Skin to skin contact in the first hour after birth and early breastfeeding in mothers with confirmed or suspected covid 19

Dr Ravari 24 Dec 2020
Skin to skin contact in the first hour after birth and
Early Breastfeeding in mothers with confirmed or
suspected COVID-19
‫کودکان‬ ‫متخصص‬ ‫راوری‬ ‫دکترمحمود‬
‫شيرمادر‬ ‫با‬ ‫تغذيه‬ ‫ترويج‬ ‫کشوری‬ ‫عضوکميته‬
‫شيرمادر‬ ‫با‬ ‫تغذيه‬ ‫ترويج‬ ‫علمي‬ ‫انجمن‬ ‫مديره‬ ‫هيئت‬ ‫عضو‬
1

Dr Ravari gums 27 sept 2020
2
We thank all the critical care nurses
working on COVID-19, and the
midwives who deliver our children.

Dr Ravari 24 Dec 2020Dr Ravari sept 2020
3

• The Lancet Breastfeeding Series (2016) reported that
scaling up breastfeeding could prevent around 823,000
child deaths annually, equivalent to 13% of all deaths in
children under two, and prevent an extra 20,000
deaths from breast cancer every year.
Breastfeeding reduces 64% of morbidity and mortality
in diarrhoea, 74% in the severity of RSV and its
hospitalization with 72% .
This demonstrates the protective benefits of
breastfeeding, which pertain to COVID-19 pandemic.
Breastfeeding
4

Breastfeeding and feeding with
breastmilk
• Breastfeeding is strongly recommendedfor all
women and newborn infants.
– Because of its known lifelong importance for
women’s and children’s health and wellbeing
(WHO,2020b;WHOEuro,2020) .
– Human milk contains numerous live
constituents, including immunoglobulins,
antiviral factors, cytokines and leucocytes that
help to destroy harmful pathogens and boost
the infant’s immune system (WHO Euro, 2020).
5
RCM Professorial Advisory Group Uploaded: 24/06/20

breastmilk
• The unique value of breastfeeding to newborn
infants, women, and public health especially in
this pandemic should be recognized and
highlighted by health professionals, policy makers,
and the public.
– The active and passive immunity to infections conferred
by breastfeeding increase its benefit even further at this
time.
– There are growing indications that breastmilk may be a
valuable source of antibodies against SARS-CoV-2(Fox
et al., 2020a).
6

breastmilk
• Information and support, psychological and practical,
should be available to all women in pregnancy and
from the first feed onwards .
– to enable them to initiate and continue
breastfeeding, including breastmilk expression;
whether or not they or their infants and young
children have suspected or confirmed COVID-19
(Balogun et al., 2016; McFadden et al., 2017; The Scottish
Government, 2017; Unicef UK Baby Friendly Initiative,
2020b; World Health Organisation, 2020b).
7

breastmilk
• Women and babies should be enabled to stay
together, to have skin-to-skin contact, and to
breastfeed responsively
– to optimize the establishment of
breastfeeding (Moore et al., 2016; Unicef UK
Baby Friendly Initiative, 2020b).
8

breastmilk
• Mother’s own milk should always be the first
choice . However, if mother’s own milk is not
available or where it needs supplementation,
donor human milk is the option of choice,
especiallyfor vulnerable infants (World Health
Organisation, 2019; Shenker, Aprigio, et al., 2020).
9

breastmilk
• Women who have suspected, probable or
confirmed COVID-19 should be enabled and
supportedto breastfeed,and to practice
respiratory and hand hygiene when caring for
and feeding their infant (Royal College of Paediatrics
and Child Health, 2020; World Health Organisation,
2020c, 2020b).
10

breastmilk
• When a woman is not well enough to care for her
own infant or where direct breastfeeding is not
possible, she should be supported to express her
breastmilk by hand expression or by pump, and/or
be offered access to donor breast milk.
– All feeding equipment and pumps should be
appropriately cleaned and sterilized before use.
11

