As we are walking through these unfamiliar times as a nation and world, we find ourselves with modern medicine being ever present - enduring a pandemic none of us ever thought possible. Living isolated from one another which seemingly we have never done before in our lifetime has allowed for a surmountable amount of uncertainty, fear, anxiety and a general nature of feeling unsure in regards to how to best care for an infant, particularly when a mom has made the important choice to exclusively breastfeed her baby prior to this world change occurring. It is important to clearly delineate the things we can utilize in order to best care for patients with principles that will provide the highest likelihood of safety for a baby in the initial weeks and months of life. For both mom and healthcare provider alike, being informed and up to date is the best way to feel prepared, feel some control over certain aspects of care and ensure complete health, when and if at all possible. Similarly, remembering and adapting to the ever changing and evolving information, research and best practice standards is of utmost importance during these times.
The CDC, World Health Organization and Academy of Breastfeeding Medicine have presented clear recommendations and stances on what healthcare organizations can do to best serve the maternal patient population while admitted in the hospital and also provides clear guidance to moms as to how to best care for themselves and baby while at home - whether pregnant or delivered.
As health care providers, we must remember that breast milk has long been shown to have numerous biological components that naturally help to immediately provide for and begin boosting an infants immune system. In a time of some scary and intense germs presence within our community, the previously mentioned organizations convey support and understanding of the concept that breast milk contributes positively to giving a baby the best outcome as a result of merely providing the most natural and immunologically beneficial substance available. The recommendation and underlying theme in this is that when appropriate - breast milk be provided to a baby whose mother wishes to do so. This is important to do so that it can be said that everything is being done to achieve health, well being and a long term positive feeding experience once times normalize again some day. A mother's perception is everything - and we must work to protect that, whenever reasonable and attainable.
So- let's start with the basics.
We know that COVID-19 is a respiratory disease that is spread via droplets of respiratory secretions and person to person transmission with someone who is presumed to be or is known to be positive for the virus.
Similarly, we do know that in pregnancy, a woman's body is in a heightened state of 'over drive', if you will, putting the immune system into a state of essential immunosupression which diminishes the bodies ability to fight off infections in a regular and effective manner. Because of this, the CDC and WHO suggest that there is reason to believe that while the likelihood of contracting it is not necessarily higher, the level in which it may affect a pregnant or postpartum mom is potentially more pronounced, similar to someone who is predisposed as a result of a chronic condition or age component.
As for my mom reader of this information, this is why it is always highly recommended for women to get an Influenza shot while pregnant - for the mere reasoning that a respiratory illness will generally cause a pregnant woman to have exaggerated symptom intensity, length and outcomes. Therefore, though no research thus far shows that a pregnant woman is automatically pre-disposed to becoming ill with COVID-19 over anyone else in proximity to an exposed or positive individual, it is still important we shield the obstetric patient population the best way we know how.
Multiple sources are suggesting at this time that although minimal research has been published since the virus is still so new, there has yet to be any samples of amniotic fluid or breast milk that have come back positive for COVID-19. This suggests that the "vertical transmission" or, likelihood of mom giving it to baby in-utero is very unlikely and has yet to occur in published articles.
However, evidence suggests that due to the nature of the transmission from person to person contact with a positive COVID patient, much care and precaution should be taken when a mom is a PUI (person under investigation) or confirmed positive case for the virus.
I'd like to share with you some continued research and suggestions on how this can be managed so that a mom can feel empowered to still move forward with her desire and important responsibility to feed her baby with breast milk exclusively.
PUI, Positive COVID 19 - Mild SymptomologyIf a mom is awaiting test results for the virus panel or has received a positive result but is demonstrating only mild/manageable symptoms- the CDC and World Health Organization states that if a mother has chosen to exclusively breastfeed their infant, that they should continue to be given the proper information and resources to do so. There is clear information stated within both organizations' recommendations such as the picture to the left regarding the ways in which breastfeeding should be handled.
- A mother should be given a mask to wear during skin to skin contact and breastfeeding sessions with her baby. The World Health Organization specifically suggests that we as healthcare providers should "enable mothers and infants to remain together and practice skin-to-skin contact, and rooming-in throughout the day and night, especially straight after birth during establishment of breastfeeding, whether or not the mother or child has suspected, probable, or confirmed COVID-19." The only caveat to this information is that specific healthcare organization standards of care should be referenced as unfortunately not all organizations are in direct compliance and support of these principles.
- According to the standards set forth by both organizations, proper and frequent hand hygiene for mother while in contact with the baby should be enforced and consistently encouraged to decrease risk of transmission. In addition, evidence suggests that if a mom has recently sneezed, coughed or excessively touched the skin of her breast with unwashed hands, hygiene measures should be taken prior to laying the baby on her skin. A typical hand washing session of vigorous friction with water and soap is sufficient in removing the virus from a mother's skin. And if hand sanitizer is utilized instead, the alcohol content must be 60-95% in order to effectively remove the transmittable germs.
- In regards to routinely cleaning and disinfecting surfaces, the mother should attempt to not use her phone during a feeding or any other frequently handled devices such as a remote or commonly used device that is being handled between feedings. It would be wise to wipe down the general area in which a mom is spending her time every 2-4 hours with a disinfectant wipe or spray to ensure all germs are not remaining on surfaces for an extended amount of time.
- Of note, the CDC recommends use of: hydrogen peroxide, diluted ammonia or a bleach cleaner to effectively reduce and eliminate COVID related contaminants.
Complying with and keeping the previously mentioned principles as common practice should hopefully prevent a mom from posed heightened risk in exposing baby to this virus. This is especially important related to a baby's naturally immature immune system when in the newborn phase and infancy, alike. Similarly, these interventions can work to potentially decrease the virus from reaching a point where the positive mother's condition worsens to the point of being unwell enough that she is unable to carry out regular breastfeeding sessions.
