COVID-19 WHO and UNICEF stress the importance of breastfeeding

WHO and UNICEF are aiming to have consistent, sound reliable information based on the best available scientific evidence – guidance that will be updated as new evidence comes forward. We hope that policy makers everywhere will use these recommendations and adjust their infant feeding policies accordingly.  There have been many reports of mothers and babies being routinely separated at birth without any evidence that this is a wise or safe thing to do and overlooking the fact that breastmilk has antibodies and bio-active factors that are not present in infant milks.

Click here for an important repository from the Johns Hopkins School of Humanitarian Health on emerging evidence on Breastfeeding, Infant Feeding, Breast Milk and COVID-19. (Page down for more)

Click Here for examples of how the baby food industry continues to exploit  COVID-19, violating the International Code and misleading parents

WHO and UNICEF advice on breastfeeding and coronavirus

• UNICEF: Response to COVID-19: Guidance Note on Financial Contributions or Contributions in-kind from Food and Beverage companies Version 2 (29th April 2020)
  • This is an important guidance on whether to accept financial contributions or contributions in-kind from food and beverage companies in the context of the response to the COVID19 pandemic. It provides recommendations to mitigate risks and steps for implementation,  forbidding many of the tactics that manufacturers of baby foods and ultra-processed foods high in fats, sugar and/or salt are now using, eg cause-related marketing, contributions in kind, partnership language, co-branding.
• Protecting Maternal Diets and Nutrition Services and Practices in the Context of COVID-19 Ensure safeguards are in place to avoid conflict of interest from companies marketing breastmilk substitutes and foods for infants and young children and women and ensure that donations or free supplies are prohibited. Prevent commercial exploitation of COVID-19 through unnecessary use of specialized foods and supplements, and spillover to those who do not need them
• Frequently Asked Questions: Breastfeeding and COVID-19. (7th May 2020) WHO. With web story. The The FAQ/Decision tree will be translated into Arabic, Chinese, French, Russian and Spanish soon
• UNICEF: ADOPTION OF BREASTFEEDING RECOMMENDATIONS IN THE CONTEXT OF COVID-19KEY FINDINGS FROM AN ONLINE SURVEY IN LOW-AND MIDDLE-INCOME COUNTRIES (September 2020)
• Unicef UK Guide for local authorities First Steps Nutrition Trust. UK UNICEF Baby Friendly Initiative
• Counselling Cards on Infant and Young Child Feeding in the Context of COVID-19 UNICEF  (Issue 6 April 27)
• Infant and Young Child programming in the context of COVID-19. UNICEF Brief 2 V1 30th March
• WHO Interim guidance 13 March 2020,
• WHO Advice for the Africa region, 26th March 2020
• WHO Q&A for the public (18th March 2020).
• UNICEF Brief No 1 on Child Wasting.

OTHER IMPORTANT RESEARCH

Experiences of breastfeeding during COVID‐19: Lessons for future practical and emotional support

In the early HIV years  – until more was known –  emphasis was – understandably – placed primarily on reducing transmission. The role of exclusive breastfeeding in child survival was not recognised  and the UN policy was not changed until 2007. When commercial exploitation is added you get potentially toxic mix.

Other useful websites:

COVID-19, Maternal and Child Health, Nutrition – what does the science tell us? A Repository

This is compiled by the Johns Hopkins Center for Humanitarian Health and provides an overview of what peer-reviewed journal articles currently state on COVID-19, maternal and child health (including infants), and nutrition. As the pandemic is ongoing more and more research results are published. With this service, we aim to provide the user with a snapshot of what is published with updates every few days. We hope that you will learn and benefit from the articles presented here.

http://hopkinshumanitarianhealth.org/empower/advocacy/covid-19/covid-19-children-and-nutrition

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Infant and Young Child programming in the context of COVID-19. UNICEF Brief 2 V1 30th March1.

