Breastmilk feeding of infants at birth among people with confirmed SARS-CoV-2 infection in pregnancy — SET-NET, Five States, March 29, 2020–December 31, 2020

doi:10.21203/rs.3.rs-1498126/v1

Objective

To describe prevalence of breastmilk feeding among people with SARS-CoV-2 infection during pregnancy and examine associations between breastmilk feeding, timing of maternal infection before delivery, and rooming-in status during delivery hospitalization.

Methods

Retrospective cohort using data from five states reporting initiation of breastmilk feeding of infants at birth among people with confirmed SARS-CoV-2 infection during pregnancy in 2020.

Results

Among 9760 (weighted N) people with SARS-CoV-2 infection in pregnancy, 86.0% (95% confidence interval [CI]: 83.3%-88.7%) initiated breastmilk feeding during birth hospitalization. People with infection ≤ 14 days before delivery had significantly lower prevalence of breastmilk feeding (adjusted prevalence ratio [aPR] 0.90, 95% CI: 0.82, 0.97) compared to those with infection > 14 days before delivery. When stratified by rooming-in status, the association between timing of infection and breastmilk feeding remained only among infants who did not room-in with their mother (aPR 0.78, 95% CI: 0.66, 0.92).

Conclusion

Pregnant and postpartum people with SARS-CoV-2 infection should be advised about the importance of breastmilk feeding, how to safely feed their infants in the same room, and have access to lactation support.

COVID-19

pregnancy

fed breastmilk

Breastmilk is the best source of nutrition for most infants [1]. During the COVID-19 pandemic, maternity care practices were impacted by infection prevention and control (IPC) measures implemented to protect patients and healthcare providers (e.g., mother-infant separation, decreased access to lactation services) [2]. However, data describing frequency and factors associated with breastmilk feeding practices of infants born to people with SARS-CoV-2 infection in the United States were limited.

Recommendations regarding mother-infant contact and direct breastfeeding varied greatly early in the COVID-19 pandemic and rapidly changed over time. In the absence of direct evidence about the risk of SARS-CoV-2 transmission from mothers to infants and the severity of SARS-CoV-2 infection in infants, in February 2020, the Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) recommended considering separation of infants from mothers with suspected or confirmed COVID-19 and providing expressed breastmilk for feeding [3]. As more data accumulated on the risk of transmission of SARS-CoV-2 from mothers to their infants, especially when appropriate IPC measures were taken [4, 5], CDC and AAP updated recommendations in August 2020 to encourage rooming-in and breastfeeding, with precautions taken to protect the infant, including hand hygiene and mask use for breastfeeding mothers with SARS-CoV-2 infection [6, 7]. Understanding the impact of the COVID-19 pandemic and risk communications on breastmilk feeding is critical to inform public health recommendations, healthcare practices, and lactation support services.

We sought to report prevalence of breastmilk feeding among people with SARS-CoV-2 infection during pregnancy, assess trends in breastmilk feeding and rooming-in status over the course of the COVID-19 pandemic, and identify characteristics associated with breastmilk feeding. We also sought to examine the association between breastmilk feeding and timing of maternal SARS-CoV-2 infection in pregnancy before delivery and whether the association differs when stratified by rooming-in status.

The Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET) is a collaboration between CDC and health departments to conduct longitudinal surveillance of pregnant people and their infants to understand the effects of emerging and reemerging threats, including COVID-19 [8]. People with COVID-19 infection during pregnancy were ascertained through reporting of pregnancy in COVID-19 surveillance or linkages of COVID-19 surveillance data with local data systems (e.g., vital statistics) to ascertain pregnancy status. The SET-NET inclusion criteria indicated that a person had to have a laboratory-confirmed SARS-CoV-2 infection during pregnancy and delivered between January 20, 2020 and December 31, 2020. Data reported to CDC as of September 3, 2021 were included in this analysis. We restricted inclusion for this analysis to live births from five states collecting data on breastmilk feeding: Massachusetts, Minnesota, Nebraska, Pennsylvania, and Tennessee. People with multiple gestation pregnancies were excluded due to known decreased rates of breastmilk feeding [9]. Infant deaths that occurred on the date of delivery were also excluded due to the limited chance that breastfeeding could be initiated.