Why is it important to continue to promote and support
breastfeeding in a family with suspected or confirmed COVID-19?
• Breastfeeding protects infants from infection. Human
milk has natural bioactive factors, antibodies, and
targeted immunologic mediators; although the effects on
SARS-CoV-2 infection are not currently known, breastfed
infants are less likely to develop other viral infections.
• Counsel families to consider delaying weaning and
extending the duration of breastfeeding to maximize the
protection conferred via human milk during the
pandemic.
12

Benefits of breastfeeding during a pandemic
• Breastfeedingis good for babies.
– It protects them from many infections. breastmilk may
protectsbabies from COVID-19, and breastfed infants
are generally less likely to have severe respiratory
symptoms when they get sick.
• Breastfeedingis good for moms.
– Hormones released in the mother's body during
breastfeeding promote wellnessand can relieve stress
and anxiety.
• Breast milk is readily available.
– No purchase necessary! This can be important during
public health emergencies,when it can be more
challenging to buy formula and other feeding supplies.
13
Last Updated 9/25/2020 Source American Academy of Pediatrics (Copyright © 2020)

Breastfeeding during the COVID-19 pandemic –
a literature review for clinical practice
• Results & Conclusions:
– Current evidence states that the Coronavirus is not transmitted
via breastmilk.
– Breastfeeding benefits outweigh possible risks during the COVID-
19 pandemic and may even protect the infant and mother.
– Breastfeeding should be encouraged, mothers and infant dyads
should be cared for together, and skin-to-skin contact ensured
throughout the COVID-19 pandemic.
– Guidelines, based on this current evidence, were produced and
can be distributed to health care facilities where accessible
information is needed.
Breastfeeding during the COVID-19 pandemic – a literature review for clinical practice Lubbe et al. International Breastfeeding Journal 14 sept 2020 14

Skin-to-skin contact
• Skin-to-skin is the safest and best transition
for mothers and their infants to a new life
together.
Ensuring it happens immediately after birth,
the infant’s microbiome can develop from
the mother’s flora, so beneficial during a
pandemic
16
Breastfeeding during the COVID-19 pandemic – a literature review for clinical practice Lubbe et al. International Breastfeeding Journal 14 sept 2020

Neonatal management and outcomes during the COVID-19
pandemic: an observation cohort study
Lancet Child Adolesc Health July 23, 2020
17

What do we currently know about
newborn risk for COVID-19?
• Current data suggest that approximately 2-5% of infants
born to women with COVID-19 near the time of delivery
have tested positive in the first 24-96 hours after birth (AAP,
Updated 07/22/2020).
• Perinatal transmission of COVID-19 is unlikely to occur if
correct hygiene precautions are undertaken, and that
allowing neonates to room in with their mothers and direct
breastfeeding are safe procedures when paired with
effective parental education .
• Breastfeeding mother with COVID-19 should be supported
to hold her newborn Skin to Skin, breastfeed safely, and
share a room with her baby (Lancet Child Adolesc Health July 23, 2020).
18

Can you pass COVID-19 to your baby
by breastfeeding?
• To date, the transmission of active COVID-19 (virus that
can cause infection) through breastmilk and
breastfeeding has not been detected, though
researchers are continuing to test breastmilk.
• Engage in skin-to-skin contact with your newborn.
Placing your newborn close to you enables the early
initiation of breastfeeding which also reduces
neonatal mortality. Timing is everything and it is
recommended to initiate breastfeeding within the first
hour after delivery.
Unicef 08 June 2020 19

Skin-to-Skin is the safest transition for
both mother and baby
• Skin-to-skin, when immediate and uninterrupted, facilitates the
development of the infant’s microbiome from the mother’s flora which
is exactly what we want in times of pandemic.
• What we don’t want is other bacteria or virus to colonize the infant’s
skin nor do we want a disinfected maternal skin, if that were even
feasible.
• Skin-to-skin is important and it must be immediate. There should
be no delay, no time to observe a newborn under the warmer,
no time to put a diaper on, no time to place a bracelet.
20