This brief contains many useful recommendations, including support for breastfeeding, skin-to-skin contact, kangaroo care, access to healthy foods, safe hygiene alongside safeguards regarding commercial influence, for example:

Key messages

1: Programmes and services to protect, promote and support optimal breastfeeding (early and exclusive) and age-appropriate and safe complementary foods and feeding practices should remain a critical component of the programming and response for young children in the context of COVID-19.

5: Full adherence to the International Code of Marketing of Breast-milk Substitutes and subsequent WHA resolutions (including WHA 69.9 and the associated WHO Guidance on ending the inappropriate promotion of foods for infants and young children) in all contexts in line with the recommendations of IFE Operational Guidance.
6: Donations, marketing and promotions of unhealthy foods – high in saturated fats, free sugar and/or salt – should not be sought or accepted.

Key considerations:

• Monitor for Code violations and report them to national authorities, the nutrition cluster/sector coordination mechanism, and international monitors.
• Support government to develop policies and procedures to monitor for and act on Code violations in accordance with the WHO/ UNICEF NetCode toolkit. Typical Code violations relate to infant formula labelling, supply management, and donations.
• It is Important to raise awareness of health workers on their obligations under the Code (BMS companies may take advantage of this situation to try and promote their products through the health care system), together with disseminating information on the Code and mechanisms to report non-compliance.
• Mothers need to be re-assured that it is safe to breastfeed their children

• Donations of BMS by manufacturers has been shown to lead to increased use of substitutes and a reduction in breastfeeding. For this reason, the World Health Assembly (WHA) has stated that there should be no donations of free or subsidized supplies of breastmilk substitutes in any part of the health care system. This prohibition extends to emergency settings where governments have been urged by WHA to ensure that any required breast-milk substitutes are purchased, distributed and used according to strict criteria. For more details refer to Operational Guidance on Infant Feeding in Emergencies
  
• [Avoid partnerships with companies that produce ‘unhealthy foods]: Such engagement carries the risk of the government and its partners to be perceived as endorsing a specific brand or products. Engagement with companies producing unhealthy food may damage reputation of the host governments, donor governments and communities. It may also appear to contradict the efforts on prevention of overweight.
  • Companies that manufacture BMS should continue to be excluded from any in-kind donations, funding engagements or co-branded partnership

The brief contains many more excellent recommendations regarding health food

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Infant and Young Child Feeding in the Context of the COVID-19 Pandemic Eastern, Central and Southern Africa
March 26, 2020.   PDF

This joint note aims to consolidate the current recommendations on Infant and Young Child Feeding in the context of the COVID-19 pandemic in Eastern, Central and Southern Africa. This guidance is not intended to replace national guidance, rather to serve as a resource that is based on the latest evidence. The contents are adapted to the African region from Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected, Interim Guidance, 13 March 2020 WHO1.

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https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected)

The sections on breastfeeding are on pages 13-14:

13. Caring for infants and mothers with COVID-19: IPC and breastfeeding

Relatively few cases have been reported of infants confirmed with COVID-19 and they experienced mild illness. No vertical transmission has been documented. Amniotic fluid from six mothers positive for COVID-19 and cord blood and throat swabs from their neonates who were delivered by caesarean section all tested negative for SARS-CoV-2 by RT-PCR. Breastmilk samples from the mothers after the first lactation were also all negative for SARS-CoV-2 (68, 69).

Breastfeeding protects against death and morbidity also in the post-neonatal period and throughout infancy and childhood. The protective effect is particularly strong against infectious diseases that are prevented through both direct transfer of antibodies and other anti-infective factors and long-lasting transfer of immunological competence and memory. See WHO Essential newborn care and breastfeeding (https://apps.who.int/iris/bitstream/handle/10665/107481/e79227.pdf). Therefore, standard infant feeding guidelines should be followed with appropriate precautions for IPC.

• Infants born to mothers with suspected, probable or confirmed COVID-19 infection, should be fed according to standard infant feeding guidelines, while applying necessary precautions for IPC.