We defined infants as being fed breastmilk if the infant was ever given colostrum or breastmilk from their birth mother, even once, including feeding directly at the breast or by bottle, syringe, or other method. This did not include donor milk. Breastmilk feeding information was obtained from the birth certificate or medical records. Timing of maternal infection before delivery (determined by date of first positive SARS-CoV-2 molecular test during pregnancy or symptom onset if testing date was missing) was categorized as ≤ 14 days or > 14 days before delivery. The 14-day window was chosen to reflect practices and recommendations for isolation and quarantine procedures early in the COVID-19 pandemic. Rooming-in status of mother and infant during the birth hospitalization was obtained from medical record abstraction. Covariates explored were maternal age at infection, maternal race/ethnicity, health insurance at the time of delivery, maternal education, trimester of SARS-CoV-2 infection, maternal COVID-19 disease severity [10], labor and delivery characteristics, preterm birth, and neonatal intensive care unit (NICU) admission. Maternal COVID-19 disease severity criteria were classified as asymptomatic, mild, moderate-to-severe, or critical through use of data reported by states from case report forms or abstracted from the maternal medical records.

Of the five included states, Minnesota, Nebraska, and Pennsylvania conducted medical record abstraction for all eligible cases; these records received a weight of 1.0. Massachusetts and Tennessee implemented random sampling approaches for medical record abstraction. Sampled cases from Massachusetts and Tennessee were weighted to account for selection probability and nonresponse for each state [11]. We report weighted prevalence of breastmilk feeding by selected maternal, labor and delivery, and infant characteristics. We also present weighted prevalence of breastmilk feeding by month of delivery and rooming-in status stratified by timing of maternal infection. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) for breastmilk feeding were estimated by Cox regression using constant time at risk to examine timing of maternal infection before delivery and controlling for maternal age, maternal race/ethnicity and gestational age of infant, which are known risk factors for not initiating breastmilk feeding. Since maternal education is a strong predictor of breastmilk feeding but was highly missing from one state, we fit a second model controlling additionally for maternal education as a sensitivity analysis. We also stratified by rooming-in status to examine differences in the association between breastmilk feeding and timing of maternal infection. Analyses were conducted using SAS 9.4 software and survey procedures to account for sampling.

This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy; the activity was determined to meet the requirements of public health surveillance as defined in 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq [12].

The five states reported data on 4,015 people with SARS-CoV-2 infection in pregnancy and their singleton liveborn infants, which after weighting represents 9,760 people and their infants. Deliveries included in this analysis occurred between March 29, 2020 and December 31, 2020. Pregnant people were most commonly between 25–29 years of age (29.5%) and 30–34 years of age (29.5%). Most were reported as White, non-Hispanic (44.2%) or Hispanic or Latina (28.9%), 49.0% had Medicaid as their health insurance at delivery, and 30.3% had some college education (Table 1). Maternal infections were identified in the first trimester for 17.6%, in the second trimester for 34.9%, and in the third trimester for 47.5% of people. The median time between maternal SARS-CoV-2 infection and delivery was 116 days (IQR: 1.5 day, 169.5 days, data not shown), with 79.8% of people infected > 14 days before delivery and 20.2% ≤14 days before delivery. Among the infants, 71.2% were born via vaginal birth, 91.7% had a gestational age ≥ 37 weeks, and 14.5% of infants were reported to have been admitted to the NICU.