Skin-To-Skin care especially after birth
and breastfeeding
• The most important societies, such as WHO, UNICEF, ISUOG,
RCOG,AAP and ABM promote breastfeeding in this COVID-
19 pandemic but with special precautions. They also
encourage, whenever possible, the skin-to-skincare,
especiallyafter birth in order to facilitatetheir adaptation to
the outside world (stabilizingbaby’s temperature, breathing
rate, heart rate, and blood sugar) and the establishment of
breastfeeding
• Italian Society of Neonatology (SIN), Spanish Society of
Neonatology (SeNeo) and Union of European Neonatal &
Perinatal Societies (UENPS) follow these recommendations
•
Pereira et al. International Breastfeeding Journal (2020) 15:69 https://doi.org/10.1186/s13006-020-00314-8
21

Following delivery, should a baby still be immediately
placed skin-to-skin and breastfed if the mother is
confirmed/ suspected to have COVID-19?
• Yes. Immediate and continued skin-to-skin care,
improves the temperature control of newborns and is
associated with improved survival among newborn
babies. Placing the newborn close to the mother also
enables early initiation of breastfeeding which also
reduces mortality.
• The numerous benefits of skin-to-skin contact and
breastfeeding substantially outweigh the potential risks
of transmission and illness associated with COVID-19.
22

What precautions should I take to attend a
delivery from a mother with COVID-19?
• Don a gown and gloves, and use either an N95 respiratory mask and
eye protection goggles>>> personal protective equipment (PPE).
23

Should we continue delayed-cord
clamping practices?
• Delayed cord clamping practices should continue per
usual center practice.
• Mothers with COVID19 should use a mask while
holding their baby during delayed cord clamping.
24

Feeding and caring for infants and young
children of mothers with COVID-19
• Mother infant contact at birth :
1. Mother and infant should be enabled to remain
together while rooming-inthroughout the day and
night and practice skin-to-skincontact, including
KMC, especially immediatelyafter birth and during
establishment of breastfeeding, whether they or
their infants have suspected or confirmed COVID-
19 virus infection.
2. Neonates born to mothers with suspected or
confirmed COVID-19should be breastfed within 1
hour of birth. Mothers should apply appropriate
IPC.
WHO Clinical management of COVID-19: interim guidance 27 may 2020 25

Feeding and caring for infants and young
children of mothers with COVID-19
• Mother infant contact at birth :
3. Early and uninterrupted skin-to-skin contact
between mothers and infants should be facilitated
and encouraged as soon as possible after birth,
while applying necessary measures for IPC. This
applies also to infants who are born preterm or
low birth weight.
4. If the newborn is ill and requires specialist care
(such as neonatal unit), arrangements should be
made to allow the mother free access to the unit,
with appropriate IPC measures.
WHO Clinical management of COVID-19: interim guidance 27 may 2020
26

Dr Ravari gums 27 sept 2020
27

Rooming-in, with precautions, now OK in revised AAP newborn guidance 07/22/2020
AAP no longer recommends separating newborns from mothers with COVID-19
29

Separation
• Separation of a mother and her infant
may have potential detrimental effects on
feeding and bonding [18, 38, 40, 43–45].
– Duran P,BermanS, NiermeyerS,JaenischT,ForsterT, GomezPonce de LeonR, etal. COVID-19and newbornhealth:systematic
review.Rev PanamSaludPublica.2020;44:e54.
– Royal College of Obstetriciansand Gynaecologists,Royal College of Midwives,Royal Collegeof Paediatrics andChildHealth,Public
HealthEngland andHealthProtectionScotland.Coronavirus(COVID-19) infectionin pregnancy.Informationforhealthcare
professionalsVersion 10.1.2020. Available athttps://www.rcog.org.uk/globalassets/documents/guidelines/2020-06-18-coronavirus-
covid-19-infection-in-pregnancy.pdf.Updated19 June 2020. Accessed 17 July 2020.
– Academyof BreastfeedingMedicine,(ABM).ABMStatementon coronavirus 2019 (COVID-19).Available at:
https://www.bfmed.org/abm-statementcoronavirus.Issued10Mar 2020. Accessed 15 Mar 2020.
– WorldHealthOrganization(WHO).Clinical managementof severe acute respiratory infectionwhennovel coronavirus(nCoV)
infectionissuspected.2020. Available at:https://www.who.int/publications-detail/clinicalmanagement-of-severe-acute-respiratory-
infection-when-novel-coronavirus(ncov)-infection-is-suspected.IssuedMar2020. Accessed 13 Mar 2020.
– UNICEF.Coronavirusdisease(COVID-19):Whatparentsshouldknow howtoprotectyourself andyourchildren.Availableat:
https://www.unicef.org/ stories/novel-coronavirus-outbreak-what-parents-should-know.Issued29 Mar 2020. Accessed 20 June
2020.
– Royal College of Obstetriciansand Gynaecologists.Coronavirus(COVID-19) infection andpregnancy.Informationforpregnantwomen
and theirfamilies.2020. Available at:https://www.rcog.org.uk/en/guidelines-researchservices/guidelines/coronavirus-
pregnancy/covid-19-virus-infection-andpregnancy/.Updated10 July 2020. Accessed 17 July 2020.
Breastfeeding during the COVID-19 pandemic – a literature review for clinical practice Lubbe et al. International Breastfeeding Journal 14 sept 2020 30