Remarks: Breastfeeding should be initiated within 1 hour of birth. Exclusive breastfeeding should continue for 6 months with timely introduction of adequate, safe and properly fed complementary foods at age 6 months, while continuing breastfeeding up to 2 years of age or beyond. Because there is a dose–response effect, in that earlier initiation of breastfeeding results in greater benefits, mothers who are not able to initiate breastfeeding during the first hour after delivery should still be supported to breastfeed as soon as they are able. This may be relevant to mothers that deliver by caesarean section, after an anaesthetic, or those who have medical instability that precludes initiation of breastfeeding within the first hour after birth. This recommendation is consistent with the Global strategy for infant and young child feeding(https://apps.who.int/iris/bitstream/handle/10665/42590/9241562218.pdf), as endorsed by the Fifty-fifth World Health Assembly, in resolution WHA54.2 in 2002, to promote optimal feeding for all infants and young children.

• As with all confirmed or suspected COVID-19 cases, symptomatic mothers who are breastfeeding or practicing skin-to-skin contact or kangaroo mother care should practise respiratory hygiene, including during feeding (for example, use of a medical mask when near a child if with respiratory symptoms), perform hand hygiene before and after contact with the child, and routinely clean and disinfect surfaces which the symptomatic mother has been in contact with.
• Breastfeeding counselling, basic psychosocial support and practical feeding support should be provided to all pregnant women and mothers with infants and young children, whether they or their infants and young children have suspected or confirmed COVID-19.

Remark 1: All mothers should receive practical support to enable them to initiate and establish breastfeeding and manage common breastfeeding difficulties, including IPC measures. This support should be provided by appropriately trained health care professionals and community-based lay and peer breastfeeding counsellors. See Guideline: counselling of women to improve breastfeeding practices (https://apps.who.int/iris/bitstream/handle/10665/280133/9789241550468-eng.pdf) and the WHO Guideline: protection, promoting and supporting breastfeeding in facilities providing maternity and newborn services (https://apps.who.int/iris/bitstream/handle/10665/259386/9789241550086-eng.pdf).

• In situations when severe illness in a mother due to COVID-19 or other complications prevent her from caring for her infant or prevent her from continuing direct breastfeeding, mothers should be encouraged and supported to express milk, and safely provide breastmilk to the infant, while applying appropriate IPC measures.

Remarks: In the event that the mother is too unwell to breastfeed or express breastmilk, explore the viability of relactation, wet nursing, donor human milk or appropriate breastmilk substitutes, informed by cultural context, acceptability to mother and service availability. There should be no promotion of breastmilk substitutes, feeding bottles and teats, pacifiers or dummies in any part of facilities providing maternity and newborn services, or by any of the staff. Health facilities and their staff should not give feeding bottles and teats or other products within the scope of the International Code of Marketing of Breast-milk Substitutes and its subsequent related WHA resolutions, to breastfeeding infants. This recommendation is consistent with the WHO guidance. Acceptable medical reasons for use of breast-milk substitutes (https://apps.who.int/iris/bitstream/handle/10665/69938/WHO_FCH_CAH_09.01_eng.pdf;jsessionid=709AE28402D49263C8DF 6D50048A0E58?sequence=1).

• Mothers and infants should be enabled to remain together and practise skin-to-skin contact, kangaroo mother care and to remain together and to practise rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding, whether they or their infants have suspected, probable or confirmed COVID-19 virus infection.

Remarks: Minimizing disruption to breastfeeding during the stay in the facilities providing maternity and newborn services will require health care practices that enable a mother to breastfeed for as much, as frequently and for as long as she wishes. See WHO Guideline: protection, promoting and supporting breastfeeding in facilities providing maternity and newborn services (https://apps.who.int/iris/bitstream/handle/10665/259386/9789241550086-eng.pdf).

• Parents and caregivers who may need to be separated from their children, and children who may need to be separated from their primary caregivers, should have access to appropriately trained health or non-health workers for mental health and psychosocial support.

