnant women
represented 1% of those infected, besides, SARS CoV1 and MERS
have shown to cause serious complications during pregnancy,
so the studies were based on clarifying the risks of Covid-19 in
this age group3.
In September 2020, the Panamerican Health Organization
(PAHO) reported that more than 60,000 cases of Covid-19
occurred in pregnant women, including 458 maternal deaths
in the Americas, and called for intensied efforts to ensure
adequate prenatal care.
In Ecuador, up to July 2021, there are more than 480,720
patients infected by Covid-19, being Pichincha and Guayas
provinces with the highest percentage of cases4. In the
Americas, 258,359 cases of COVID-19 in pregnant women were
reported in July, including 2,375 deaths. In Ecuador, 10,207
cases were reported with 48 deaths, corresponding to 0.47%
of the cases, while infants continue to be the smallest age
group infected, representing 0.2% of the cases 4,5. Although the
symptoms of Covid-19 in children are less severe than in adults,
there has been evidence of increased rates of infection and
occurrence of MIDS in children, which increases the risk of
requiring intensive care and increases morbidity and mortality.
The PAHO has reported 4960 conrmed cases of MIDS in the
Americas, including 111 deaths 4,6.
The lack of knowledge as to whether SARS-CoV2 can be
transmitted from mother to child during breastfeeding
led to the rst preventive measures being taken early in
the pandemic. In China, the mother and the newborn
were separated until they tested negative for Covid-19,
resorted to cesarean section before cephalo-vaginal
delivery, suspended breastfeeding to the newborn until
the mother tested negative for Covid-19 because of the
risk of transmission, and avoided early attachment after
birth7,8. Initially, there were many questions about the proper
management of newborns and the use of breast milk, which
led to several investigations being carried out, clarifying the
means of transmission and maintaining the concept of the
best diet based on breast milk.
METHODS
A search for scientic evidence was conducted
in PUBMED, LILACS, MEDLINE and SCIELO using
the following search strategy: “breastfeeding”
AND “COVID-19” or “human milk” AND “SARS-
CoV-2”. Only studies in English and Spanish were
considered.
There were excluded all studies that did not refer
to the subject to be evaluated according to the
abstract, studies that did not mention method of
detection of Covid-19 in the mother or newborn,
and those studies for which the full text was not
available.
COVID-19 AND ITS TRANSMISSION
THROUGH BREAST MILK.
Breastfeeding has been shown in countless
studies to provide great benets to both mother
and newborn. The relationship between mother
and child provides great benets in the neural
system, becoming one of the most important
moments in the life of the human being, it
is the rst interaction with the outside world,
stabilizes breathing and temperature9, provides
great immunological benets to the newborn,
breastfeeding infants have a 64% reduction in the
incidence of intestinal infections, reduces by 74%
the severity of Respiratory Syncytial Virus, provides
nutrients for the development of the child; it offers
benets to the mother such as reducing the risk of
postpartum depression, anemia, breast cancer,
among others 10,11.
The coronavirus uses the Angiotensin 2
(ACE2) receptor for its internalization into the
body’s cells, this receptor is widely distributed
throughout the body including in the epithelial
cells of mammary glands. For this reason, there
is a possibility that the virus may be transmitted
through breastfeeding 12.
Lactoferrin is considered an important factor in
breast milk. Lactoferrin is known to inhibit both
the attack and growth of Respiratory Syncytial
Virus (RSV) and adenovirus. In the SARS CoV
epidemic in 2002, studies revealed that lactoferrin
competes with the binding sites of the virus, it
means it competes with the ACE2 receptors
inhibiting infection. SARS-CoV2 shares the same
binding site as SARS-CoV, so breast milk could
be a protective factor in reducing transmission
of the virus to the newborn 13. Another defense
mechanism provided by breastfeeding is the
demonstrated increase of type I interferon in
children infected with inuenza virus. In patients
BREASTFEEDING IN CHILDREN WITH MOTHERS
SUFFERING FROM COVID-19 (...) Arévalo Zabala C, et al.
