Breastfeeding in the era of COVID-19 - Dra. Ana Villaseñor-Todd

HUMAN MILK IS SO IMPORTANT THAT MILKY WAY IS MADE OF IT

The story goes that Hercules and his twin brother were sons of Zeus and the mortal queen Alcmene. Only Hercules inherited the semi-divine condition of his father. Zeus tricked his wife Hera by putting the baby to suckle from her breast to confirm his status of God and thus, granting him the formidable strength that characterized him. Hera took notice and removed Hercules from her breast. From the spurt of milk that came out, they say that the Milky Way was created in the sky.

Today, we know that the best food for infants is breast milk; according to the World Health Organization (WHO), it should be given exclusively until the first six months of life and supplemented with other food until 2 years of age or older. The first hours and days of a newborn’s life are the ideal time to establish breastfeeding and provide mothers with the support they need to successfully breastfeed their infants.1

Several factors affect the development of the gut microbiota in early life, among which breastfeeding plays a key role. Newborns adapt to the extrauterine environment through the development of intestinal immune homeostasis. Initial bacterial colonization is necessary for adequate intestinal immune development. An environmental determinant for proper colonization is breast milk. Although the term infant is capable of developing an immune response, the effector-immune component requires bacterial stimulation. Breast milk stimulates the proliferation of a diverse and balanced microbiota, which initially influences a shift from a predominant intrauterine TH2 response to a balanced TH1/TH2 response and with the activation of regulatory T-cells by specific organisms stimulated by breast milk (Bifidobacterium, Lactobacillus, and Bacteroides).2 The nutritional benefits that breast milk confers to the infant, such as digestion, prevention of infectious disease complications, and proper orofacial development, are incalculable and have been extensively studied. However, the effects on other variables, such as cognitive development, does not seem to be strongly related to the properties of the milk, but rather with the impact that the act of breastfeeding creates on the mother-child binomial, especially, the effect of “maternal sensitivity”, a concept of attachment theory, which refers to the mother’s ability to read the infant’s attachment signals and respond to them in a contingent and adequate manner, generating biological synchrony between the two.

The Seven Works of Mercy. Caravaggio, 1607

This synchrony, dependent on maternal sensitivity, is the main characteristic for the development of an affective bond described as a “secure attachment”. Scientists propose that this synchronization process between mother and child is reinforced during the act of breastfeeding, and that is the element that goes beyond the mere nutritional composition of the milk. For example, it is known that skin-to-skin contact, as well as gaze feedback between the two, creates a secretion of oxytocin that, in addition to acting physiologically for milk production, proceeds on certain parts of the mother's brain, such as the amygdala, regulating emotions and promoting a state of well-being. There a thousand physiological reasons to justify breastfeeding, but there is an extra ingredient that we have not mentioned, often expressed in a theme of pagan origins known as The Roman Charity (https://youtu.be/6JB7zA4l1m0), the main players are Cimon and Pero, described in the artistic account of Valerius Maximus.

Pero is a newborn woman, Cimon is her father, who was imprisoned and condemned to death by starvation; his daughter came every day to the cell to nurse him. The encounters would be eventually discovered, causing such admiration to the Roman authorities that the prisoner would be released, being an example of filial love and a symbol of charity. This scene has captivated painting and sculpture from the sixteenth to the eighteenth centuries on countless occasions by artists from all over Europe, and by Caravaggio. This extra element of breastfeeding, which some may play an important role in all the benefits of breast milk, was not included in the products created since 1865 known as Liebig’s Soluble Food for Babies. It was a powder containing cow's milk, wheat and malt flour, and potassium bicarbonate, and was the first commercial substitute for breast milk, the result of a rigorous scientific study. In the early 19th century, infant death rates were high: only 2 out of 3 infants who were not breastfed lived to their first birthday. Liebig aimed to rescue the African population from starvation.2

When this breast milk substitute was obtained, it was quickly marketed by the pharmaceutical industry, but also by women when they entered the labor market to get out of the recession caused by World War II, with advertising assuring that it had the same benefits that breast milk. First, working women began to use it, especially because of the length of the workday, since there were not hygienic, comfortable, and private places (it is grim that these conditions prevail in some places today) where they could extract breast milk to preserve it while they continued their workday. Thus, weaning began to occur earlier, and a new culture of normalizing the use of formula and bottle-feeding, and seeing it as unpleasant and distressing to breastfeed their babies directly from the breasts began to permeate.

