BREASTFEEDING AND COVID-19

PRESENTERS Doug Drevets, MD – Infectious Disease, University of Oklahoma Health Sciences Center

Kate Arnold, MD – OB/GYN, Women’s Health Director, Variety Care

Malinda Webb, MD – Pediatrician, Stillwater Medical Center, Chapter Breastfeeding Coordinator, OK AAP

Rebecca Mannel, MPH, IBCLC – Director, OK Breastfeeding Resource Center, OUHSC and Executive Director, OK Mothers’ Milk Bank

OUTLINE

Transmission/Symptoms Current Medical Recommendations

Care After Discharge Importance of Breastfeeding, Donor Milk

IMPACT ON CARE OF BREASTFEEDING MOTHERS AND INFANTS

Immediate separation of mother and baby while test results pending

Admitting healthy baby considered a PUI to NICU isolation room

Limiting direct breastfeeding, lack of skin to skin contact, promoting milk expression or no breastfeeding if mother is PUI or positive

Limited teaching due to early discharge

Limited in-person outpatient lactation consults (<4 wks of age) or converting to telephone or telehealth

WIC conducting telephone appointments only

No home visits by health department staff (Children First, etc), only telephone

LORI FELDMAN-WINTER, MD, MPHPROFESSOR OF PEDIATRICS, COOPER MEDICAL SCHOOL, NJ

As we struggle to develop guidance for breastfeeding during the COVID-19 outbreak, we must always consider the risks of not exclusively breastfeeding. Mother-baby separation, use of pumps and other equipment to express and feed human milk to a newborn, and other techniques to reduce both contact and droplet spread, may seem reasonable as ways to reduce viral spread from the mother to her newborn. However, each of these strategies comes with a risk of supplementation or cessation of breastfeeding.

First do no harm. Without all the evidence, and especially in times of overwhelmingly rapid spread of COVID-19, depletion of resources including health care workers and spaces to care for mother and baby, we must act prudently to protect the health of the mother and her baby. This includes effective management of exclusive breastfeeding and recognizing the potential increased risk of disease in formula fed infants.

With permission from Dr. Feldman-Winter

BACKGROUND ON CORONAVIRUSES AND COVID-19

Coronaviruses are large, enveloped, positive strand RNA viruses that infect humans and other animals.

Diseases caused by coronaviruses range from the common cold caused by “seasonal coronaviruses” to severe respiratory illnesses.

Severe illnesses causes by coronaviruses include:

SARS (Severe Acute Respiratory Syndrome)

Identified in 2002 and caused 774 deaths / 9.6% case fatality rate

MERS (Middle East Respiratory Syndrome)

Identified in 2012 and has caused 866 deaths / 34% case-fatality rate

COVID-19

Identified in 2019 and has so far caused about 80,000 deaths worldwide / ~2% case fatality rate (NIAID-RML)

TRANSMISSION OF RESPIRATORY VIRUSES AND COVID-19

SPECIAL CIRCUMSTANCES

If the individual is pregnant or breastfeeding, there is a possibility of mother-to-baby transmission

Vertical transmission

Blood

Placenta

Birth canal

Transmission via breastmilk

Otter, JA et al. J. Hosp. Inf. 2016, 92:235.

VERTICAL TRANSMISSION AND TRANSMISSION VIA BREASTMILK ARE UNLIKELY TO OCCUR Vertical Transmission:

Chen reviewed records of 9 pregnant women with COVID-19. Found no evidence for intrauterine infection caused by vertical transmission in women who develop COVID-19 pneumonia in late pregnancy.

Schwartz analyzed reports on 38 pregnant women with COVID-19. Found no evidence that SARS-CoV-2 undergoes intrauterine or transplacental transmission from infected pregnant women to their fetuses.

Breslin et al reported on 18 infants born to mothers in NYC with COVID-19. Found no evidence of viral infection by nasopharyngeal swabs post-partum and all infants were discharged to home.

Breastfeeding: Chen et al study from China, a group of six mothers testing positive for COVID-19 were studied

after giving birth. Breastmilk samples from six patients were tested for SARS-CoV-2, and all were negative for the virus.