Table 1

Maternal, labor and delivery, and infant characteristics associated with breastmilk feeding during birth hospitalization among people with SARS-CoV-2 infection during pregnancy, Surveillance for Emerging Threats to Mothers and Babies Network, March 29, 2020 – December 31, 2020
	Overall N = 4015^a				Breastmilk feeding				No breastmilk feeding
	Overall N = 4015^a				during birth hospitalization [n = 3540, w%= 86.0 (83.3,88.7)]				during birth hospitalization [n = 475, w%=14.0 (11.3,16.7)]
	N	Weighted %^b	95% CI		N	Weighted %^c	95% CI		N	Weighted %^c	95% CI		P^d
Age (years)
< 25	894	23.4	20.3	26.6	764	83.5	79.1	87.9	130	16.5	12.1	20.9	0.2345
25–29	1194	29.5	26.0	33.0	1048	84.4	78.0	90.8	146	15.6	9.2	22.0
30–34	1200	29.5	26.3	32.8	108	90.4	87.8	92.9	119	9.6	7.1	12.2
≥35	708	17.5	14.5	20.6	632	85.3	77.1	93.5	76	14.7	6.5	22.9
Not reported	19				15				4
Race/ethnicity
Hispanic or Latina	1186	28.9	26.1	31.7	1024	84.9	87.8	87.9	162	15.1	12.0	18.2	0.0012
Asian, non-Hispanic	276	4.6	3.7	5.4	213	83.4	78.3	88.4	63	16.6	11.6	21.7
Black, non-Hispanic	772	20.1	16.8	23.4	680	77.8	68.6	86.9	92	22.2	13.1	31.4
White, non-Hispanic	1575	44.2	40.3	48.1	1439	90.7	86.9	94.5	136	9.3	1.9	13.1
Multiple or other race, non-Hispanic^e	117	2.3	1.6	3.0	105	83.6	69.7	97.4	12	16.4	7.0	30.3
Not reported	89				79				10
Health insurance at delivery
Private	1853	45.3	41.5	49.1	1706	90.8	87.4	94.3	147	9.2	5.7	12.6	0.0006
Medicaid	1696	49.0	45.2	52.8	1423	81.2	76.8	76.8	273	18.8	14.3	23.2
Other & Self-pay/none	374	5.6	4.0	7.3	328	86.4	79.1	93.6	46	13.6	6.4	20.9
Not reported	92				83				9
Maternal education
Less than high school	387	16.5	13.6	19.3	311	81.9	76.2	87.6	76	18.1	12.4	23.8	< .0001
High school	457	24.2	20.1	28.2	368	73.7	63.9	83.4	89	26.3	16.6	36.1
Some college	540	30.3	25.8	34.8	466	84.8	78.3	91.4	74	15.2	8.6	21.7
College or greater	508	29.0	24.3	33.7	480	95.5	93.2	97.8	28	4.5	2.2	6.8
Not reported	2123				1915				208
Prenatal care appointments
Yes	3919	99.2	98.8	99.6	3466	86.1	83.4	88.9	453	13.9	11.1	16.6	0.253
Number of Visits (Median, IQR)	10.2 (8.3, 12.0)				10.4 (8.4, 12.0)				9.3 (7.3, 11.1)
No	34	0.8	0.4	1.2	25	76.2	55.8	96.6	9	23.8	3.4	44.2
Unknown	62				49				13
Trimester in which maternal SARS-CoV-2 infection occurred
First trimester	573	17.6	14.1	21.2	530	85.0	76.6	95.4	43	15.0	4.6	25.4	0.5681
Second trimester	1343	34.9	31.2	38.6	1217	88.4	83.8	93.1	126	11.6	6.9	16.2
Third trimester	2095	47.5	43.8	21.1	1789	84.5	82.0	87.1	306	15.5	12.9	18.0
Not reported	4				4
Timing of maternal SARS-CoV-2 infection before delivery