Should Infants Be Separated from Mothers with
COVID-19?!
• Separation may not preventinfection.
• Interruption of skin-to-skin care disrupts newborn
physiology.
• Separation stresses mothers.
• Separation interferes with provisionof maternal milk to the
infant, disrupting innate and speciﬁc immune protection.
• Early separation disrupts breastfeeding,and not
breastfeeding increases the risk of infant hospitalization for
pneumonia.
• Separate isolation doubles the burden on the health system.
BREASTFEEDING MEDICINE Volume 15, Number 5, 2020 Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2020.29153.ams
31

The AAP offers the following guidance for rooming-in:
• Mothers who are acutely ill may not feel up to providing all care for their
babies. They might need to be temporarily separated or have the infant cared
for by another, healthy caregiver in the room.
A nurse in protective suit attends to a baby with COVID-19 at an isolation ward 32

Considerations for discussions on whether a
neonate should remain in the mother’s room
include:
• Mothers who room-in with their infants can more easily learn and
respond to their feeding cues, which helps establish breastfeeding.
• Mother-infant bonding is facilitated by keeping the neonate with its
mother.
• Rooming-in promotes family-centered care and can allow for parent
education about newborn care and infection prevention and control
practices.
• Separation may be necessary for mothers who are too ill to care for their
infants or who need higher levels of care.
• Separation may be necessary for neonates at higher risk for severe
illness (e.g., preterm infants, infants with underlying medical conditions,
infants needing higher levels of care).
• Separation in order to reduce the risk of transmission from a mother
with suspected or confirmed SARS-CoV-2 to her neonate may not be
necessary if the neonate tests positive for SARS-CoV-2.
Caring for Newborns | COVID-19 | CDC Updated Aug. 3, 2020
33

Evaluation and Management Considerations for
Neonates At Risk for COVID-19
• Current evidence suggests the risk of a neonate
acquiring SARS-CoV-2 from its mother is low.
Further, data suggests that there is no difference
in risk of SARS-CoV-2 infection to the neonate
whether a neonate is cared for in a separate
room or remains in the mother’s room.
CDC Updated Aug. 3, 2020 34

WHO recommendations 23 June 2020
• Mother and infant should be enabled to remain
together while rooming-in throughout the day
and night and to practice skin-to-skin contact,
including kangaroo mother care, especially
immediatelyafter birth and during establishment
of breastfeeding, whether they or their infants
have suspected or confirmed COVID-19.
35

Coronavirus (COVID-19) Infection
• Women with suspected or confirmed COVID-19 should
be supported and enabled to remain together with their
babies when the woman is well enough, and to practice
skin-to-skin/kangaroo care, if the newborn baby does
not require additional medical care at this time.
• Women who have suspected, probable or confirmed
COVID-19 should be enabled and supported to
breastfeed, if this is what they choose.
Information for healthcare professionals
Version 11: Published Friday 24 July 2020
Royal College of Obstetricians and Gynaecologists,
36

If a mother and/or infant has COVID-19,
how can I support breastfeeding?
 Mother wants to breastfeed
directly
 Mother wants to express her milk
 Mother chose not to breastfeed
during the first weeks after birth
American Academy of Pediatrics, Last Updated 06/11/2020
37

