Risks and Benefits of Breastfeeding in COVID-19: Integrative Literature Review

Articles from 2020 and 2021 collected from the PubMed, CAPES, Virtual Health Library, Google Scholar, SciELO, and UpToDate databases were analyzed. Books and government documents published in the last decade (2010-2020) were also consulted.

Study Selection

Sixteen works were used in the present study. The date of publication and discussion of SARS-CoV-2 transmission through breastmilk were the inclusion criteria. Thus, articles containing repeated information or with no relevance to add to the production were excluded. Data collection comprised critical reading and synthesis of the main information obtained on the subject, which were performed for the preparation of the present study. The research took place in the period from March 27 to April 2, 2021.

Synthesis of the data

Breast milk has diverse benefits for both the nursing mother and the infant. The presence of viral RNA by real-time polymerase chain reaction (RTPCR) in milk from disease-positive mothers has been detected in a few cases, and infant infections in these conditions suggest oral transmission of maternal or third-party origin. The virulence of the novel coronavirus in human milk is not confirmed, while significant amounts of exclusive antibodies are.

Conclusion

Lactation in the context of COVID-19 has shown greater benefits than risks of vertical transmission. Therefore, it should be encouraged when possible.

Keywords:
COVID-19; SARS-CoV-2 infection; breastfeeding; vertical infectious disease transmission; immunology

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[1] Address for correspondence
João Guilherme de Moura Oliveira, Aluno de Graduação em Medicina, Rua Rio Comprido, Bairro Cinco, 32010-025, Contagem, MG, Brazil (e-mail: jgmoura.oliveira@gmail.com).