> 14 days	2938	79.8	77.7	82.0	2669	88.2	84.9	91.4	269	11.8	8.6	15.1	0.0002
≤ 14 days	972	20.2	18.0	22.3	779	77.8	73.8	81.9	193	22.2	18.1	26.2	0.0002
Unknown	105				92				13
Severity of COVID-19
Asymptomatic infection	577	18.5	16.0	21.0	493	82.4	77.4	87.4	84	17.6	12.6	22.6	0.5274
Mild	964	56.5	51.7	61.2	849	84.9	78.8	91.1	115	15.1	8.9	21.2
Moderate/severe	438	22.5	17.9	27.0	383	84.0	72.8	95.2	55	16.0	4.8	27.2
Critical	80	2.6	1.8	3.3	51	68.2	56.2	80.2	29	31.8	19.8	43.8
Insufficient information	1956				1764				192
Severity of COVID-19 within 14 days of delivery
Asymptomatic infection	375	47.1	41.6	52.5	310	80.0	73.5	86.6	65	20.0	13.4	26.5	0.0047
Mild	187	35.4	29.8	40.9	153	80.0	72.5	87.6	34	20.0	12.4	27.5
Moderate/severe	86	13.0	9.4	16.5	73	82.3	71.6	93.0	13	17.7	7.0	28.4
Critical	34	4.5	2.8	6.3	11	43.7	23.6	63.8	23	56.3	36.2	76.4
Insufficient information	395				324				71
Induction of labor
Yes	1582	40.4	36.5	44.2	1417	87.4	82.4	92.4	165	12.6	7.6	17.6	0.4552
No	2404	59.6	55.8	63.5	2099	85.1	82.0	88.1	305	14.9	11.9	18.0	0.4552
Not reported	29				24				5
Mode of delivery
Vaginal delivery	2837	71.2	68.0	74.3	2513	86.4	83.3	89.5	324	13.6	10.5	16.7	0.681
C-section delivery	1174	28.8	25.7	32.0	1024	85.1	79.8	90.5	150	14.9	9.5	20.2	0.681
Not reported	4				3				1
Gestational age at birth (median, IQR)	39.1 (38.1, 39.9)				39.1 (38.4, 40.0)				38.9 (38.0, 39.4)
Term (≥ 37 weeks)	3641	91.7	90.3	93.1	3253	87.0	84.1	89.9	388	13.0	10.1	15.9	0.0035
Preterm (< 37 weeks)	355	3.3	6.9	9723.0	272	76.5	69.1	84.0	83	23.5	16.0	30.9	0.0035
Unknown/not reported	19				15				4
NICU admission
Yes	431	14.5	12.1	17.0	325	75.9	68.7	83.1	106	24.1	16.9	31.3	0.0015
No	3258	85.5	83.0	87.9	2944	87.9	84.6	91.1	314	12.1	8.9	15.4	0.0015
Not reported	326				271				55
Roomed-in with mother
Yes	1920	75.2	72.5	77.8	1754	89.9	87.7	92.2	166	10.1	7.8	12.3	< .0001
No	607	24.8	22.2	27.5	469	76.2	71.1	81.2	138	23.8	18.8	28.9	< .0001
Not reported	1488				1317				171
Note: CI = Confidence Interval; NICU = Neonatal Intensive Care Unit
^aWeighted n = 9760
^bWeighted % is calculated as a column percent
^cWeighted % is calculated as a row percent
^dComparing breastmilk feeding during delivery hospitalization to no breastmilk feeding during delivery hospitalization; P-value calculated using chi-squared test; Fisher's exact test used for expected cell counts less than 5.
^eOther race category comprised of American Indian or Alaska Native and Native Hawaiian or Pacific Islander, which were reported too infrequently to calculate reliable estimates.