Pasteurized Donor Human Milk: Studies have documented complete heat inactivation of genetically similar viruses such as SARS and MERS, specifically heat treatment of 60°C for 30 minutes. (the method used by all nonprofit US milk banks)

Chen et al, 2020; Schwartz DA 2020; Breslin et al 2020

COVID-19 INFECTION IN CHILDREN IS UNCOMMON COMPARED WITH INFECTION IN ADULTS

Infant Infection Rates Study in Korea showed 32 of 4,212 (0.8%) cases were in children 0-9 years with youngest at 45

days of life.

Study in China of infants found 9 infants (1-11 months) hospitalized with COVID-19. Total cases at the time were 31, 211. None of the infants required intensive care or had severe complications. All had infected family members.

US/CDC study of 149, 082 COVID-19 cases reported through April 2, 2020

2,572 (1.7%) occurred in patients aged <18 years who account for 22% of the U.S. population.

Infants <1 year accounted for 15% (398/2,572) of pediatric COVID-19 cases, but remain underrepresented compared with the percentage of the U.S. population aged <1 year (0.27% versus 1.2%).

Miriam 2006; Rabenau 2005; van Doremalen 2014; HMBANA 2020; KSID 2020; Wei et al 2020Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep. ePub: 6 April 2020

HOSPITALIZATION OF CHILDREN IN THE UNITED STATES

Of 2,572 children with COVID-19

5.7% (147/2,572) were hospitalized

0.58% (15/2,572) were admitted to an ICU.

Compared with adults aged 18–64 years

10%–33% were hospitalized

1.4%–4.5% were admitted to an ICU.

Children aged <1 year accounted for the highest percentage (15%–62%) of hospitalization among pediatric patients.

62% (59/95) of children aged <1 year were hospitalized, including five who were admitted to an ICU. Los Angeles Times

https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6914e4-H.pdf

SYMPTOMS AND SEVERITY OF PEDIATRIC COVID-19 PATIENTS IN THE UNITED STATES

Underlying medical conditions

23% of children had at least one underlying condition.

chronic lung disease (including asthma) (40/80),

cardiovascular disease (25/80)

immunosuppression (10/80)

77% of hospitalized children, including all six admitted to an ICU, had one or more underlying medical condition.

Three deaths were reported; these cases are under review to confirm COVID-19 as the likely cause of death.

https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6914e4-H.pdf

Sign/Symptom

No. (%) with sign/symptom

Pediatric AdultFever, cough, or shortness of breath

213 (73) 10,167 (93)

Fever 163 (56) 7,794 (71)Cough 158 (54) 8,775 (80)Shortness of breath 39 (13) 4,674 (43)Headache 81 (28) 6,335 (58)Sore throat 71 (24) 3,795 (35)Myalgia 66 (23) 6,713 (61)Diarrhea 37 (13) 3,353 (31)Nausea/Vomiting 31 (11) 1,746 (16)Runny nose 21 (7.2) 757 (6.9)Abdominal pain 17 (5.8) 1,329 (12)

IMPORTANCE OF BREASTFEEDING FOR INFANT HEALTH

Human milk microbiome consists of numerous bioactive factors which shape the infant’s gut microbiome and contribute to short and long-term infant health. Environmental exposures during the critical window of breastfeeding initiation, such as lack of direct feeding at the breast, can alter the infant’s immune programming.

Active immune components in human milk include: soluble immune factors, antimicrobial proteins and peptides, functional fatty acids, hormones, oligosaccharides, nucleic acids, stem cells, antioxidants and a wide array of microbes.

Beghetti et al, 2019

IMPORTANCE OF BREASTFEEDING FOR INFANT HEALTH

“Early colostrum and exclusive breastfeeding establish an optimal and intact immune system. Protective proteins abound in human milk…[that] promote development of the infant’s immune system.”

“Early introduction of supplemental formula is associated with a greater than twofold increase in risk of early cessation of breastfeeding even when controlling for confounding variables.”

There are substantial differences in the composition of gut microbiome in preterm infants fed formula vs mother’s own milk or donor human milk.

Beghetti 2019; Feldman-Winter et al, 2020

IMMUNE COMPONENTS IN PASTEURIZED DONOR HUMAN MILK

Effect of pasteurization on immunological factors Loss or reduction of some elements: lactoferrin, lysozyme, lipase, some growth factors

70-80% of Secretory IgA remains

No change in: Oligosaccharides (HMOs)

Vitamins

LCPUFAs

Lactose

epidermal growth factor (EGF)

O’Connor et al, 2015

IMMUNE COMPONENTS IN PASTEURIZED DONOR HUMAN MILK

Probiotic effect of beneficial microbes in human milk does not rely on their viability but the host’s ability to recognize their components and stimulate the immune system.

