Managing COVID-19-Positive Maternal–Infant Dyads: An Italian Experience

Dear Editor:

We report our experience in Italy during COVID-19 viral outbreak. At time of writing, on April 13, 2020, the number of confirmed cases was 1,699,595 worldwide, with 106,138 deaths, resulting in a crude fatality rate of 6.2%. ¹

Although children seem to have a milder disease than adults, newborns and infants could be more at risk than other pediatric categories; thus, they deserve special attention because of insidious and nonspecific symptoms. ²

Although there is currently no evidence showing a vertical transmission of SARS-CoV-2 infection in fetuses of women developing COVID-19 pneumonia in late pregnancy, ³ a major concern involves the possible transmission of the infection to their fragile infants, in particular after delivery. The virus can be detected by real-time polymerase chain reaction (RT-PCR) in different biological fluids (bronchoalveolar-lavage fluid, sputum, saliva, nasopharyngeal swabs, and feces) but no positive breast milk samples have been found in different reported cohorts for a total number of 32 dyads. ²

Therefore, for COVID-19-positive new mothers, whenever possible, it is advisable to plan a joint management of the mother with her infant, to promote the beginning of breastfeeding, while assessing on a case-by-case basis if eventual drugs administered to infected mothers could be harmful to the infant. According to the indications of the Italian Society of Neonatology, ⁴ if a mother previously identified as COVID-19 positive is asymptomatic or paucisymptomatic, rooming-in is a reasonable management and direct breastfeeding is prudent, ensuring strict measures of infection control (washing often mother's hands before touching the infant and wearing a face mask). In most cases, a hospital stay of ∼1 week is preferred.

Herein we describe our experience in our children's hospital, which is a referral care center in Rome (Italy) for ill out born neonates, who are transferred from other institutions. We report the first two maternal–infant dyads presenting to our emergency department because of a positive nasopharyngeal swab for SARS-CoV-2 both in the mother and in the child; clinical characteristics are summarized in Table 1. They were probably infected by a third person at the same time. Neither the mothers nor the infants needed intensive care unit admission; therefore, newborns were prudently isolated from their paucisymptomatic mothers.

We analyzed expressed breast milk samples of both mothers, and SARS-CoV-2 was not detected by RT-PCR, as already described. ² Virus detection analysis after pasteurization was not performed because the virus was not found already in expressed milk.

To the best of our knowledge, these are the first data on postnatal horizontal COVID-19 infection in newborns and breast milk analysis in Italy. We confirm that SARS-CoV-2 seems to spare breast milk and horizontal transmission from mother to neonate could occur through respiratory droplets rather than through milk. Therefore, when SARS-CoV-2 is identified both in the mother and in the child, there are no reason to stop breastfeeding and separate them. Whenever direct breastfeeding is not possible, the use of expressed mother's milk should be considered and promoted to take advantage of its unquestionable benefits.

In conclusion, we agree that medical staff and nurses should not only focus on care of COVID-19 mothers and infants, but also protect, promote, and support breastfeeding. Breastfeeding creates a unique relationship between mother and child, thus reducing the length of hospital stay and the negative effects linked to quarantine and stress because of this pandemic viral outbreak.