Overall, 86.0% (95% CI: 83.3%-88.7%) of mothers reported feeding breastmilk to their infant during the birth hospitalization (Table 1). The age distribution was not statistically different between mothers who provided breastmilk and those who did not. Mothers with Medicaid and those of Black, non-Hispanic race/ethnicity had a lower prevalence of breastmilk feeding than those with private insurance or of other race/ethnicities. Mothers with college or greater education had a higher prevalence of breastmilk feeding than those with less education. Mothers whose infants were born preterm or were admitted to the NICU also had a lower prevalence of breastmilk feeding relative to mothers of term infants or whose infant was not admitted to the NICU. In addition, mothers who had infection ≤ 14 days before delivery or had critical illness ≤ 14 days before delivery had a lower prevalence of breastmilk feeding compared with mothers with infection > 14 days before delivery or mothers with asymptomatic, mild, or moderate-severe COVID-19.

After adjusting for maternal age, maternal race/ethnicity, and gestational age, mothers with SARS-CoV-2 infection ≤ 14 days before delivery were less likely to feed breastmilk compared with mothers with infection > 14 days before delivery (aPR 0.90, 95% CI: 0.84, 0.96) (Table 2). Results were similar in the secondary analysis when adjusting additionally for education (aPR 0.90, 95% CI: 0.82, 0.97).

Table 2

Unadjusted and adjusted prevalence ratios of breastmilk feeding during delivery hospitalization by timing of maternal infection before delivery, overall and stratified by rooming-in status, among people with SARS-CoV-2 infection during pregnancy, Surveillance for Emerging Threats to Mothers and Babies Network, March 29, 2020 – December 31, 2020
	Unadjusted			Adjusted Model 1*			Adjusted Model 2**
	Unweighted N	PR	95% CI	Unweighted N	PR	95% CI	Unweighted N	PR	95% CI
Timing of maternal infection before delivery
> 14 days		ref			ref			ref
≤ 14 days	3910	0.88	(0.82, 0.94)	3820	0.90	(0.84, 0.96)	1796	0.90	(0.82, 0.97)
Timing of maternal infection before delivery by rooming-in status
Roomed-in with infant
> 14 days		ref			ref			ref
≤14 days	1908	0.96	(0.89, 1.03)	1860	0.96	(0.89, 1.03)	604	0.95	(0.84, 1.07)
Did not room-in with infant
> 14 days		ref			ref			ref
≤14 days	579	0.77	(0.67, 0.88)	576	0.75	(0.65, 0.86)	290	0.78	(0.66, 0.92)
Note: PR = Prevalence Ratio; CI = Confidence Interval
*Model 1: adjusted for maternal age, maternal race/ethnicity, and gestational age
**Model 2: adjusted for maternal age, maternal race/ethnicity, gestational age, and education
* March 2020 data are not reported because of small numbers.

Overall, 75.2% (95% CI: 72.5–77.8) of mothers roomed-in with their infants. Prevalence of breastfeeding was significantly higher among mothers who roomed-in with their infants compared with those who did not (89.9% vs 76.2%) (Table 1). Among mothers who did not room-in with their infants, those with infection ≤ 14 days before delivery were less likely to feed breastmilk compared with mothers with infection > 14 days before delivery (aPR 0.75, 95% CI 0.65, 0.86) (Table 2). Results were similar when adjusting additionally for education (aPR 0.78, 95% CI 0.66, 0.92). However, among mothers who did room-in, there was no association between timing of maternal infection before delivery and breastmilk feeding (aPR: 0.96; 95% CI 0.89, 1.03).

In April and May 2020, prevalence of breastmilk feeding among people with SARS-CoV-2 infection ≤ 14 days before delivery was < 70% which was significantly lower than breastmilk feeding prevalence among those with SARS-CoV-2 infection > 14 days before delivery, but differences in prevalence of breastmilk feeding was not significantly different in June through December of 2020 (Fig. 1). March 2020 births were not included in Fig. 1 due to small numbers. The frequency of rooming-in was lowest early in the pandemic, with only 23.9% of people with infection ≤ 14 days before delivery and 45.9% of those with infection > 14 days before delivery rooming-in with their infants in April of 2020. Frequency of rooming-in increased for both groups over time, but people with infection ≤ 14 days before delivery remained less likely to room-in later months compared with those who had infection identified > 14 days before delivery.

