Breastfeeding in Women with Covid19 infection-Expert group meeting for development of standard treatment protocols for clinical management of covid- 19 complicating pregnancy at New Delhi 8th December 2021

1. Breastfeeding In COVID-19
Infection
Expert Group Meeting For Development Of Standard
Treatment Protocols (STPs) For Clinical Management Of
COVID- 19 Complicating Pregnancy
Organised by WHO-CCR & AIIMS, New Delhi
7-8TH December 2021

2. Professor Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
Joint Treasurer, FOGSI (2021-2024)
Vice President, MOGS (2021-2022)
Member Oncology Committee, SAFOG (2020-2021) (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
54 publications in International and National Journals with 73 citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2021)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Course Coordinator of 3 batches of Advanced Minimal Access Gynaec
Surgery
(AMAS) at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP
,
DIPLOMA IN ENDOSCOPY (USA)

3. Introduction
• COVID-19 was declared as a global public health emergency by the World
Health Organization on 30 January 2020.
• Incidentally, the first case of COVID-19 was diagnosed and declared in
India on the same day.
• Later, on 11 March 2020, WHO declared it as a pandemic.
• In India, the pandemic, especially in its second wave, has put enormous
burden on the health infrastructure.

4. • In India, from 3rd January 2020 to 3rd December 2021, there have
been 3,46,15,757 (3Cr 46Lacs) confirmed cases of COVID-19
with 4,70,115 deaths, reported to WHO.
• As of 29 November 2021, a total of 124,01,57,719 vaccine doses (124
Crores) have been administered.
Source: World Health Organization Dashboard

6. The Rationales Of Vaccine In COVID-19
• To reduce the risk of infection as it is a public health problem
• To reduce the risk of severe acute morbidity and mortality from the
infection
• To prevent long term effects of infection
• To prevent transmission to other individuals

7. Does SARS-COV-2 Virus Get
Transmitted Through Breastmilk?
No case of transmission through breastmilk has been
reported.
In few samples of breastmilk, mRNA was isolated, but it
was likely due to contamination or dead viral particles*
SARS-CoV-2 specific IgA and IgG antibodies with
neutralizing capacity, have been consistently isolated from
breastmilk indicating the possibility of babies acquiring
passive immunity from the mother**
*Pace RM, Williams JE, Järvinen KM et al. mBio. 2021
**Pereira, A., Cruz-Melguizo, S., Adrien, M. et al. Int Breastfeed J 2020

8. Breastfeeding By Mothers
With COVID-19 Is Safe!
Benefits
• Huge survival benefits with early
initiation and exclusive
breastfeeding
• Well-known and irreplaceable
health benefits both for the
mother and infant
Risks
• Risk of transmission of COVID-19
to neonate while breastfeeding is
very low & can be reduced to ZERO
with adequate respiratory etiquettes
• Even if transmitted, majority of
neonates remain asymptomatic or
have mild symptoms
*World Health Organization. (2020). Breastfeeding and COVID-19: scientific brief, 23 June 2020. World Health Organization. https://apps.who.int/iris/handle/10665/332639
*Salvatore CM, Han JY, Acker KP, et al. Lancet Child Adolesc Health. 2020
*More K, Chawla D, Murki S, Tandur B, Deorari AK, Kumar P; National Neonatology Forum (NNF) COVID-19 Registry Group. National Neonatology Forum (NNF) India COVID-19 Registry. Indian Pediatr. 2021

9. The Continuity Chain - together it works!
Early skin to skin contact
• Reduces mortality
• Survival benefit several times higher than mortality risk of COVID 19
Breastfeeding
• Innumerable benefits
• Low risk of transmission
Rooming In
• No increased risk of transmission with precautions

10. Breastfeeding In Hospitals
• In hospitals, nurses trained in essential newborn care
and lactation management should be provided for
support
• Mother, caretakers and nurses should follow
respiratory hygiene (triple layered surgical mask,
cough and sneeze etiquettes)
• If rooming-in is not possible, the neonate should be
fed expressed breastmilk (EBM) of the mother by a
nurse or trained healthy family member
• Observe respiratory etiquettes

11. Breastfeeding At Home
• Continue exclusive breastfeeding
• Follow respiratory hygiene like in the hospital
• Avoid formula or mixed feeding
• A healthy, asymptomatic and willing family
member, negative for SARS-CoV-2 and not in
direct contact with persons with suspected or
confirmed infection to stay with the mother and
baby to assist and provide support for
breastfeeding.

12. Vaccination Of Breastfeeding Women
• Vaccination against COVID-19 should be offered to all
pregnant and lactating women, irrespective of the
presence of co-morbidities.
• Pregnant and lactating women are to be immunized
with any of the vaccines currently available in the
country.
• Vaccines can be offered at any gestational age in
pregnancy, but the second dose should preferably be
completed before the third trimester.

