Introduction

This guidance is for maternity, neonatal and child and family health services and is focussed on the feeding of infants when the mother has suspected, probable or confirmed COVID-19 in the acute healthcare setting or at home. The criteria for suspected, probable or confirmed cases of COVID-19 is clearly defined by NSW Health. 

This guideline is based on available evidence to date on COVID-19. The importance of uncertainty is acknowledged, and this guideline may be subject to change over the course of the pandemic as relevant evidence emerges. The guideline focuses on specific considerations for infant feeding relevant to the COVID-19 environment.  The guidance supplements, but does not replace, existing NSW Health guidance on infant feeding:

This guideline should be used in conjunction with the following NSW Health documents which focus on special considerations for care in the COVID-19 environment:

Community transmission of COVID-19 and application of appropriate personal protective equipment (PPE) continues to be a key focus for the health system, with the safety of maternity patients and staff our priority. Maternity, neo-natal and child & family health services should monitor the COVID-19 risk level and respond according to CEC - COVID-19 Response and Escalation Framework. Authorisation for an escalation of risk should be based on direction from the NSW Public Health Emergency Operations Centre (PHEOC) and the Clinical Excellence Commission.

The correct infection prevention and control (IPC) precautions must be followed for all aspects of clinical care, such as assisting a mother who is suspected, probable or confirmed to have COVID-19 to breastfeed or to express breastmilk. 

For information on IPC practices see the CEC website COVID-19 Infection Prevention and Control

Key CEC documents include:

General Principles

Breastmilk and COVID-19

At present the World Health Organisation states that data are not sufficient to conclude vertical transmission of COVID-19 through breastfeeding1; Breastmilk protects babies against infection and chronic disease and therefore is extremely important for all babies, particularly in the current environment. Given these factors, the known lifelong health and development benefits of breastfeeding to both mothers and babies currently substantially outweighs the potential risks of transmission of COVID-19. 

Breastfeeding, or expressing breastmilk when mother and baby are separated, should therefore be strongly encouraged and supported, irrespective of COVID-19 status of the mother or the baby. The mother’s decision to breastfeed will be influenced by her state of health, and whether she is well enough to start or continue to breastfeed or express breastmilk.  Health workers should discuss each mother’s individual situation with her and support her in her infant feeding choices.

Protecting the baby from COVID-19 transmission

It appears that newborn babies and older infants are at low risk of COVID-19 infection. However, if the mother is suspected, probable or confirmed to be infectious and co-located with her baby in hospital or at home, the baby is at risk of transmission via the mother’s respiratory secretions. The mother should therefore take special hygiene precautions when feeding the baby, expressing breastmilk, practicing skin to skin contact, or undertaking care where she is closer than 1.5 metres from the baby. 

These hygiene precautions include:

  • Washing hands frequently with soap and water or using alcohol-based hand rub, especially before touching the baby
  • Wearing a surgical mask:
    • Replacing masks when damp
    • Disposing of masks immediately after use
    • Not re-using a mask
    • Not touching the front of the mask but untying it from behind or remove by the ear loops
    • Washing hands with soap and water or using alcohol-based hand rub after removing the mask
  • Sneezing or coughing into a tissue, immediately disposing of it and using alcohol-based hand rub or washing hands with soap and clean water
  • Regularly cleaning and disinfecting surfaces and utensils if expressing.

These precautions must continue until the mother is no longer considered infectious and can be released from isolation, and on advice from her medical team.

Feeding considerations

The principles of protecting the baby from COVID-19 transmission by maintaining strict respiratory and hand hygiene practices (Section 2.2) apply equally to breastfeeding, feeding expressed breast milk (EBM) or feeding formula when the mother, partner or carer is suspected, probable or confirmed to have COVID-19.

When the mother and baby are separated because mother and/or baby are unwell with COVID-19, or while the baby remains an identified close contact of a confirmed case of COVID-19, the baby is effectively in isolation to protect others. The number of carers should be limited where possible to reduce the risk of transmission. The carer at home or in hospital who feeds the baby should take appropriate hygiene precautions to prevent any risk of transmission to themselves, while being aware that close interaction with a primary caregiver is essential for the baby’s emotional wellbeing. These hygiene precautions are the same as those documented in 2.2 Protecting the Baby from COVID-19 Transmission.

A health worker feeding EBM to the baby, within the health facility, should use standard precautions and follow the usual process of ensuring the safe management of breastmilk as directed by Maternity – Breast Milk: Safe Management.

Special Considerations

Breastfeeding

Table 1.  Special considerations for breastfeeding

​IssueConsideration​
​Antenatal preparation

​Mothers should be informed of the benefits of breastfeeding and the importance of breastmilk’s protective factors in the context of Covid-19. 