51
REVISIÓN DE LA LITERATURA
Revista Médica Vozandes
Volumen 32, Número 2, 2021
with Covid-19 it has been shown that there is an altered
response of this interferon, so breastfeeding can become
an ally of defense against SARS-CoV214.
After recognizing the great properties of breast milk and in
view of the advent of the pandemic, both the CDC and
several hospitals in China decided to suspend breastfeeding
of mothers with Covid-19, several studies were conducted
to determine the presence of the virus in breast milk and
determine whether there is a risk of transmission by this
means.
In China, Yang et al. carried out a review of breastfeeding
in children born to mothers with Covid-19, they evaluated
13 mothers who tested positive for Covid-19, but all were
negative when tested for nucleic acid in breast milk8.
Wang et al. described a study of a 34-year-old woman who
presented Covid-19 infection in the third trimester, after
birth both mother and child tested positive for the virus, but
the nasopharyngeal swab of the newborn was taken at 36
hours of life, the newborn was separated from its mother
from birth and received breast milk substitutes, and the test
for SARS-CoV2 in breast milk was negative. In this study it
was not possible to determine the means of infection of the
newborn15.
Liu et al., presents another case series of 19 mothers infected
with Covid-19, RT-PCR test was performed on breast milk
from 10 mothers whose results were negative, the form of
breast milk collection was not specied16.
Gao et al. conducted a more detailed study measuring the
presence of antibodies against Covid-19 in breast milk, the
study was performed in 7 pregnant women with positive
RT-PCR for Covid-19, the presence of the nucleic acid was
not evidenced in any sample of breast milk, in 3 samples
neutralized antibodies against SARS-CoV2 were identied17.
Fox et al. conducted a study using breast milk specically
from mothers with Covid-19, 15 milk samples were taken,
each of 30 ml between days 14 and 30 after presenting
symptoms, 80% of the samples analyzed showed IgA
reactivity, of the 12 positive samples 4 showed reactivity for
IgG and IgM, 2 samples showed positivity for IgG and not
for IgM and one sample showed reactivity for IgM and not
for IgG. This study demonstrated the presence of antibodies
against SARS-CoV2 in breast milk, which can be transmitted
to the newborn, improving its immunological status18.
Dong et al. published another case of a 33-year-old
woman who presented a positive picture for Covid-19 at 38
weeks of gestation, the delivery was uncomplicated and
in the same room an oropharyngeal smear was performed
on the newborn, which was negative for Covid-19. Breast
milk samples were collected to detect SARS-CoV2 RNA
and were negative. Elisa detected antibody levels against
SARS-CoV2, IgG and IgA. At hospital discharge, antibodies
were performed on the newborn, who presented IgG
titers. A month and a half after discharge, antibodies
were performed on the mother, her breast milk and the
newborn, and the persistence of high levels of IgG
in maternal serum and breast milk was evidenced,
but no antibodies were detected in the newborn19.
The antibodies transmitted from mother to child
have a duration of 6 to 12 months, what is striking
in this study is the short duration of antibodies in the
newborn, which shows that it is still vulnerable to
infection by the virus.
There are two cases published by different authors
that evidenced the presence of Covid-19 virus
genetic material in breast milk without demonstrating
its virulence capacity, the rst study published by
Grob et al, followed two breastfeeding mothers with
positive Covid, mother one presented respiratory
symptoms from the second day of delivery, the
newborn and the mother were isolated, both were
Covid positive. Mother 2 was hospitalized in the
same room as mother 1 after delivery, after being
separated after mother 1 presented symptoms
mother 2 was discharged on the 4th day with the
newborn. On the 8th day, mother 2 presented mild
symptoms and was hospitalized, two days later
the newborn presented symptoms, and both were
positive for SARS-CoV2. In both mothers, breast
milk samples were collected after performing an
adequate hand and breast disinfection process, the
rst obtained a negative PCR in breast milk and the
second was PCR positive in breast milk on days 10,
12 and 13 of symptom initiation with a copy number
1∙32 × 105 copies per mL in whole milk and 9∙48 × 104
copies per/mL in skim milk, coincided with the stage
of mild symptomatology, subsequent samples were
negative, as there has been direct contact with the
mother without protection, contagion by drops is
considered.