We found a significantly lower prevalence of initiation of breastmilk feeding among people with confirmed SARS-CoV-2 infection within two weeks before delivery. After controlling for known factors associated with breastmilk feeding, including maternal age, race/ethnicity, gestational age, and education, the association between timing of infection before delivery and breastmilk feeding was attenuated towards the null among mothers who roomed-in with their infants. Among mothers who did not room-in, however, we continued to see a significant reduction in prevalence of breastmilk feeding for those with infection closer to delivery. Given how little was known about the impact of SARS-CoV-2 infection and potential concern of adverse impacts on the infant, separation of mothers from infants for IPC precautions could have led to less breastmilk feeding initiation or less support to mothers with SARS-CoV-2 infection earlier in the pandemic and among mothers with infection closer to delivery. Breastmilk feeding and rooming-in appeared to improve later in the epidemic when the recommendations were updated to emphasize the importance of breastmilk feeding while following safety precautions.

Statewide breastmilk feeding prevalence reported during the majority of 2020 were similar to baseline estimates of the five included states from SET-NET. 83% of infants were ever fed any breastmilk [13]. People with lower education status, younger age, and of Black race are less likely to initiate feeding breastmilk [1, 13, 14]. These characteristics are also associated with an increased risk of SARS-CoV-2 infection [15]. We found that breastmilk feeding was also lowest among people with fewer years of education and of Black race which emphasizes the continued need for focused and culturally relevant breastfeeding promotion efforts in tandem with education regarding the breastmilk feeding practices in the setting of COVID-19. Variations in frequency of breastmilk feeding followed known demographic and birth characteristics, including a lower frequency among mothers enrolled in Medicaid and lower education levels, as well as infants born preterm, admitted to the NICU, or who did not room-in [1].

Previous studies have demonstrated infants rooming in with mother encourages initiation of the infant being fed breastmilk, and rooming-in is recommended by numerous public health and clinical organizations to support breastfeeding [1, 16, 17, 18, 19]. While early recommendations included consideration for temporary separation of mothers with COVID-19 from their newborns, multiple studies have now found low incidence of SARS-CoV-2 infection among infants born to people with SARS-CoV-2 infection [20] and low risk of transmission from mother to infant when appropriate IPC is followed [21]. The AAP and CDC recommend that mothers with COVID-19 room-in with their infants and use appropriate IPC measures (e.g., masks, hand hygiene) even if asymptomatic [6, 7].

While most infants who test positive for SARS-CoV-2 have mild or asymptomatic infection, severe disease does occur rarely [22, 23]. In addition to the numerous well-documented benefits of breastfeeding to both mothers and infants [1], accumulating evidence suggests antibodies against COVID-19 are present in breastmilk of mothers with SARS-CoV-2 infection. Multiple reports have now described detection of SARS-CoV-2 specific IgA and IgG in breastmilk after infection [24, 25]. Breastmilk has not been found to contain any SARS-CoV-2 that is replication competent, and thus, there has not been documented risk of transmission through breastmilk [24]. While it is unclear exactly what level of protection against postnatal SARS-CoV-2 infection these antibodies may provide for infants receiving breastmilk, there is a large body of existing evidence that breastmilk feeding reduces infants’ risk of respiratory tract infections [26, 27].

There are several limitations to note. First, important predictors of maternal breastmilk feeding initiation such as marital status and prior initiation of breastfeeding are not included in the SET-NET dataset, and about half of the people did not have enough information available to be able to classify disease severity, which may be an important factor in the ability or decision to initiate breastmilk feeding. Thus, residual confounding may exist. Second, we were not able to assess or control for facility-level factors that may influence breastfeeding initiation. Third, SARS-CoV-2 testing or screening practices have varied over the course of the pandemic, complicating interpretation of trends over time. Finally, this analysis is limited to breastmilk feeding practices at birth hospitalization, does not account for initiation after birth hospitalization, and further follow up of this cohort is needed to assess the full impact of SARS-CoV-2 infection on breastmilk feeding practices overtime.

All pregnant people, including those with SARS-CoV-2 infection, should be counseled on the benefits of breastmilk feeding, the low risk of transmission of SARS-CoV-2 from mothers to infants, and how to safely provide breastmilk to their infants with appropriate IPC measures if they have COVID-19. Healthcare providers and healthcare facilities should ensure that people with COVID-19 are supported to breastfeed.