Where the mother is COVID-19 positive in the third trimester and wishes to breastfeed an individualised care plan should be prepared so the mother can initiate breastfeeding as soon as possible after the birth.

A comprehensive breastfeeding history should be taken with appropriate referral/s for any identified issues.
Mothers should plan for her partner/family member/friend to assist if her or her baby’s clinical condition change.

Parents should be advised of online breastfeeding information and education resources.

​Established breastfeeding​​If the mother contracts COVID-19 while she is breastfeeding an infant of any age, she should be supported to continue breastfeeding unless she no longer wishes to breastfeed or is too unwell to do so. See section 2.2 above.  Expressing breastmilk may be an option for a mother who requires hospital admission and separation from her baby is necessary.
​Re-lactation support

​​If the mother is too unwell to breastfeed or express breastmilk for some time she may be supported to re-lactate once she is well enough. Support is available from Child & Family Health Nursing, the Australian Breastfeeding Association and the Lactation Consultants of Australia and New Zealand.

Expressed breastmilk

Table 2. Special considerations for expressed breastmilk (EBM)

​IssueConsideration​
Expressing breast milk​

Appendix A

The mother should maintain strict hand and respiratory hygiene (by wearing a surgical mask - see 2.2 above) before and while expressing breastmilk or touching any pump or bottle parts.  Hospital breast pumps should be thoroughly cleaned after each use using detergent and warm water or disinfectant wipes.  The mother should maintain strict hand and respiratory hygiene (by wearing a surgical mask - see 2.2 above) before and while expressing breastmilk or touching any pump or bottle parts. 
Hospital breast pumps should be thoroughly cleaned after each use using detergent and warm water or disinfectant wipes. 

When at home all feeding equipment, including pumps, should be washed and disinfected according to the manufacturer’s instructions. The CDC How to keep your breast pump kit clean provides general advice for parents/carers.

Containers of EBM should be labelled in the usual way, wiped with detergent solution and bagged for transporting to hospital.

Mothers expressing breastmilk at home for their baby on the neonatal unit should be provided with enough EBM containers, labels and enough bags for transporting.

Health workers assisting a Covid-19 positive mother with expressing milk should use contact and droplet PPE.

​Transporting EBM to NICU/SCN from home Appendix A
Transportation of the breastmilk to the neonatal unit from home should be by a person who is not in self-isolation for any reason.  The process must be carefully described and planned for each mother and family on an individual basis. 

Formula feeding

Table 3. Special considerations for formula feeding

​Issue​Consideration
​Antenatal education​A mother’s decision to formula feed should be an informed choice after providing information on the protective effects of breastmilk in the context of the COVID-19 pandemic.
​Supply of formula

​Obtaining the usual brand of infant formula may be difficult when families are self-isolating or when baby formula stocks are low during the pandemic. If parents are unable to get their usual brand of infant formula they can use any formula that is age-appropriate, as all formulas have a similar nutritional composition. Parents need to be made aware that the preparation instructions may vary from formula to formula.

Any specialised formula use will need to be discussed on an individual basis.

Monitoring infant feeding

Awareness of poor feeding in an infant

Poor feeding and lethargy are often signs of illness in a baby, and should be investigated promptly, especially where a baby is co-located with a mother or other family members who are suspected or confirmed to have COVID-19.

Districts and networks should develop clear local guidance to ensure rapid referral, assessment and readmission for babies where necessary.  Health workers should ensure that mothers and their families are aware and informed of the signs and symptoms of an unwell baby and provided with details of how and who to contact should they have concerns.   

Assessing infant feeding via telehealth

The Australian Breastfeeding Association has prepared an information video called assessing newborn intake in the context of Covid-19.  This video may assist health workers to assess infant feeding via telehealth.

Appendices

Appendix A

Special precautions for management of expressed breast milk (EBM) of mothers with suspected, probable or confirmed  COVID-19

Resources

The following additional resources may be useful for health workers:

Document information

Developed by

Health and Social Policy Branch (HSPB)

Consultation

  • Child and Family Health Advisory Groups (CAFHAG)
  • Maternity, Child and Family Health (HSPB)
  • Maternity Community of Practice working group
  • Neonatal Community of Practice Working Group
  • NSW Breastfeeding Working Group
  • NSW NICU Lactation Consultants

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning

Reviewed by

Clinical Leads, Maternity, Neonatal and Child and Family Health, Clinical Excellence Commission

For use by

Maternity, neonatal and child and family health services


Current as at: Thursday 8 April 2021
Contact page owner: Health Protection NSW