Another publication with virus isolation in breast
milk was published by Tam et al., which mentions
the clinical case of a 40-year-old woman who is
breastfeeding an 8-month-old infant, the mother
was hospitalized after presenting respiratory
symptoms, the swab was positive for Covid-19, after
the beginning of maternal symptoms the infant
presented symptoms one day later, the PCR was
performed with positive results. Samples of breast
milk were taken with all cleaning measures and virus
RNA was identied up to 15 days after the onset of
symptoms; it was not possible to identify whether the
RNA was viable or only residual21. In these two cases,
both children were directly exposed to the mother
without the use or protection, which is why the main
cause of contagion is considered, but not the use
of breast milk.
In the presence of a lesion in the maternal areola,
there could be a doubt that this could be a factor
to increase the risk of transmission of the virus to the
newborn during breastfeeding.
52 Revista Médica Vozandes
Volumen 32, Número 2, 2021
Pace et al, conducted a study to determine whether RNA of the
virus can be detected in breast milk and breast skin of infected
women, the risk of transmission during suckling from a mother
with mastitis, and measured the concentrations of antibodies
to SARS-CoV2 transmitted in breast milk. Milk samples were
collected under all asepsis and antisepsis standards, with
protective measures: face mask, gloves, hand washing of the
mothers, breast skin swabs were taken before and after washing
the breasts, sodium/potassium was quantied as an indirect
marker of mastitis (a Na/K index greater than 0.6 was interpreted
as subclinical mastitis). 18 women entered the study, 50% had
subclinical mastitis, no breast milk sample identied virus RNA
despite the previous nding of subclinical mastitis in half of the
women in the study. Virus RNA was isolated from a swab taken
prior to breast cleansing, but when an attempt was made to
identify it in the post-cleansing swab, the result was negative.
This study concludes that breast milk is not a transmitter of the
SARS-CoV2 virus, breast washing led to the non-detection of the
virus, which supports that proper hygiene prevents transmission
breast milk samples. Also identied antibodies to SARS-CoV2
that were more IgA than IgG, supporting previous studies that
breast milk provides a signicant degree of immunity to the
newborn to combat the virus 22.
In some studies where neonates were separated from their
mothers at birth, they were infected later, demonstrating that
the separation of newborns is not a protective factor, since
the neonate has contact with multiple health professionals,
increasing the risk of infection, poor oral tolerance to formula
feeding, alteration in thermal control, among others23.
The current evidence on breast milk from mothers with Covid-19,
so far, has shown to be safe for newborns, once again conrming
the importance of the immunological contribution by transferring
antibodies against the virus protecting the newborn, the risk
remains the transmission of the newborn through drops of the
infected mother. For this reason, the American Academy of
Pediatrics supports breastfeeding in patients without severe
symptoms; in case of severe symptoms, it is recommended to
pump breast milk under adequate hygiene measures and to
feed the newborn with unpasteurized breast milk (since there is
no evidence of probable transmission of the virus and because it
reduces the immunological value) given by a healthy person24,25.
To prevent transmission, the mother should adopt adequate
hand hygiene measures before and after contact with the
newborn, washing the breast before and after
breastfeeding, strict use of masks, keeping the
newborn at 2 meters distance in the room, use of
a physical barrier, and periodic disinfection of the
room. Isolation of the newborn from the mother
has not proven to be benecial so far25-26.
About early attachment, the WHO and the Italian
Society of Neonatology recommend maintaining
skin-to-skin contact in the delivery room and the
likelihood of breastfeeding in the same room. The
use of breast milk expressed from mothers with
unpasteurized Covid-19 can be used to feed
newborns who have been separated from their
mothers due to health conditions27,28.