Mother wants to breastfeed directly
• Encourage proper hand washing with soap and water
prior to handling the infant and advise the mother to
wear a mask while nursing.
• Holding the baby skin-to-skinhelps with latching and
hormonal responses that trigger milk release.
• When not nursing, the infant can be cared for by a
healthy caregiver, if available, and/or maintained in a
separate room or at least 6 feet away from the mother.
• Once the mother has met time and symptom-based
criteria for being noncontagious, these precautions can
be discontinued
39

If a mother and/or infant has COVID-19, how
can I support breastfeeding?
• Mothers with suspected or confirmed SARS-CoV-2
infection should not be considered as posing a
potential risk of virus transmission to their
neonates if they have met the criteria for
discontinuing isolationand precautions until:
– she has been afebrile for 24 hours without use of
antipyretics;
– at least 10 days have passed since her symptoms first
appeared (or, in the case of asymptomaticwomen
identified only, at least 10 days have passed since the
positive test result), and
– symptoms have improved.
Caring for Newborns | COVID-19 | CDC Updated Aug. 3, 2020 40

Mother wants to express her milk
1. Prior to expressing milk, the mother should put on
a mask and thoroughly clean her hands as well as
any pump parts, bottles(cups), and artificial
nipples.
2. Optimal milk expression is facilitated by use of an
efficient electric double pump. She should express
milk as often as her baby is eating or at least 6 to 8
times per 24 hours.
3. The mother can use her hands for simultaneous
breast massage/compressionduring pumping to
improve milk flow, breast emptying, and likely
calorie content of her milk.
AAP, Updated 07/22/2020 41

Mother wants to express her milk
4. The expressed milk can be fed (by cup)to the
infant by a healthy caregiver.
5. Support should be provided to the mother to
reintroduce direct breastfeeding when she is
well.
6. A mother’s milk supply is established in the
first few weeks postpartum, so this is a critical
time to support milk production.
7. Families should be reassured that the mother’s
milk is safe and important for baby.
AAP, Updated 07/22/2020
42

Mother chooses not to breastfeed
during the first weeks after birth
• During the first week postpartum,
consider asking family whether
they might reconsider this choice,
and engage in a discussion about
the importance of breastfeeding
and expressed human milk in
protecting against infections and
other diseases during this most
vulnerable time.
‫شود‬ ‫پرهیز‬ ‫شدت‬ ‫به‬ ‫مصنوعی‬ ‫شیر‬ ‫تجویز‬ ‫و‬ ‫مادر‬ ‫شیر‬ ‫مورد‬ ‫بی‬ ‫قطع‬ ‫از‬
43

The AAP provided this summary of its related
guidance for newborn care during the pandemic:
• Mothers with COVID-19 and newborn infants may room-in
according to usual center practice.
• During the birth hospitalization, the mother should maintain a
reasonable distance from her infant when possible. When
mother provides hands-on care to her infant, she should wear a
mask and perform hand-hygiene.
• Health care workers should use gowns, gloves, standard
procedural masks, and eye protection (face shields or goggles)
when providing care for well infants.
• If noninfected partners or other family members are present
during the birth hospitalization, they should use masks and hand
hygiene when providing hands-on care to the infant.
44
American Academy of Pediatrics, Last Updated 07/22/2020

• If the neonate remains in the mother’s room, measures
that can be taken to minimize the risk of transmission
from a mother with suspected or confirmed COVID-19
to her neonate include:
1. Engineering controls, such as maintaining a physical distance
of >6 feet between the mother and neonate or placing the
neonate in an incubator, should be used when feasible.
2. Mothers should wear a mask and practice hand hygiene
during all contact with their neonates. Of note, plastic infant
face shields are not recommended and masks should not be
placed on neonates or children younger than 2 years of age.
CDC Updated Aug. 3, 2020 45

plastic infant face shields are not recommended and masks should not be placed on
neonates or children younger than 2 years of age
CDC Updated Aug. 3, 2020
Nipple mask plastic infant face shields
46

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