As a result of the nature of this virus and the virulence/intensity that has shown to be present so far, it is unfortunate that preparing for the worst is important and something we are having to face in order to prepare for the potential of a patient facing a worst case scenario level of illness.
The World Health Organization suggests that if a woman becomes:
- too unwell to breastfeed her baby with the previously discussed measures taken
- and the mother's physical condition progresses to the point of heightened ventilatory support,
If a mom is being cared for and is admitted within a Baby Friendly hospital, there should be every measure and effort taken by the obstetric staff of the hospital to personally visit the ICU on a scheduled basis in order to set up and supervise a 15min pumping session for the mom. Remembering the motto of 8 or more feedings in 24 hours is essential for establishing an adequate milk supply for mom to maintain once recovered from her condition. At night, a five hour stretch of time can be given to allow for maternal rest and staff reprieve in coming to assist in the pumping sessions. In addition, if a dad or support person is allowed within the room or vicinity, they can be instructed and educated upon logistics in setting up and carrying out the pumping sessions. ICU staff could also be instructed upon how to complete this - however, in these times, it is naive to suggest that there would be any allowance for an ICU nurse to have much time to devote to this, in the midst of pandemic related census and increased care load for the nurses other patients.
Re-lactation which is the re establishment of milk supply after a significant health crisis can be attained but is a difficult process when continuing to recover from many other aspects of how the virus may affect a person's body and general health afterwards. Further research should be done by mom and support should be given by a board certified lactation consultant, if this is of interest or necessity.
Other Recommendations are:
1) If a mother (PUI or positive) has to pump her breasts with an automatic breast pump, it is essential to provide a breast pump that can solely stay within the mother's room. Educating and enforcing proper and extensive hand hygiene prior to and after touching the pump parts and accessories is key. The pump parts should also be thoroughly cleaned after use with a gentle dishwashing soap of choice. Usually, any dishwashing soap found at a store is sufficient both in times of normalcy and in regards to this virus at hand. Recommendations for part sterilization should be regularly performed as well - which is usually defined as a steam sterilization geared specifically to the brand of parts utilized and usually should be done with every 24 hours of use.
2) The Academy of Breastfeeding Medicine suggests and advises that in order to decrease rate of transmission to baby during non essential periods of contact, the infant be kept in a bassinet six feet away from a PUI or positive COVID mother. Full disclosure: in researching this topic, this is somewhat conflicting in regards to the CDC and WHO's recommendations to:
- carry out as much skin to skin and breastfeeding as possible
- to allow for immediate bonding
- and to provide for adequate establishment of supply and newborn stabilization,
3) In hospitals, there should be a designated 'hot zone' area in which there are no other patients other than presumed positive or confirmed positive patients being cared in that vicinity for the time being. This area should be staffed by a consistent nurse and care team so that cross contamination is prevented and other moms and babies are protected. This can work to largely reduce transmission rates and should be implemented particularly on units such as obstetrical floors with mixed antepartum, intrapartum and postpartum patients so that optimization of 'healthy care' aspects to those who have not been previously or knowingly exposed to anyone who is sick. A presumed or confirmed positive patient should stay within this area until confirmed negative or discharged from the hospital. This will call for a cause in flexibility needs to be presented to staff, in turn asking care teams to work to adapt to and refresh upon concepts of care not commonly performed such as postpartum or newborn care not routinely done within an obstetric nurses scope of regularly performed duties. Ultimately, this allows COVID patients to not be moved from their initial admission room to be transferred to a postpartum unit or any other area within the hospital, whenever possible.
Of importance: please note that this blog is written solely based on the recommendations from nationally and internationally recognized, reputable organizations in regards to their thoughts, research and success in caring for pregnant and postpartum women. I agree and feel that the recommendations set forth are quite sensible and manageable for the average obstetric team at most hospitals, and especially those Baby Friendly designated.
As for my experience as a labor and delivery nurse, I will say that the organization I work for directly - seems to be on board with some of the principles of care, whereas we have a need for development and migration back to the recommendations considering the efficacy and success in carrying out what these notable organizations are recommending. Utilizing the resources cited at the end of this post when conversing with your care providers as a patient, mom and parent can be helpful in allowing you to feel informed and allows you a good opportunity to advocate for the best outcome you desire and hoped for even prior to this pandemic ever complicating a normal postpartum experience.
Similarly, as healthcare providers, we must completely and wholly educate our patients so that mom can very much so experience and perceive her rights to care for her baby the way she desires to do so. Meanwhile, remembering how difficult and life changing it must be to have a baby in these unsure times. Providing individualized and situational based care, considering a patients unique level of physical stability and taking into account her innate desires to provide for her baby should never be taken for granted - as this is part of what she will always remember and will ultimately shape her ideas around in regards to her success in breastfeeding her infant up until the recommend six months to one year of age for the baby as recommended by the WHO, CDC and ABM.
References-
CDC:
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html
Updated- 4/15/2020
World Health Organization:
https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-pregnancy-childbirth-and-breastfeeding
Updated- 3/18/2020
Academy of Breastfeeding Medicine:
https://www.bfmed.org/abm-statement-coronavirus
Updated- 3/10/2020
Kellymom.com
https://kellymom.com/covid19/covid-19-summary/
Updated: 4/20/2020
Of note, multiple research articles that are shown to have been produced primarily in China can be access in the link above. At the bottom of the article, some extremely interesting research articles can be referenced for further research and evidence and deeper understanding on transmission likelihood and other topics of interest.
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