PDHM using Holder pasteurization might also harbor this “ghost microbiota” or “para-probiotics”.

Beghetti et al, 2019

SUMMARY OF CURRENT RECOMMENDATIONS

World Health Organization

Italian Society of Neonatology and Union of European Neonatal and Perinatal societies

Academy of Breastfeeding Medicine

Centers for Disease Control and Prevention

American College of Obstetricians and Gynecologists

American Academy of Pediatrics

WORLD HEALTH ORGANIZATION

“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 infection control and prevention (IPC).”

“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 practiserespiratory 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

Clinical Management (page 13)

WORLD HEALTH ORGANIZATION

“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.”

“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.”

Clinical Management (page 13)

ITALIAN SOCIETY OF NEONATOLOGY AND UNION OF EUROPEAN NEONATAL AND PERINATAL SOCIETIES, MARCH 28, 2020

If a mother previously identified as COVID-19 positive or under investigation for COVID-19 is asymptomatic or paucisymptomatic at delivery, rooming-in is feasible and direct breastfeeding is advisable, under strict measures of infection control.

On the contrary, when a mother with COVID-19 is too sick to care for the newborn, the neonate will be managed separately and fed fresh expressed breast milk, with no need to pasteurize it, as human milk is not believed to be a vehicle of COVID-19.

ACADEMY OF BREASTFEEDING MEDICINE

In Hospital:

The choice to breastfeed is the mother’s and families.

If the mother is well and has only been exposed or is a PUI with mild symptoms, breastfeeding is a very reasonable choice and diminishing the risk of exposing the infant to maternal respiratory secretions with use of a mask, gown and careful handwashing is relatively easy.

If the mother has COVD-19, there may be more worry, but it is still reasonable to choose to breastfeed and provide expressed milk for her infant. Limiting the infant’s exposure via respiratory secretions may require more careful adherence to the recommendations depending on the mother’s illness.

ACADEMY OF BREASTFEEDING MEDICINE

There are several choices in the hospital concerning housing for a breastfeeding mother and her infant.1. Rooming-in (mother and baby stay in the same room without any other patients in that room)

with the infant kept in a bassinet 6 feet from the mother’s bed and taking precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, for direct contact with the infant and while feeding at the breast. Ideally, there should be another well adult who cares for the infant in the room.

2. Temporary separation – primarily because the mother is sick with the COVID-19 infection and needs medical care for herself in the hospital. Mothers who intend to breastfeed/continue breastfeeding should be encouraged to express their breast milk to establish and maintain milk supply. If possible, a dedicated breast pump should be provided… This expressed breast milk should be fed to the newborn by a healthy caregiver.

BREASTFEEDING MEDICINE JOURNAL PRESS RELEASE

Coronavirus Treatment and Risk to Breastfeeding Women, March 4, 2020Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, states:

“Given the reality that mothers infected with coronavirus have probably already colonized their nursing infant, continued breastfeeding has the potential of transmitting protective maternal antibodies to the infant via the breast milk. Thus, breastfeeding should be continued with the mother carefully practicing handwashing and wearing a mask while nursing, to minimize additional viral exposure to the infant.”

CENTERS FOR DISEASE CONTROL AND PREVENTIONInterim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings: Transmission after birth via contact with infectious respiratory secretions is a concern. To reduce the

risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (e.g., separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.

The risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the healthcare team.

A separate isolation room should be available for the infant while they remain a PUI.

Posted February 18, 2020

CENTERS FOR DISEASE CONTROL AND PREVENTIONInterim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings: If colocation (sometimes referred to as “rooming in”) of the newborn with his/her ill mother in the

same hospital room occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, facilities should consider implementing measures to reduce exposure of the newborn to the virus that causes COVID-19.

Consider using engineering controls like physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the ill mother.

If no other healthy adult is present in the room to care for the newborn, a mother who has confirmed COVID-19 or is a PUI should put on a facemask and practice hand hygiene before each feeding or other close contact with her newborn.