CONCLUSION
The current evidence shows that breastfeeding
provides protection to the newborn through
the transmission of antibodies to the child,
mainly immunoglobulin A, which provides
immunologically active cells that support the
immature immune system. Although there are two
studies that have shown the presence of the virus
in breast milk, there are no records proving the
infection of the newborn through breastfeeding,
so it is recommended to continue breastfeeding,
in case the mother is able to do it directly, or to
feed the newborn with breast milk expressed
without pasteurization by a healthy caregiver in
case the mother is not able to do it.
Always keep protective measures such as frequent
hand washing, breast washing before and after
breastfeeding, the use of masks and cleanliness of
the entire place where the mother stays.
Regular check-ups in newborn are necessary,
whether remote or face-to-face. When in
doubt about the management of the newborn,
specialized medical personnel should always be
contacted.
Arévalo Zabala C, et al.
BREASTFEEDING IN CHILDREN WITH MOTHERS
SUFFERING FROM COVID-19 (...)
Referencias
1. Tan WJ, Zhao X, Ma XJ, Wang W, Niu P, Xu W, et
al. A novel coronavirus genome identied in a
cluster of pneumonia cases — Wuhan, China
2019-2020. China CDC Weekly 2020; 2:61-2.
2. Organización Panamericana de la Salud. En-
fermedad por Coronavirus (Covid-19). OPS.
https://www.paho.org/es/tag/enfermedad-
por-coronavirus-covid-19
3. Páez LS, Novoa S, Nieto B, Yépez E. Covid-19 y
Embarazo. 2.ª ed. León W, Masache J, Abar-
zua. Capitulo Covid-19 y Embarazo. Quito-
Ecuador; Mayo-2020.
4. Organización Panamericana de la Salud.
Actualización Epidemiológica: Enfermedad
por coronavirus (Covid-19)-22 de julio 2021.
Disponible en: https://www.paho.org/es/
le/92055/download?token=3nPUqnh4.
5. Ministerio de Salud Pública del Ecua-
dor, Informe Nacional COE N 512, dis-
ponible en https://www.salud.gob.ec/
wp-content/uploads/2021/07/INFOGRA-
FIA-NACIONALCOVID19-COE-NACIONAL-
08h00-23072021.pdf
6. Dong Y, Mo X, Hu Y, Qin X, Jiang F, Jiang Z,
et al. Epidemiological Characteristics of 2143
Pediatric Patients With 2019 Coronavirus Di-
sease in China. Pediatrics. 2020; doi: 10.1542/
peds.2020-0702
7. Chen D, Yang H, Cao Y, Cheng W, Duan T, Fan
C, et al. Expert consensus for managing preg-
nant women and neonates born to mothers
with suspected or conrmed novel coronavi-
rus (COVID-19) infection. Int J Gynaecol Obs-
tet. 2020 May;149(2):130-136.
8. Yang N, Che S, Zhang J, Wang X, Tang Y,
Wang J, et al. Breastfeeding of infants born to
mothers with COVID-19: a rapid review. Ann
Transl Med. 2020 May; 8(10): 618.
9. Fernández FJ, Vázquez JM, González U, Gó-
53
REVISIÓN DE LA LITERATURA
Revista Médica Vozandes
Volumen 32, Número 2, 2021
mez J, ParrónT, Rodríguez L. Infección por co-
ronavirus covid-19 y lactancia materna: una
revisión exploratoria. Revista Española de Sa-
lud Pública 2020;94(1): e1-e9
10. Lubbe W, Botha E, Niela-Vilen H, Reimers P.
Breastfeeding during the COVID-19 pande-
mic – a literature review for clinical practice.
BMC. 2020;15:82.
11. Brahm P, Valdés V. Benecios de la lactancia
materna y riesgos de no amamantar. Rev.
chil. pediatr. 2017, 88, n.1, pp.07-14.
12. Kumar PS, Pathak M, Rana J, Tiwari R, Na-
tesan S, Dhama J, et al. Possibility of SARS-
CoV-2 transmission from the breast milk of
COVID-19 affected women patients to their
infants: worries and strategies to counter it.
Infez Med. 2020 Sep 1;28(3):291-294.