14. Key points to remember while
breastfeeding in COVID-19

15. Key points to remember for
breastmilk expression

16. Do’s

17. Don’ts

18. Few Key Points To Remember
• Mother infant dyad should always be roomed in
• Breastfeeding by mothers with COVID-19 is safe for
the babies
• Respiratory etiquettes must be followed by mothers
and caregivers during feeding and caregiving
activities
• Vaccination is safe and should be offered to all
pregnant and lactating mothers

19. Skills Required For Breastfeeding
The Learners are expected to master the
following skills :
• Position check while breastfeeding
• Attachment check while breastfeeding
• Correct technique for breast milk expression

20. Considerations
Level of activity of the virus in the local community
• Potential efficacy of the vaccine
• Lack of safety data specific to its use in pregnancy
• Risk and potential severity of maternal disease, including the possible
effects of the disease on the fetus (preterm birth) and newborn
• Timing of vaccination during pregnancy

24. Vaccines Available In India
1. COVISHIELD – produced by Serum Institute of India (SII) in collaboration with Astra-
Zeneca
2. COVAXIN – produced by Bharat Biotech Ltd. This is an indigenous vaccine and is an
inactivated (killed) whole virus vaccine.
3. ZYCOV-D- produced by Zydus Cadila Healthcare. It is a DNA plasmid based COVID-
19 vaccine.
4. SPUTNIK-V- produced by Gamaleya Research Institute. It is an adenovirus vector based
vaccine.
The vaccines are approved for emergency use for individuals over 18 years of age by the
Central Drugs Standard Control Organization (CDSCO) of India.

25. FIGO Statement On COVID 19
Vaccination And Breastfeeding
2nd March 2021

26. 25th April 2021

28. Recommended Vaccine Timing According
Due To RCOG Guidelines
30th June 2021

29. • Vaccines, Volume 9, Issue 6, 17th June 2021
• The study included 32 breastfeeding women with the aim to evaluate the
immune response to COVID-19 vaccinations in breastfeeding women.
• The immune response to the vaccination against SARS-CoV-2 is strongest 7 ± 3
days after the second dose.
• The levels of IgA and IgG antibodies specific to the SARS-CoV-2 spike antigen
in breast milk and serum samples from mothers after a COVID-19 vaccine were
positively correlated.

30. • In the United Nations, from December 14, 2020, to February 28, 2021, data from the “v-safe after
vaccination health checker” surveillance system was used to characterize the initial safety of mRNA
Covid-19 vaccines in pregnant women.
• Among 3958 participants enrolled in the study, 827 had a completed pregnancy, of which 115 (13.9%)
resulted in a pregnancy loss and 712 (86.1%) resulted in a live birth (mostly among participants with
vaccination in the third trimester).Adverse neonatal outcomes included preterm birth (in 9.4%) and small
size for gestational age (in 3.2%); no neonatal deaths were reported. Although not directly comparable,
calculated proportions of adverse pregnancy and neonatal outcomes in persons vaccinated against Covid-
19 who had a completed pregnancy were similar to incidences reported in studies involving pregnant
women that were conducted before the Covid-19 pandemic.
• Preliminary findings did not show obvious safety signals among pregnant persons who received mRNA
Covid-19 vaccines.

31. American Journal of Obstetrics and Gynaecology, volume 225, Issue 3, September 1, 2021.
• A study 131 women (84 pregnant, 31 lactating and 16 non pregnant) were enrolled in a
prospective study at two tertiary care centres between Dec 2020 to February 2021.
• Vaccine induced antibody titres were recorded, baseline and after second dose of vaccine.
• They concluded that coronavirus disease 2019 messenger RNA vaccines generated robust
humoral immunity in pregnant and lactating women, with immunogenicity and reactogenicity
similar to that observed in nonpregnant women. Vaccine-induced immune responses were
statistically significantly greater than the response to natural infection. Immune transfer to
neonates occurred via placenta and breastmilk.

33. Additional Reading Material
Title URL
Breastfeeding and COVID-19 (NHP) https://www.nhp.gov.in/breastfeeding-and-covid-19_pg
Breastfeeding and COVID-19
(WHO)
https://www.who.int/publications/i/item/10665332639
NNF-FOGSI-IAP Clinical practice
guidelines , perinatal- neonatal
management of COVID-19 ver. 3.0
www.nnfi.org
Breastfeeding during COVID-19 https://www.who.int/pmnch/covid-19/toolkits/maternal-newborn/breastfeeding/en/
Breastfeeding during the COVID-19
pandemic
https://www.unicef.org/eap/breastfeeding-during-covid-19
Breastfeeding and COVID-19 https://www.who.int/news-room/commentaries/detail/breastfeeding-and-covid-19
Coronavirus disease (COVID-19):
Breastfeeding
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-
a-detail/q-a-on-covid-19-and-breastfeeding

34. Thank you