Posted February 18, 2020

CENTERS FOR DISEASE CONTROL AND PREVENTIONInterim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings: If a mother and newborn do room-in and the mother wishes to feed at the breast, she should put on a

facemask and practice hand hygiene before each feeding.

During temporary separation, mothers who intend to breastfeed should be encouraged to express their breast milk to establish and maintain milk supply.

If possible, a dedicated breast pump should be provided.

Prior to expressing breast milk, mothers should practice hand hygiene.

After each pumping session, all parts that come into contact with breast milk should be thoroughly washed and the entire pump should be appropriately disinfected per the manufacturer’s instructions.

This expressed breast milk should be fed to the newborn by a healthy caregiver.

Posted February 18, 2020

CENTERS FOR DISEASE CONTROL AND PREVENTIONEmail response from Cria Perrine, PhD, Commander, US Public Health Service, Team Lead in Division of Public Health, Nutrition and Physical Activity:

“We have heard similar concerns from other partners about how CDC’s interim guidance for inpatient obstetric healthcare settings is being interpreted. The guidance includes considerations to reduce the risk of transmission of the virus that causes COVID-19 from a mother to her newborn including consideration of temporary separation of mothers and their infants, however we do not recommend routineseparation. The risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the healthcare team. CDC is currently working to revise the interim guidance to clarify this.”

CENTERS FOR DISEASE CONTROL AND PREVENTIONPregnancy and Breastfeeding (guidance for the public)

Mother-to-child transmission Mother-to-child transmission of coronavirus during pregnancy is unlikely, but after birth a

newborn is susceptible to person-to-person spread.

A very small number of babies have tested positive for the virus shortly after birth. However, it is unknown if these babies got the virus before or after birth.

The virus has not been detected in amniotic fluid, breastmilk, or other maternal samples.

Posted April 3, 2020

CENTERS FOR DISEASE CONTROL AND PREVENTIONPregnancy and Breastfeeding (guidance for the public)

Breastfeeding if you have COVID-19 Breast milk provides protection against many illnesses and is the best source of nutrition for

most infants.

You, along with your family and healthcare providers, should decide whether and how to start or continue breastfeeding

In limited studies, COVID-19 has not been detected in breast milk; however we do not know for sure whether mothers with COVID-19 can spread the virus via breast milk.

If you are sick and choose to direct breastfeed:

Wear a facemask and wash your hands before each feeding.

Posted February 18, 2020

CENTERS FOR DISEASE CONTROL AND PREVENTIONPregnancy and Breastfeeding (guidance for the public)

Breastfeeding if you have COVID-19 If you are sick and choose to express breast milk:

Express breast milk to establish and maintain milk supply.

A dedicated breast pump should be provided.

Wash hands before touching any pump or bottle parts and before expressing breast milk.

Follow recommendations for proper pump cleaning after each use, cleaning all parts that come into contact with breast milk.

If possible, consider having someone who is well feed the expressed breast milk to the infant.

Posted February 18, 2020

AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS

ACOG quotes the CDC guidelines:There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended. Whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and health care practitioners.

Currently, the primary concern is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.

AMERICAN ACADEMY OF PEDIATRICS

As of April 2, 2020:Q: Can mother and well newborns room-in?

A: While difficult, temporary separation of mother and newborn will minimize the risk of postnatal infant infection from maternal respiratory secretions. Ideally admit infant to an area separate from unaffected infants and use gowns, glove, eye protection goggles and standard procedural masks for care of well newborns. Any temporary separation of mother and newborn is acknowledged to be challenging. If mother chooses to room-in despite recommendations; or if your center cannot provide the infant a separate area, the infant should remain at least 6 feet from mother. Curtain placement or use of an isolette may facilitate separation.

OTHER FACTORS TO CONSIDER WITH AAP’S RECOMMENDATION

1. This is impractical for a large delivery service in an area where virtually everyone is a PUI

2. The risk of exposing health care workers far exceeds the exposure of mother to her infant and is offset by the increased chance her breastfeeding will get off to a better start.

3. There is simply insufficient PPE to care for every baby delivered in isolation

AMERICAN ACADEMY OF PEDIATRICS

As of April 2, 2020:Q: Can the baby breast feed?

A: Studies to date have not found SARS-CoV-2 in breast milk. Mothers may express breast milk after appropriate breast and hand hygiene, and this may be fed to infant by uninfected caregivers. If the mother requests direct breastfeeding, she should comply with strict preventive precautions, including the use of mask and meticulous breast and hand hygiene.