Title	Authors	Date of publication	Study	Brief description
The Effect of Coronavirus Disease 2019 on Cardiovascular Disease	Askin et al.¹1 Askin L, Tanriverdi O, Askin HS. The effect of Coronavirus Disease 2019 on cardiovascular disease. Arq Bras Cardiol. 2020;114(05): 817-822. Doi: 10.36660/abc.20200273 https://doi.org/10.36660/abc.20200273...	2020	Review article	The article addresses the pathophysiology of the disease and delves into the risk of its evolution within vascular comorbidities. Finally, it was used for the introduction of the theme and epidemiological contextualization.
Protocolo de Manejo Clínico do Coronavírus (COVID-19) na Atenção Primária à Saúde	Ministério da Saúde²2 Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Protocolo de manejo clínico do Coronavírus (COVID-19) na atenção primária à saúde: Versão 7 [Internet]. 2020 [cited 2021 Mar 28]. Available from: https://saude.rs.gov.br/upload/arquivos/202004/14140606-4-ms-protocolomanejo-aps-ver07abril.pdf https://saude.rs.gov.br/upload/arquivos/...	2020	Protocol	The protocol addresses the acute condition of COVID-19 within the full clinical spectrum, and provides guidance for therapy.
Severe COVID-19: understanding the role of immunity, endothelium, and	Brandão et al.³3 Brandão SCS, Godoi ETAM, Ramos JOX, de Melo LMMP, Sarinho ESC. Severe COVID-19: understanding the role of immunity, endothelium, and coagulation in clinical practice. J Vasc Bras. 2020;19:e20200131. Doi: 10.1590/1677-5449.200131 https://doi.org/10.1590/1677-5449.200131...	2020	Review article	The article presents an association between COVID-19 and the endothelial
coagulation in clinical practice				involvement that this health condition causes in this tissue. In addition, it illustrates the immunophysiology of the disease.
Alimentos, Sars CoV-2 e Covid-19: contato possível, transmissão improvável	Franco et al.⁴4 Franco BD, Landgraf M, Pinto UM. Alimentos, Sars-CoV-2 e Covid-19: contato possível, transmissão improvável. Estud Av. 2020;34 (100):189-202. Doi: 10.1590/s0103- 4014.2020.34100.012 https://doi.org/10.1590/s0103-...	2020	Review article	The article discusses the possibility of SARS-CoV-2 transmission through food, and was used to contextualize this aspect.
Guia de Vigilância Epidemiológica: Emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019	Ministério da Saúde⁵5 Ministério da Saúde. Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019: COVID-19 [Internet]. Brasília (DF): Ministério da Saúde; 2021 [cited 2021 Mar 29]. Available from: https://www.gov.br/saude/pt-br/coronavirus/publicacoes-tecnicas/guias-e-planos/guia-devigilancia-epidemiologica-covid-19	2021	Epidemiological surveillance guide	The document addresses the epidemiology of COVID-19 by specific age groups, and was used to contextualize the risk scenario for pregnant women from a prevalence and death perspective.
Guia Alimentar para crianças brasileiras menores de 2 anos	Ministério da Saúde⁶6 Ministério da Saúde. Secretaria de Atenção Primaria à Saúde. Departamento de Promoção da Saúde. Guia alimentar para crianças brasileiras menores de 2 anos [Internet]. Brasília (DF): Ministério da Saúde; 2019 [cited 2021 Apr 1]. Available from: http://189.28.128.100/dab/docs/portaldab/publicacoes/guia_da_ crianca_2019.pdf http://189.28.128.100/dab/docs/portaldab...	2019	Food guide	The document presents a dietary guideline for Brazilian children < 2 years old and objectively addresses breastfeeding, as well as its benefits and an explanation of how to proceed.
[BREASTFEEDING x COVID-19: Elaboration of a SOP for the stages of extraction and storage of breast Milk]	Fernandes et al.⁷7 Fernandes E, Sousa J, Silva R, Serquiz A. [BREASTFEEDING x COVID-19: elaboration of a SOP for the stages of extraction and storage of breast milk]. Rev Extensão Soc.. 2020;12(01):30-45. Doi: 10.21680/2178-6054.2020v12n1ID20791 https://doi.org/10.21680/2178-6054.2020v...	2020	Standard operating procedure	The standard operating procedure guides how breastfeeding should be performed in times of COVID-19. Care at the time of breast milk extraction is the main issue addressed.
Guidance on breastfeeding during the Covid-19 pandemic	Calil et al.⁸8 Calil VMLT, Krebs VLJ, Carvalho WB. Guidance on breastfeeding during the Covid-19 pandemic. Rev AssocMed Bras (1992). 2020; 66(04):541-546. Doi: 10.1590/1806-9282.66.4.541 https://doi.org/10.1590/1806-9282.66.4.5...	2020	Review article	The article addresses the importance of breastfeeding, the existing data regarding transmission, the guidelines of the public health agencies, and possible scenarios in the health condition of mother and child to guide the practice under discussion.
Breastfeeding importance and its therapeutic potential against SARS-CoV-2	Vasques et al.⁹9 Vasques da Costa A, Purcell Goes C, Gama P. Breastfeeding importance and its therapeutic potential against SARS-CoV-2. Physiol Rep. 2021;9(03):e14744. Doi: 10.14814/phy2.14744 https://doi.org/10.14814/phy2.14744...	2021	Review article	The article presents scientific data regarding the benefits of breastfeeding, especially considering the immunological resources in the context of COVID 19.
Epidemiologia	Gordis L¹⁰10 Gordis L. Epidemiologia. 5a ed. Rio de Janeiro: Thieme Revinter; 2017	2017	Book	The book was used to support epidemiological concepts in the context of disease transmission. Chapter 2 was used.
Transmission of SARS-CoV-2 through breast milk and breastfeeding: a living systematic review	Centeno-Tablante et al.¹¹11 Centeno-Tablante E, Medina-Rivera M, Finkelstein JL, Rayco-Solo P, Garcia-Casal MN, Rogers L, et al. Transmission of SARS-CoV-2 through breast milk and breastfeeding: a living systematic review. Ann N Y Acad Sci. 2021;1484(01):32-54. Doi: 10.1111/nyas.14477 https://doi.org/10.1111/nyas.14477...	2021	Review article	The paper is a literature review of evidence of SARS-CoV-2 in breast milk. The authors address several studies that present statistical data and health conditions of mothers and children on COVID-19 and breastfeeding.
Susceptibility to COVID-19 in pregnancy, labor, and postpartum period: immune system, vertical transmission, and breastfeeding	Vale et al.¹²12 Vale AJ, Fernandes AC, Guzen FP, Pinheiro FI, de Azevedo EP, Cobucci RN. Susceptibility to COVID-19 in pregnancy, labor, and postpartum period: immune system, vertical transmission, and breastfeeding. Front Glob Womens Health.. 2021;2:602572. Doi: 10.3389/fgwh.2021.602572 https://doi.org/10.3389/fgwh.2021.602572...	2021	Review article	The article addresses questions about the pathophysiology of COVID-19, especially in pregnant and postpartum women. They discuss a little about vertical transmission, and put the focus of research on the guidelines for mothers and children in the postpartum period.
Covid-19 and breastfeeding: what's the risk?	Hand et al.¹³13 Hand IL, Noble L. Covid-19 and breastfeeding: what's the risk? J Perinatol. 2020;40(10):1459-1461. Doi: 10.1038/s41372-020-0738-6 https://doi.org/10.1038/s41372-020-0738-...	2020	Comment	The paper affirms the numerous benefits that breastfeeding promotes in the health of mother and child. In addition, statistical data on the presence and transmission of SARS-CoV-2 in breast milk is also emphasized.
Breastfeeding during the COVID 19 pandemic – a literature review for clinical practice	Lubbe et al.¹⁴14 Lubbe W, Botha E, Niela-Vilen H, Reimers P. Breastfeeding during the COVID-19 pandemic - a literature review for clinical practice. Int Breastfeed J. 2020;15(01):82. Doi: 10.1186/s13006- 020- 00319-3 https://doi.org/10.1186/s13006-...	2020	Review article	The study, with a clinical practice oriented approach, addresses the possible scenarios regarding mother and child conditions in the context of COVID-19. It also highlights data on the transmission of SARS-CoV-2 through breast milk.
Characterization of SARS-CoV-2 RNA, antibodies, and neutralizing capacity in milk produced by women with COVID-19	Pace et al.¹⁵15 Pace RM, Williams JE, Järvinen KM, Belfort MB, Pace CDW, Lackey KA, et al. Characterization of SARS-CoV-2 RNA, antibodies, and neutralizing capacity in milk produced by women with COVID-19. mBio. 2021;12(01):e03192-e20. Doi: 10.1128/mBio https://doi.org/10.1128/mBio...	2021	Prospective study	The article presents a study conducted in mothers who were infected with SARS-CoV-2, discussing the presence of virus RNA, specific antibodies, and neutralizing ability against the novel coronavirus in the breast milk samples tested.
Antibodies in the breast milk of a maternal woman with COVID-19	Dong et al.¹⁶16 Dong Y, Chi X, Hai H, Sun L, et al. Antibodies in the breast milk of a maternal woman with COVID-19. Emerg Microbes Infect. 2020;9 (01):1467-1469. Doi: 10.1080/22221751.2020.1780952 https://doi.org/10.1080/22221751.2020.17...	2020	Letter	The paper presents a case report that takes into consideration the clinical findings in puerperae and neonates who tested positive for COVID-19. The focus of the discussion was on breastfeeding.