13. Peroni D, Fanos V. Lactoferrin is an impor-
tant factor when breastfeeding and CO-
VID-19 are considered. Acta Paediatrica.
2020;109:2139–2140.
14. Hand I, Noble L. Covid-19 and breastfe-
eding: what’s the risk?. J PerinatoL. 2020
Oct;40(10):1459-1461.
15. Wang S, Guo L, Chen L, Liu W, Cao Y, Zhang
J, et al. A case report of neonatal COVID-19
infection in China. Clin Infect Dis. 2020 Jul
28;71(15):853-857.
16. Liu W, Wang J, Li W, Zhou Z, Liu S, Rong Z. Clinical
characteristics of 19 neonates born to mothers
with COVID-19. Front Med. 2020 Apr 13: 1–6.
17. Gao X, Wang S, Zeng W, Chen S, Wu J, Lin
X, et al. Clinical and immunologic features
among COVID-19–affected mother–infant
pairs: antibodies to SARS-CoV-2 detected in
breast milk. New Microbe and New Infect
2020;37:100752
18. Fox A, Marino J, Amanat F, Krammer F, Hahn-
Holbrook J, Zolla-Pazner S, et al. Evidence of
a signicant secretory-IgA-dominant SARS-
CoV-2 immune response in human milk fo-
llowing recovery from COVID-19. BMJ. 2020
19. Dong Y, Chi X, Hai H, Sun L, Zhang M, Xie W-F,
et al. Antibodies in the breast milk of a mater-
nal woman with COVID-19. Emerg Microbes
Infect. 2020 Dec;9(1):1467-1469.
20. Grob R, Conzelmann C, Müller J, Stenger S,
Steinhart K, Kirchhoff F, et al. Detection of
SARS-CoV-2 in human breastmilk. Lancet.
2020 Jun 6;395(10239):1757-1758
21. Tam P, Ly K, Kernich M, Spurrier N, Lawrence
D, Gordon D, et al. Detectable severe acu-
te respiratory syndrome coronavirus 2 (SARS-
CoV-2) in human breast milk of a mildly symp-
tomatic patient with coronavirus disease
2019 (COVID-19). Clinical Infectious Diseases,
2020; 72:128–130
22. Pace R, Williams J, Jarvinen K, Belfort M, Pace
C, Lackey K, et al. COVID-19 and human milk:
SARS-CoV-2, antibodies, and neutralizing ca-
pacity. medRxiv. Preprint. 2020 Sep 18.
23. Thi TH, Thi KP, Huynh LT, Minh LC, Nam Giang
HT, Thu Nguyen PT, et al. Appropriate care for
neonates born to mothers with COVID-19 di-
sease. Acta Paediatrica. 2020;109:1713–1716
24. American Academy of Pediatrics. Breastfe-
eding guidance post hospital discharge for
mothers or infants with suspected or conr-
med SARS-CoV-2 infection. 2020.
25. Giuliani C, Li Volsi P, Brun E, Chiambretti A,
Giandalia A, Tonutti L, et al. Breastfeeding
during the COVID-19 pandemic: Suggestions
on behalf of woman study group of AMD.
Diabetes Res Clin Pract. 2020 Jul; 165: 108239.
26. Walker K, Grace N, Thornyon J, O Donoghue
K, Dorling J, Comeau J, et al. Maternal trans-
mission of SARS-COV-2 to the neonate, and
possible routes for such transmission: A syste-
matic review and critical analysis. BJOG 2020;
127: 1324-1336.
27. Davanzo R, Moro G, Sandri F, Agosti M, Mo-
retti C, Mosca F. Breastfeeding and corona-
virus disease-2019: Ad interim indications of
the Italian Society of Neonatology endor-
sed by the Union of European Neonatal &
Perinatal Societies. Matern Child Nutr. 2020
Jul;16(3):e13010
28. Tomori C, Gribble K, Palmquist A, Ververs M,
Gross M. When separation is not the answer:
Breastfeeding mothers and infants affec-
ted by COVID-19. Matern Child Nutr ; 16(4):
e13033, 2020 10.