Remarks: Given the high prevalence of common mental disorders among women in the antenatal and postpartum period, and the acceptability of programmes aimed at them, interventions targeted to these women need to be more widely implemented. Prevention services should be available in addition to services that treat mental health difficulties. This recommendation is consistent with the IASC Reference group for Mental Health and Psychosocial Support in Emergency Setting 2020 Briefing note on addressing mental health and psychosocial aspects of COVID-19 outbreak – version 1.1 (https://interagencystandingcommittee.org/system/files/2020-03/MHPSS%20COVID19%20Briefing%20Note%202%20March%202020-English.pdf) and the Improving early childhood development: WHO guideline (https://www.who.int/publications-detail/improving-early-childhood-development-who-guideline).

 

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WHO Q&A published 18th March

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UNICEF/Global Nutrition Cluster/GTAM Brief No 1: Management of Child Wasting in the Context of COVID-19. March 27th, 2020

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UNICEF Baby Friendly Initiative: 

There is a wealth of evidence that breastfeeding reduces the risk of babies developing infectious diseases. There are numerous live constituents in human milk, including immunoglobulins, antiviral factors, cytokines and leucocytes, that help to destroy harmful pathogens and boost the baby’s immune system. Considering the protection that human milk and breastfeeding offers the baby and the minimal role it plays in the transmission of other respiratory viruses, it seems sensible to do all we can to continue to promote, protect and support breastfeeding.

To facilitate breastfeeding, mothers and babies should be enabled to stay together as much as possible, to have skin-to-skin contact, to feed their baby responsively and to have access to ongoing support when this is needed.

When mothers are partially breastfeeding, they can be encouraged to maximise the amount of breastmilk they are able to give or, if they choose, to be supported to return to full breastfeeding. If mothers are considering stopping breastfeeding, it is worth having a sensitive conversation about the value of continuing during the Covid-19 outbreak

Interim WHO advice for clinical managers:

https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

Includes an updated section on “Caring for infants and mothers with COVID-19: IPC and breastfeeding”

“Mothers and infants should be enabled to remain together and practise skin-to-skin contact, kangaroo mother care and to remain together and to practise rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding, whether they or their infants have suspected, probable, or confirmed COVID-19.

Remarks: Minimizing disruption to breastfeeding during the stay in the facilities providing maternity and newborn services will require health care practices that enable a mother to breastfeed for as much, as frequently, and as long as she wishes. See WHO Guideline: protection, promoting and supporting breastfeeding in facilities providing maternity and newborn services (https://apps.who.int/iris/bitstream/handle/10665/259386/9789241550086-eng.pdf).”

 

1. Key messages  on nutrition in the context of COVID-19.

1. Breastfeeding in the context of COVID-19

• The benefits for the baby of not separating it from its mother in the early newborn period are well documented; keeping the baby with the mother provides protective effects for child survival, in general, and early initiation of breastfeeding allows passive transfer of antibodies that protect the newborn infant from infections, including respiratory infections.
• Since this is a respiratory virus (like influenza, and other coronaviruses), it is unlikely to be transmitted via breast milk. However, there is a risk of transmission from an infected mother to her infant through direct contact and respiratory droplets, as well as contact with contaminated surfaces.
• Therefore, considering the benefits of breastfeeding, at this time it is advised for infected mothers well enough to breastfeed to continue to do so, while practicing appropriate infection prevention and control measures. This includes respiratory hygiene (wear a medical mask while feeding child, following best practices on how to wear, remove and dispose of masks and on hand hygiene after removal), hand hygiene before and after breastfeeding (wash hands with soap and water), avoid touching eyes, nose and mouth, and cleaning and disinfecting any contaminated surfaces.

• All mothers in affected and at-risk areas with symptoms consistent with 2019-nCoV (fever, cough, difficulty breathing) should seek medical care early, and follow instructions from the health care provider including.

o    cover their mouth and nose, when coughing or sneezing.

o    practice hand hygiene, washing often with soap; and

o    dispose of infected waste (e.g. soiled tissue) in a bin with a lid.