Unfortunately, during those years we observed a decrease in the practice of exclusive breastfeeding, and the use of mixed feeding (breast and formula feeding), as well as artificial breastfeeding from birth, took root. Such practices were regulated by WHO in 1981 and by that time, the slogan that breast milk is always above the benefits that breast milk substitutes can provide was being introduced.3 In fact, in 1991, WHO and UNICEF developed the Baby-Friendly Hospital Initiative (BFHI), where they established 10 steps to help mothers successfully breastfeed. To date, it is a certification given to hospitals that promote breastfeeding from pregnancy and during birth, and support is also provided after the discharge of the couple; 152 countries are in favor of this initiative, including Mexico, which in 2012 had a percentage of exclusive breastfeeding at 6 months of age of 14.4% and through the dissemination of the BFHI was able to increase it to 28.6%.4

As in many other areas of our lives, the COVID-19 pandemic has disrupted much of what we had established and has created fears and adjustments in populations that were considered to be at high risk, including pregnant women. As is well known, COVID-19 is an infectious disease caused by the SARS-CoV-2 virus. It is mainly transmitted by direct contact with respiratory droplets larger than five microns through hands, contaminated fomites and contact with the mucous of the mouth, nose, or eyes.5

At the beginning of the pandemic, since the virus behavior in pregnant women and newborn was unknown, recommendations were made to separate the couple when the mothers were suspected or confirmed to have COVID-19 disease, which meant not only performing skin-to-skin contact at the time of birth, and that the mother and child should not be housed together.6 Delayed breastfeeding (pumping breast milk and administering it through a device such as a cup, spoon, or bottle), or even withholding breast milk altogether was encouraged, and exclusive formula and bottle feeding were promoted while the mother was infected. Naturally, this has generated fear in the act of breastfeeding, as well as early weaning with all the complications related to it. Fortunately, today we know more about the behavior of the SARS-CoV-2 virus. In a multicenter study conducted in Sweden, the investigators stated that out of 2323 neonates born to SARS-CoV-2-positive mothers, only 21 neonates (0.90%) tested positive for SARS-CoV-2 in the first 28 postnatal days. In the vast majority of cases, transmission occurred through maternal respiratory secretions, and recent publications have demonstrated that vertical transmission is possible, although very rare.7 No viable infectious virus has been detected in breast milk, and even neutralizing IgA and IgG antibodies have been found in human milk against multiple SARSCoV-2 antigens.8 In other words, there is, currently, no absolute contraindication to breastfeeding, and the risk of contagion does not seem to outweigh the benefits of providing it.

On the other hand, and in those cases in which the use of substitutes is necessary, the implementation of complementary measures that promote and strengthen the extra elements of the breastfeeding benefit, in addition to the nutritional aspects, could help mitigate distress and uncertainty. That is, skin-to-skin contact under strict handwashing, before touching the baby and feeding, and after any contact of respiratory or oral secretions by the mother or the use of masks if the mother is suspected or positive for SARS-CoV-2 virus allows for a visual exchange between the two and can preserve and encourage this positive aspect of the act of breastfeeding, maintaining safety in event that can arise from compassion and respect for the other. However, if conditions cannot be guaranteed during birth, skin-toskin contact should be postponed until the mother and NB are in co-housing.

Regardless of the condition of the mother or the newborn, the objective required by the current condition should not be lost sight of. While the pandemic has favored “home office”, incorporating women into a sexually segregated labor market has proven to be neither as satisfying nor as profitable experience. As we could expect, wage gaps, extremely low salaries, precariousness, glass ceiling, but also women breastfeeding in public bathrooms, continue to be stigmatized. The required change has not occurred in the private sphere; we need to consider a real sharing of work with equity, starting today with the ennoblement of spaces; to really make an impact we cannot wait for everything to happen in the next generation of humans.

Dra. Ana Villaseñor-Todd

Mexican scientist recognized by her research on minimal hepatic encephalopathy, oxidative stress, quality of life, and social cognition. As a professional physician, she completed her postgraduate studies at Texas A&M University; currently, she is a candidate to receive the Medical Doctor degree by the UANL.

TECHNICAL COMMITTEE

Dr. Erika del Carmen Ochoa-Correa, Pediatrician, Neonatologist, Lactation Consultant, IBCLC (International Board-Certified Lactation Consultant). Dr. Xochitl Duque- Alarcon, Expert Psychiatrist in the study of effects of early experiences on emotional development.