ACKNOWLEDGMENTS

We thank the staff supporting the SET-NET work, including those at participating health departments, for data collection and reporting. We thank the following persons for their contributions to this project: Eirini Nestoridi, MD, Massachusetts Department of Public Health; Shannon Baack, Minnesota Department of Health; Ona Loper, Minnesota Department of Health; and Elizabeth Harvey, PhD, Tennessee Department of Health. Finally, we thank the COVID-19 Pregnancy and Infant Linked Outcomes Team, the Epidemiology and Surveillance Task Force.

CONFLICT OF INTEREST

The authors of this manuscript have no conflicts of interest to disclose. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

FUNDING INFORMATION

This study was performed as regular work of the Centers for Disease Control and Prevention. This work is supported by the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) Cooperative Agreement (ELC CK19-1904) and through contractual mechanisms, including the Local Health Department Initiative. This study/report was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists (CSTE) and funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 1NU38OT000297-03-00.

Eidelman AI, Schanler RJ, Johnston M, et al. Breastfeeding and the Use of Human Milk. Pediatrics. 2012;129(3):e827-e841. doi:10.1542/peds.2011-3552
Perrine CG, Chiang KV, Anstey EH, et al. Implementation of Hospital Practices Supportive of Breastfeeding in the Context of COVID-19 - United States, July 15-August 20, 2020. MMWR Morb Mortal Wkly Rep. Nov 27 2020;69(47):1767–1770. doi:10.15585/mmwr.mm6947a3
Vu Hoang D, Cashin J, Gribble K, Marinelli K, Mathisen R. Misalignment of global COVID-19 breastfeeding and newborn care guidelines with World Health Organization recommendations. BMJ Nutr Prev Health. Dec 2020;3(2):339–350. doi:10.1136/bmjnph-2020-000184
Woodworth KR, Olsen EO, Neelam V, et al. Birth and Infant Outcomes Following Laboratory-Confirmed SARS-CoV-2 Infection in Pregnancy - SET-NET, 16 Jurisdictions, March 29-October 14, 2020. MMWR Morb Mortal Wkly Rep. Nov 6 2020;69(44):1635–1640. doi:10.15585/mmwr.mm6944e2
Zambrano LD, Ellington S, Strid P, et al. Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status - United States, January 22-October 3, 2020. MMWR Morb Mortal Wkly Rep. Nov 6 2020;69(44):1641–1647. doi:10.15585/mmwr.mm6944e3
Evaluation and Management Considerations for Neonates At Risk for COVID-19. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html. Published 2020.
FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19. aap.org. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/. Published 2021.
Woodworth KR, Reynolds MR, Burkel V, et al. A Preparedness Model for Mother-Baby Linked Longitudinal Surveillance for Emerging Threats. Matern Child Health J. Feb 2021;25(2):198–206. doi:10.1007/s10995-020-03106-y
Sisk PM. Lactation Counseling for Mothers of Very Low Birth Weight Infants: Effect on Maternal Anxiety and Infant Intake of Human Milk. PEDIATRICS. 2006;117(1):e67-e75. doi:10.1542/peds.2005-0267
Galang RR, Newton SM, Woodworth KR, et al. Risk Factors for Illness Severity Among Pregnant Women With Confirmed Severe Acute Respiratory Syndrome Coronavirus 2 Infection—Surveillance for Emerging Threats to Mothers and Babies Network, 22 State, Local, and Territorial Health Departments, 29 March. Clinical Infectious Diseases. 2021;73(Supplement_1):S17-S23. doi:10.1093/cid/ciab432
Sampling and Weighting Methods For COVID-19 End of Pregnancy Medical Record Abstraction. Cdc.gov. https://www.cdc.gov/ncbddd/set-net/documents/set-net-pregnancy-sampling-white-paper-508.pdf. Published 2021.
