Authors' Response.

Dear Editor,

We received a letter in which the author named Turkish Neonatal Society’s breastfeeding suggestions as ‘overly-cautious approach’ for a mother with possible or confirmed coronavirus disease 2019 (COVID-19) instead of being in favor of giving mother’s milk to her infant. The author also claimed that Turkish Neonatal Society’s (TNS) proposal gives an impression of discouraging breastfeeding by stating “we are not completely sure that the virus cannot be transmitted via breast milk” (1, 2). We want to discuss this important subject with the chronologic progression of the pandemic in Turkey and two recently published articles by the TNS.

The first COVID-19 case was reported on March 11th, 2020, in Turkey, where 1.2 million infants are born annually. In the context of COVID-19 in a country with a high birth number, the TNS established a Task Force immediately which worked in coordination with the Ministry of Health COVID-19 Scientific Committee, and published a proposal with the evidence available in March 2020, to handle newborns with SARS-CoV-2 infections and outbreaks in neonatal intensive care units (NICU). The Task Force specially mentioned in the introduction of the proposal that recommendations should be modified based on accumulated clinic evidence and experience because of the limited cases and clinical evidence in neonatal COVID-19 at that time (2). The TNS proposes that breastfeeding decision may be given individually based on the ‘mother’s health status’, and encourages mothers to express their breast milk to establish and maintain milk supply even they are hospitalized or are apart from their newborns. It includes that while feeding at the breast, all possible precautions should be taken to avoid contamination of the virus, including careful handwashing and wearing a face mask, which are universal recommendations nowadays. These cautions are preventive measures to decrease the risk of contamination, and should not be interpreted as an impression of discouraging breastfeeding.

The TNS founded a Neo-Covid Research Group to evaluate epidemiologic and clinical characteristics of COVID-19 in mother-infant dyads and published two studies recently that we believe may represent the current condition in our country. The first study was a multicenter cohort study conducted among newborns born to 125 mothers with COVID-19 in 34 NICUs in Turkey. The majority of the newborns (n=108, 86.4%) born to COVID-19 mothers were followed in isolation rooms in the NICU for a while, whereas others were monitored with a distance of two meters away from the mother (n=11, 8.8%) or cared for by family members in a separate room (n=6, 4.8%). Concerning breastfeeding, most of the neonates were fed with formula (n=71, 56.8%) or expressed breast milk (n=45, 36%), followed by breastfeeding (n=9, 7.2%) with caution. All neonates with COVID-19 (n=4) were fed with formula. Oncel et al. commented that in contrast to the recommendations in the TNS proposal, isolation of the patients in the NICU, health status of the mothers, and the anxiety of both parents and physicians on the possible contamination to breast milk could have affected the rate of breastfeeding in their cohort, and suggested that family support should be a part of the care in the NICU (3). Similarly, the Neo-COVID-19 Research Group from Spain reported a multicenter study, which also gave data regarding feeding type. Only 41.7% of the newborns received exclusive breastfeeding at discharge, which was lower than expected (4).

The second study of the TNS was a prospective multicenter cohort study including 24 NICUs around Turkey, wherein outpatient neonates with COVID-19 were registered in an online national database. The management of all 37 neonates with COVID-19 was made in accordance with the proposal provided by the society. Nine mothers (22%) continued breast-feeding, whereas 22 neonates (52%) were fed with expressed milk and only 11 neonates (26%) were fed with formula. The reality is that feeding neonates with breastmilk in the NICU during COVID-19 is a great challenge. NICU visits, especially if the mother is also infected and transferring expressed milk to the NICU, are all delicate issues that should be carefully planned without putting NICU staff and other neonates in the NICU under risk. This study showed that it was through the august efforts of the NICU staff that 74% of the neonates in this study continued to be fed with breastmilk (5).

In conclusion, we agree that mother-infant dyads should receive care together, breastfeeding should be encouraged, and families should be supported to overcome their anxiety about the risk of contamination through breastfeeding. Indeed, recent studies showed that milk produced by an infected mother was a source of anti-SARS-CoV-2 IgA and IgG, which may neutralize SARS-CoV-2 activity and play a protective role against the transmission and severity of the disease in the infant (5, 6). Therefore, continuing breastfeeding with appropriate infection control measures is strongly recommended.