OTHER FACTORS TO CONSIDER WITH AAP’S RECOMMENDATIONS

1. We do not have data that supports increased transmission or illness in newborns directly breastfeeding vs. those receiving mother's milk among mothers well enough to breastfeed directly (PUI, asymptomatic or pauci-symptomatic).

2. This recommendation makes it seem as though direct breastfeeding can only be done against medical advice.

3. The risk of transmission to others, health care workers handling pumps, pump equipment, and expressed milk in bottles, involves many more individuals at higher risk (adults) than the newborns who would otherwise be directly breastfeeding.

4. Any interference in early initiation of breastfeeding carries the risk of early cessation of breastfeeding. Not breastfeeding is a risk factor for illness in the infant, including an increase in infant mortality.

RISKS OF ROUTINE MANDATORY SEPARATION OF MOTHER AND BABY

Cascade of harm and trauma:

Disrupted lactation and early cessation of breastfeeding

Increased risk of maternal and infant readmissions

Lack of space and supplies

Use of NICU beds for “healthy” babies

Psychological trauma and attachment disorders

Decreased breastfeeding in low-income/minorities

RISKS OF ROUTINE MANDATORY SEPARATION OF MOTHER AND BABY

Discharging mothers who have not been allowed to initiate direct breastfeeding will lead to early cessation

Decrease in breastfeeding support from WIC with telephone only

Increased demand for WIC services due to job losses

Increased demand on formula supply chain – stockpiling formula similar to toilet paper

Food/formula insecurity especially for low income families

Safe formula preparation may not be emphasized

Increase in attempted home births

SUPPORTING THE BREASTFEEDING DYADWEIGHING THE RISKS AND BENEFITS, MELISSA BARTICK, MD

“One must weigh the risk of the newborn getting severe COVID-19 infection, which is rare but likely finite, with the risk of undermining the establishment of breastfeeding and the consequences of breastfeeding failure, which can be significant, particularly in low-income settings.

Failure to establish breastfeeding could put the newborn at risk of food insecurity and other infections.

If an infected mother is not planning to breastfeed, then separation may make more sense if other factors allow, and separation seems more important if a newborn has underlying health conditions.”

https://trends.hms.harvard.edu/2020/03/31/covid-19-separating-infected-mothers-from-newborns-weighing-the-risks-and-benefits/

SUPPORTING THE BREASTFEEDING DYADELMHURST HOSPITAL, NEW YORK CITY

Since March 30, screening every mother, so every mother and infant is a PUI.

All infants who do not require NICU care are isolated with their mothers. Mothers breastfeed with mask and hand washing. Every mother and infant requires PPE. Every delivery requires PPE.

Healthy mothers are discharged at 24 hours for vaginal delivery and 48 hours for cesarean section, to decrease census.

Lawrence Noble, MD, MPH, FABM, Neonatologist

SUPPORTING THE BREASTFEEDING DYADELMHURST HOSPITAL, NEW YORK CITY

Mothers are not allowed any visitors, both during labor/delivery and postpartum. In the NICU we allow just one designated visitor.

Many mothers are positive, whereas the infants on initial screens are negative.

If positive, mothers continue breastfeeding after discharge with masks and hand washing. If the father or other relative is “healthy,” they can take care of the infant without a mask. We recommend that the mother continue using a mask and hand washing for at least a week from when symptoms started, with at least 3 days without symptoms.

Lawrence Noble, MD, MPH, FABM, Neonatologist

NEW YORK PRESBYTERIAN HOSPITALCOLUMBIA UNIVERSITY MEDICAL CENTER, NEW YORK CITY

25,000 births per year systemwide

ALL women tested on admission to L&D

To date, 50% are +. Of the + women, 30% are asymptomatic

Moms who are COVID + are rooming in and breastfeeding

Babies of COVID + moms are tested at 24 hours of life

Early discharge for COVID + couplets (<24 hrVag; < 48 hr C/S)

Special clinic for babies of COVID + moms to get in-person f/u in 1st week

“not a lot of + newborns despite the very large number of + mothers”

Melissa Glassman, MD, Medical Director, Newborn Clinic

MANAGING PUI OR + PATIENT AT DELIVERY/POSTPARTUM

If hospital is routinely separating mother and baby Initiation of EARLY, FREQUENT milk expression is vital

