First do no harm overlooked: Analysis of COVID-19 clinical guidance for maternal and newborn care from 101 countries shows breastfeeding widely undermined

Karleen Gribble; Jennifer Cashin; Kathleen Marinelli; Duong Hoang Vu; Roger Mathisen

doi:10.3389/fnut.2022.1049610

First do no harm overlooked: Analysis of COVID-19 clinical guidance for maternal and newborn care from 101 countries shows breastfeeding widely undermined

Front Nutr. 2023 Jan 17:9:1049610. doi: 10.3389/fnut.2022.1049610. eCollection 2022.

Authors

Karleen Gribble¹, Jennifer Cashin², Kathleen Marinelli³, Duong Hoang Vu⁴, Roger Mathisen⁴

Affiliations

¹ School of Nursing and Midwifery, Western Sydney University, Parramatta, NSW, Australia.
² Alive & Thrive Southeast Asia, FHI 360, Washington, DC, United States.
³ Department of Pediatrics, University of Connecticut School of Medicine, Hartford, CT, United States.
⁴ Alive & Thrive Southeast Asia, FHI 360, Hanoi, Vietnam.

Abstract

Background: In March 2020, the World Health Organization (WHO) published clinical guidance for the care of newborns of mothers with COVID-19. Weighing the available evidence on SARS-CoV-2 infection against the well-established harms of maternal-infant separation, the WHO recommended maternal-infant proximity and breastfeeding even in the presence of maternal infection. Since then, the WHO's approach has been validated by further research. However, early in the pandemic there was poor global alignment with the WHO recommendations.

Methods: We assessed guidance documents collected in November and December 2020 from 101 countries and two regional agencies on the care of newborns of mothers with COVID-19 for alignment with the WHO recommendations. Recommendations considered were: (1) skin-to-skin contact; (2) early initiation of breastfeeding; (3) rooming-in; (4) direct breastfeeding; (5) provision of expressed breastmilk; (6) provision of donor human milk; (7) wet nursing; (8) provision of breastmilk substitutes; (9) relactation; (10) psychological support for separated mothers; and (11) psychological support for separated infants.

Results: In less than one-quarter of country guidance were the three key breastfeeding facilitation practices of skin-to-skin contact, rooming-in, and direct breastfeeding recommended. Donor human milk was recommended in under one-quarter of guidance. Psychological support for mothers separated from their infants was recommended in 38%. Few countries recommended relactation, wet nursing, or psychological support for infants separated from mothers. In three-quarters of country guidance, expressed breastmilk for infants unable to directly breastfeed was recommended. The WHO and the United Kingdom's Royal College of Obstetricians and Gynecologists were each cited by half of country guidance documents with the United States Centers for Disease Control and Prevention directly or indirectly cited by 40%.

Conclusion: Despite the WHO recommendations, many COVID-19 maternal and newborn care guidelines failed to recommend skin-to-skin contact, rooming-in, and breastfeeding as the standard of care. Irregular guidance updates and the discordant, but influential, guidance from the United States Centers for Disease Control may have been contributory. It appeared that once recommendations were made for separation or against breastfeeding they were difficult to reverse. In the absence of quality evidence on necessity, recommendations against breastfeeding should not be made in disease epidemics.

Keywords: COVID-19; breastfeeding; policy; psychosocial support systems; rooming-in care.

Grants and funding

The Alive & Thrive initiative, managed by FHI Solutions, is currently funded by the Bill & Melinda Gates Foundation, the Government of Ireland, UNICEF, and the World Bank. Staff time to write this manuscript was covered by grants from the Bill & Melinda Gates Foundation (OPP50838) and the Government of Ireland to Alive & Thrive/FHI Solutions (DV, JC, and RM).