Abstract
The global pandemic caused by the severe acute respiratory syndrome coronavirus-2, better known as coronavirus disease 2019 (COVID-19), has resulted since early 2020, in the infection of million individuals globally, with a mortality and morbidity rate that has wreaked havoc on society in general and the world health care system in particular. Mid-April 2021 global statistics have documented at least 135 million cases of COVID-19, and >3 million deaths, along with a major disruption of the world' s economy and the social fabric of society.
Beyond the scientific challenge of developing proper clinical protocols and public health regulations has been the need to formulate such policies in real time while being hampered with incomplete, contradictory, and evolving knowledge complicated by varied clinical experiences. As such, over the past year, authorities addressed this major public health emergency with recommendations that have frequently subsequently undergone revision, remodeling and even 180° U-turns as to what should be done.
This was not surprising, in fact probably it was inevitable, given the absence of a gold standard that would have been normally generated by proper prospective randomized studies. Simply put, clinical and public health protocols and policies were formulated as to how to treat, mitigate, and limit the deadly spread of this virulent and highly infection novel virus without the “luxury” of an evidence-based data set to guide us.
Among the most striking evidence of this process has been the evolving (and at times contradictory) recommendations as how to manage breastfeeding and the use of breast milk from and by mothers suspected or diagnosed with COVID-19 disease.
In the absence of any hard data, but, faced with reality that babies were being born and mothers who were suspected to be (let alone diagnosed) with COVID-19 needed to know if there was a risk to breastfeed their newborn infants, the CDC 1 and American Academy of Pediatrics initially recommended separation of the mother and infant and to discard any expressed milk. This was considered to be the “safe” policy. Inevitably, as it became clear that most COVID-19 cases were asymptomatic or only mildly ill with nonspecific clinical signs, there accumulated outcome clinical data from such “infected” breastfeeding mothers and their infants.
Analyzing these data (that was both anecdotal and somewhat systematically collected) it became increasingly clear that the risk to the new born was very minimal (if at all) while the health advantages for the mother and infant dyad of breastfeeding were well established. Thus, the recommendations “flipped” and the policy of not separating the infant from mothers and encouraging breastfeeding became the norm. 2
Subsequent studies documented that breast milk contained protective COVID-19 antibodies from the mother 3 and that it was extremely rare (if at all) that there was any viral transmission per se to the breast milk, let alone clinical neonatal disease. As such, not only was there no longer any hesitation to recommend breastfeeding immediately after birth but rather active advocacy and support breastfeeding for such mothers. Even feeding pumped breast milk from symptomatic COVID-19 mothers to their infants was recommended.
As a result of the initial decision to exclude breastfeeding mothers from the initial vaccine trials and in the absence of any formally generated safety data the initial “proper” recommendations were to exclude mothers who were breastfeeding from formal vaccination programs. However, inevitably enough mothers were vaccinated and they provided milk samples for analysis and what was documented was the presence of a variety of maternal antibodies in the breast milk. Thus, the policy of “separation” was fully 180° changed and all mothers now were encouraged both to be vaccinated and to continue with breastfeeding.
The ultimate measure of this complete change from the restrictive policies of most health organizations from 6 to 8 months ago is the anecdotal reports of vaccinated mothers donating their antibody-rich breast milk to be fed to infants of unvaccinated mothers. 4 The desire for this biologically precious product has also led to a resurgence of re-lactation procedures by mothers who are vaccinated against COVID-19 after they have already weaned their infants.
The message from recounting this sequence of events is twofold. The development of public health and medical management policies is a fluid process and rigid inflexible decisions should not be carved in stone, but should be modified and changed as new substantiated scientific information is generated. That is what science is all about and these decisions should rest with the professional scientists who are capable of generating, evaluating, and properly implementing the consequences of this knowledge and experience. Politicization of the medical decision-making process is basically inappropriate and ethically problematic. In addition it often freezes and fixes policy at the wrong in time in what is a dynamic, fluid, and evolving process.