Encourage HAND EXPRESSION vs pumping for the first 2-3 days

Provide pasteurized donor human milk as a bridge until mothers can initiate breastfeeding

Refer for lactation support after discharge

Give guidelines for when mother can directly breastfeed

Teach proper hand hygiene and bottle preparation

MANAGING PUI OR + MOM IN COMMUNITY/AFTER DISCHARGE

Keep mother and baby breastfeeding using mask and gloves, hand hygiene

Recruit other family members if available to help with other baby care

Restrict visitors to the home

Once mother is fever-free for 72 hours and 7 days past initial onset, then she can discontinue the mask. Continue diligent hand hygiene.

Early discharges need early follow-up for lactation support, newborn weight checks

Most pediatric practices still seeing infants less than 6 months in-person

MANAGING PUI OR + MOM IN COMMUNITY/AFTER DISCHARGE

Home visiting services not available through health department, only telephone

Some private practice IBCLCs still doing home visits

Breastfeeding support groups may be meeting virtually

Oklahoma Breastfeeding Hotline available 24/7 via phone or texting

HUMAN MILK BANKING ASSOCIATION OF NORTH AMERICA

Numerous safeguards are in place by our member banks to protect the quality and integrity of every bottle processed including strict donor screening, validated pasteurization and third-party microbiological testing:1. First, donors are screened for medical and lifestyle risk factors, and serum is screened for HIV, HTLV,

syphilis, and Hepatitis B and C.

2. Then, milk is pasteurized, a process that kills HIV and cytomegalovirus as well as other viruses and bacteria.

3. Lastly, no milk is dispensed after pasteurization until a culture is negative for bacteriological growth.

Studies have documented complete heat inactivation of genetically similar viruses such as SARS and MERS. New research indicates that heat treatment to 56C for 30 minutes or 70C for 10 minutes completely inactivates the SARS-CoV-2, the virus that causes the COVID-19 disease.

Chin et al, Lancet Microbe, April 2, 2020

HMBANA Milk Banks

COVID-19 Information for Donors from Oklahoma Mothers’ Milk Bank: www.okmilkbank.org

Please give immediate notice to OMMB:If you have cared for, lived with, or otherwise had close contact with individuals diagnosed with or suspected of having COVID-19.• There will be a 28-day deferral (period in which we cannot accept milk) on donations. • This also applies to healthcare workers who are in contact with COVID-19 patients.

If you have been diagnosed with or have been suspected of having COVID-19 yourself, please contact OMMB, even if your symptoms have resolved.• Milk donation will be deferred for 7 days prior to symptoms arising and for 21 days after your

diagnosis.

COVID-19 Information for Donors from Oklahoma Mothers’ Milk Bank: www.okmilkbank.org

In an attempt to reduce our donors' exposure to healthcare facilities and to limit your need to leave your car, our depot sites will be arranging to meet you outside for drop-offs.

• Please call the facility and give an expected time of arrival. • Upon arrival, please call the facility again to let them know you have arrived.• If it is not necessary to exit your car, please do not. Depot staff or

volunteers will take the milk from your car directly.

At our main location in downtown OKC, we will be meeting you downstairs and taking the milk directly from your car. Please do not exit your vehicle.

OTHER RESOURCES

Oklahoma Breastfeeding Hotline: 877-271-MILK or text OK2BF to 61222.

Free 24/7 access to lactation care from IBCLCs

Oklahoma AAP: https://www.okaap.org/breastfeeding/

Oklahoma Breastfeeding Resource Center: https://obrc.ouhsc.edu/

Regularly updated list of lactation support statewide

Telehealth and in-person lactation consults through OU Physicians

Sample policies for transport/handling of expressed breastmilk for NICU infants

NEW: Prenatal Breastfeeding Education module for pregnant women, English and Spanish!

Coming soon!

OTHER RESOURCES

Separating infected mothers from newborns. Bartick MD. https://trends.hms.harvard.edu/2020/03/31/covid-19-separating-infected-mothers-from-newborns-weighing-the-risks-and-benefits/

Information for mothers by Sahira Long, MD: Can I breastfeed if I have COVID-19?