Code Of Federal Regulations Title 45 Public Welfare Part 46 Protection Of Human Subjects. Department of Health and Human Services; 2009. https://www.hhs.gov/ohrp/sites/default/files/ohrp/policy/ohrpregulations.pdf.
Chiang KV, Li R, Anstey EH, Perrine CG. Racial and Ethnic Disparities in Breastfeeding Initiation horizontal line United States, 2019. MMWR Morb Mortal Wkly Rep. May 28 2021;70(21):769–774. doi:10.15585/mmwr.mm7021a1
Results: Breastfeeding Rates. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/data/nis_data/results.html. Published 2021.
Abedi V, Olulana O, Avula V, et al. Racial, Economic, and Health Inequality and COVID-19 Infection in the United States. J Racial Ethn Health Disparities. Jun 2021;8(3):732–742. doi:10.1007/s40615-020-00833-4
McGuire S. Centers for Disease Control and Prevention. 2013. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta, GA: U.S. Department of Health and Human Services, 2013. Adv Nutr. May 2014;5(3):291-2. doi:10.3945/an.114.005900
Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. Primary Care Interventions to Support Breastfeeding: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. Oct 25 2016;316(16):1694–1705. doi:10.1001/jama.2016.8882
Guideline: Protecting, Promoting And Supporting Breastfeeding In Facilities Providing Maternity And Newborn Services. World Health Organization; 2017.
Ragusa R, Marranzano M, La Rosa VL, et al. Factors Influencing Uptake of Breastfeeding: The Role of Early Promotion in the Maternity Hospital. Int J Environ Res Public Health. Apr 30 2021;18(9)doi:10.3390/ijerph18094783
Olsen EOM, Roth NM, Aveni K, et al. SARS-CoV-2 infections among neonates born to women with SARS-CoV-2 infection: maternal, pregnancy and birth characteristics. Research Square Platform LLC; 2021.
Walker K, O'Donoghue K, Grace N, et al. Maternal transmission of SARS-COV‐2 to the neonate, and possible routes for such transmission: a systematic review and critical analysis. BJOG: An International Journal of Obstetrics & Gynaecology. 2020;127(11):1324–1336. doi:10.1111/1471-0528.16362
Wallace B, Chang D, Woodworth K, et al. Illness severity indicators in newborns by COVID-19 status in the United States, March-December 2020. J Perinatol. Nov 2 2021;doi:10.1038/s41372-021-01243-y
Shaiba L, Altirkawi K, Hadid A et al. COVID-19 Disease in Infants Less Than 90 Days: Case Series. Front Pediatr. 2021;9. doi:10.3389/fped.2021.674899
Pace RM, Williams JE, Järvinen KM, et al. COVID-19 and human milk: SARS-CoV-2, antibodies, and neutralizing capacity. Cold Spring Harbor Laboratory; 2020.
Juncker HG, Romijn M, Loth VN, et al. Antibodies Against SARS-CoV-2 in Human Milk: Milk Conversion Rates in the Netherlands. Journal of Human Lactation. 2021;37(3):469–476. doi:10.1177/08903344211018185
Ip S, Chung M, Raman G, Trikalinos TA, Lau J. A summary of the Agency for Healthcare Research and Quality's evidence report on breastfeeding in developed countries. Breastfeed Med. Oct 2009;4 Suppl 1:S17-30. doi:10.1089/bfm.2009.0050
Dieterich CM, Felice JP, O'Sullivan E, Rasmussen KM. Breastfeeding and health outcomes for the mother-infant dyad. Pediatr Clin North Am. Feb 2013;60(1):31–48. doi:10.1016/j.pcl.2012.09.010

Breastmilk feeding of infants at birth among people with confirmed SARS-CoV-2 infection in pregnancy — SET-NET, Five States, March 29, 2020–December 31, 2020

Status:

Journal Publication

Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Introduction

Methods

Results

Discussion

Public Health Implications

Declarations

References

Status:

Journal Publication

Version 1