Breast milk and its anti-infective and anti-inflammatory factors have become particularly important in alleviating infectious diseases. Breastfeeding also seems to be related to increased type I interferon production in infants infected with influenza virus, and in a study of 26 COVID-19 adult in an ICU environment, it was found that interferon production was compromised in 20%.20,21 The prognosis of patients and these patients is poor, the length of stay in the intensive care unit is longer, and the need for invasive ventilation is greater. A recent report found that 12 of 15 mothers (80%) previously infected with COVID-19 had a strong sIgA antibody SARS-CoV-2 immune response in their breast milk.22

A study by Chen et al. of 9 patients with pneumonia caused by COVID-19 did not find the virus in 6 patients’ samples, which came from amniotic fluid, cord blood, breast milk and oropharyngeal swabs. Three of these newborns presented molecular tests positive for COVID-19, and the authors questioned the existence of possible vertical transmission of the virus since all measures recommended for infection control were adopted. However, the samples of amniotic fluid, umbilical cord blood, and breast milk did not show the presence of the virus.19

A case study conducted at the University of Puerta Hierro with 22 mothers with neonatal COVID-19 infection showed that 20 out of 22 mothers (90.9%) chose to breastfeed their babies during hospitalization. During the follow-up period, there were no major complications and no newborn infections during breastfeeding.23 Yang et al. believe that SARS-CoV-2 is unlikely to be transmissible via breast milk, but the quality of evidence remains low.24

Therefore, the existing data so far, although not very reliable from a scientific point of view, show that the main route of COVID-19 transmission to newborns is droplet infection from caregivers, or secondly through contact with contaminated biomaterials. Vertical mother-to-fetus transmission seems to be possible, but it is not documented and does not seem to be very frequent.

As SARS-CoV-2 is transmitted via close contact and droplets, transmission from mother to infant may be possible while breastfeeding. A case series indicated that influenza infected breastfeeding women who washed hands thoroughly did not transmit to their children during a one-month follow-up, regardless of if the mothers wore a mask or not.25

Several case has been report supporting that SARS-CoV-2 does not transmit by breast milk.26–38 Case from Fenizia et al., Wu et al., and Gross et al., reports of positive SARS-CoV-2 RT-PCR in breast milk samples.39–41 A recent report from Italy described two maternal–infant dyads who presented with positive nasopharyngeal swabs for SARS-CoV-2 at 10 and 18 days after birth but breast milk of both mothers was negative for SARS-CoV-2 and they hypothesized that the mothers and infants were probably infected by a third person at the same time.8

Our review (Table 1) shows that vertical mother to fetus transmission through breast milk is rare. There is no evidence novel coronavirus can pass to infants through breast milk, because the virus was not found in breast milk. This possibility cannot be completely ruled out, because the data available are based on limited clinical experience developed over few months during the novel COVID-19 pandemic, studies performed in women affected by COVID-19, and data collected during previous infectious outbreaks caused by other types of coronavirus, including severe acute respiratory syndrome, severe acute respiratory syndrome coronavirus. In 21 literature our review, we found there are 3 cases show positive SARS-CoV-2 detected in breast milk while the others literature shows no detected. In terms of associated mode in delivery there is no different between vaginal and caesarian for increase the risk of transmission. In Table 1 also show the number of infants who positive and negative in throat swab SARS-CoV-2 and we found only 3 cases have been reported positive in throat swab in infant and we also note additional information at some case with positive throat swab PCR.

Breastfeeding has been proven to have many benefits for child especially the breast milk contains antibodies such as IgA, IgM, IgG. Circulating antibodies can diffuse into breast milk and pass on to offspring, giving them passive immunity. Newborns will rely on passive immunity from the mother. From this statement it becomes a hypothesis of several studies to see how to provide breast milk with COVID-19 on the health of newborns.