Resources for Skilled Lactation Providers on COVID-19: http://ilca.org/covid-19/

ABM Podcast: Adapting the practice of breastfeeding medicine during the COVID-19 pandemic

https://podcasts.apple.com/us/podcast/breastfeeding-medicine-podcast/id417009927?mt=2

California Breastfeeding Coalition webinar: COVID-19: Infant Feeding during the Postpartum Period

https://zoom.us/rec/share/uN1Ef4n9zF5LXo2U-GDTdv8IMIDZeaa8gXJM-_YJxEhnf53l6o3DIlrQXo0kV0hi

CMQCC/CPQCC webinar: Preparing your maternal and neonatal units to respond to COVID-19

https://caperinatalprograms.org/

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12. Sweeney. Testing continues after infant who tested positive for coronavirus dies. Chicago Tribune. March 31, 2020. Available at: https://www.chicagotribune.com/coronavirus/ct-coronavirus-baby-death-update-20200330-rlomi5xh2bca3oczsqp7gspd54-story.html

13. Murdock and Altimari. Questions remain about the death of a Hartford infant, despite governor’s claim death was linked to coronavirus. Hartford Courant. April 3, 2020. Available at: https://www.courant.com/breaking-news/hc-br-infant-death-coronavirus-positive-20200404-54z75ceqzfei7ajtwskc4ncrua-story.html

14. Beghetti et al. Human Milk’s Hidden Gift: Implications of the Milk Microbiome for Preterm Infant’s Health. Nutrients 2019.

REFERENCES15. Feldman-Winter et al. Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infant ≥35 Weeks. Pediatrics 2020.

16. Human milk pasteurization: benefits and risks. O'Connor DL, Ewaschuk JB, Unger S. Curr Opin Clin Nutr Metab Care. 2015

17. World Health Organization. Clinical management of severe acute respiratory infection when COVID-19 is suspected. Interim Guidance. 13 March 2020. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

18. Riccardo D. Breastfeeding and Coronavirus Disease-2019. Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies. March 28, 2020. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/mcn.13010

19. Centers for Disease Control and Prevention. Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings. February 18, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html

20. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Pregnancy and Breastfeeding. April 3, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html

21. CDC Email Response from Cria Perrine, PhD to Becky Mannel. March 27, 2020. Available on request from Mannel. Rebecca-mannel@ouhsc.edu

22. Academy of Breastfeeding Medicine. ABM Statement on Coronavirus 2019 (COVID-19). March 10, 2020. Available at: https://www.bfmed.org

23. Breastfeeding Medicine Press Release. Coronavirus Treatment and Risk to Breastfeeding Women. March 4, 2020. Available at: https://home.liebertpub.com/news/coronavirus-treatment-and-risk-to-breastfeeding-women/3662

24. American Academy of Pediatrics. Initial Guidance. Management of Infants Born to Mothers with COVID-19. April 2, 2020. Available at: https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf

25. American College of Obstetricians and Gynecologists.

26. Human Milk Banking Association of North America. Milk Banking and COVID-19. March 6, 2020. Available at: www.hmbana.org/news

27. Chin et al. Stability of SARS-CoV-2 in different environmental conditions. Lancet Microbe 2020. Published Online April 2, 2020. Available at: https://doi.org/10.1016/S2666-5247(20)30003-3

OTHER RELEVANT REFERENCES

Chen et al., The Lancet. 2020; 395:809-815. doi.org/10.1016/S1473-3099(20)30192-4

Liu et al., Preprints. 2020; 2020020373.

Kam et al., Clinical Infectious Diseases. 2020;ciaa201. doi:10.1093/cid/ciaa201.

Fan et al., Clinical Infectious Diseases. 2020;ciaa226. doi:10.1093/cid/ciaa226.

Cui et al. Journal of Infectious Diseases. 2020;jiaa113. doi:10.1093/infdis/jiaa113.

Wang et al. Clinical Infectious Diseases. 2020;ciaa225. doi:10.1093/cid/ciaa225.

Li et al. Emerging Infectious Diseases. 2020;26(6):10.3201/eid2606.200287. doi:10.3201/eid2606.200287.

Dong et al. JAMA. doi:10.1001/jama.2020.4621

QUESTIONS??

Doug Drevets, MDInfectious Disease, OUHSC

Kate Arnold, MDOB/GYN, Variety Care

Malinda Webb, MDPediatrics, OK AAP

Becky Mannel, MPH, IBCLCOBRC, OK Mothers’ Milk Bank