Dong et al. determined the antibody to SARS-CoV-2 in breast milk's mother who confirmed with COVID-19. The titers of IgA antibody in breast milk elevated in positive throat swabs SARS-CoV-2 mother. They also show that there is no detection of SARS-CoV-2 in the mother's body fluids (especially in breast milk) serially collected after delivery when her throat swabs showing positive. No neonate had positive result for SARS-CoV-2 RNA at the birth.28 Human milk IgA provides a key antibacterial defense Inhibition of pathogenic bacteria on neonatal gastrointestinal tract Attaches to the mucosal surface, neutralizes microbial toxins, and provides passive.8 IgA mostly produced in lamina propria adjacent to mucosal. Secretory immunoglobulin (sIgA) acts directly on the mucosal surface by inhibiting the binding of microbes to the host epithelial cell receptors and trapping pathogenic microorganisms in the mucus and increasing intestinal ciliary activity. In addition, sIgA can neutralize SARS-CoV-2 before they reach and bind the epithelial cellsWith this mechanism, sIgA breast milk can provides protection against the entry of the SARS-CoV-2 virus on the mucosal surface of the airways.42

Based on prospective case control study by van Keulen et al. explained that breast milk contains specific IgA antibody for SARS-CoV-2 on 24 of the 29 confirmed cases (83%) based on swab tests and 6 of the 9 suspected cases (67%).43 Besides IgA, some protective antibody can be passed by breastfeeding from the mother to the offspring, preventing or decreasing the severity the children's diseases such IgM and IgG. Case report by Yu et al., the mother's milk was positive for SARS-CoV-2 IgG and negative for IgM and on hospital day 14, the infant's serum was positive for both SARS-CoV-2 IgG and IgM, suggesting either breast milk transfer to the infant or infant de novo production of the IgG and/or IgM, or both mechanisms.44

In the study of Abuidhail et al. was found that IgG concentrations had a linear relationship with breastfeeding activity for 6 months. So the activity of breastfeeding can affect the concentration of IgG in breast milk to protect the baby from infection.45 IgG is the main antibody in secondary immune response if there is reinfection. IgGs such as IgG3 and IgG1 can attack the viral envelope glycoprotein so that this will provide an effective systemic antibody for viruses. IgG also acts as an antibody that degrades intracellular viruses by binding to a crystallizable cytosolic fragment (Fc) motif containing -21 tripartite receptor (TRIM21).46

Study of Kohler et al., 6 mothers with confirmed COVID-19, SARS-CoV-19 was not detected in the serum or throat swab by RT-PCR in any of their newborns. But virus-specific antibodies were detected in neonatal blood sera samples. The IgG concentrations were elevated in 5 infants.47

IgG is passively transferred across the placenta from mother to fetus beginning at the end of the second trimester and reaches high levels at the time of birth.47 All cases we shown in Table 2.

It has been explained that the risk of transmission and transmission of SARS-Cov-2 through breast milk is minimal. In addition, there are specific antibodies that can against SARS-CoV-2 as passive immunity for babies as body defense. WHO, UNICEF, WABA, ILCA's, UNFPA, and ABM recommend continuing to breastfeed mothers with COVID-19. We also recommend several provisions for breastfeeding in mothers with COVID-19.

Skin contact help effectiveness of breastfeeding and improve body temperature regulation, blood sugar control and mother–infant attachment, and reduce the mortality and risk of serious infections in low-birth-weight infants. Skin to skin contact also increase psycologic correlation between baby and mother. The important thing is skin to skin breastfeeding better than indirect breastfeeding such as use pumping equipment.48 Mother with moderate until severe illness cannot breastfeeds directly, so the best choice is indirect breastfeeding. The breast tube and container should be clean every time. Strict hand hygiene must be observed when pump and storage the breast milk.49

Infection control and prevention is very important while breastfeeding. Especially with direct breastfeeding, droplets containing viruses on the surface of the mother's body can increase the risk of the baby becoming infected. Based on previous study by Pandofi et al. concluded that mothers with symptoms should clean their hands thoroughly with soap and air before touching the baby and cover their nose and mouth with a tissue when sneezing or coughing when in contact with the baby.50 From a study by Cheema et al. also concluded that asymptomatic and mildly ill mothers are recommended for Mothers should wear a mask when breastfeeding and wash their hands and breasts with soap and water before breastfeeding. During intervals between feedings it is advisable to place the baby at least 2 meters apart.51

Based on study by Gilany concluded that mothers with COVID-19 should limit contact with their babies except while breastfeeding. When breastfeeding, babies are very vulnerable to droplets from the mother through respiratory secretions, so the mother must wear a mask when breastfeeding. Joint care is permitted provided that there are no other patients in the room and the baby is in a separate bed with a minimum distance of two meters from the mother's bed. There should be another healthy adult caring for the newborn in the room. If the mother is in moderate to severe condition it is recommended for use by the mother's baby. From all recommendation and literature, we conclude the recommendation breastfeeding for mother with explanation through Fig. 1.

Fig. 1.

Approach breastfeeding in mother with COVID-19.

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