This guidance was developed to support pediatricians providing direct care for breastfeeding families after discharge from the newborn hospital stay. Breastfeeding concerns during the first few weeks are associated with a decreased duration of breastfeeding (especially concerns about sore nipples/difficulties latching, low milk supply and medications). A breastfeeding parent with significant COVID-19 illness due to SARS-CoV-2 infection may have been separated from the newborn infant after birth or experienced other events disrupting breastfeeding initiation.
The American Academy of Pediatrics (AAP) strongly supports breastfeeding as the best choice for infant feeding, even if the breastfeeding parent and/or infant is infected with SARS-CoV-2. Published studies have confirmed that there is no viable or contagious SARS-CoV-2 virus in human milk from persons with acute infection. Furthermore, studies have demonstrated that pasteurization methods (such as those used to prepare donor milk) inactivate SARS-CoV-2 after it has been experimentally introduced into human milk. In addition, published studies have reported both IgA and IgG neutralizing antibodies in human milk against multiple SARS-COV-2 antigens following COVID-19 illness and an even more robust antibody presence after COVID-19 vaccination. Therefore, physicians should advocate for and encourage breastfeeding as well as vaccination among breastfeeding/lactating persons and their family members/caregivers. Postdischarge guidance and education are essential to support families, ensure the health of breastfeeding parents and infants and ensure that families’ breastfeeding goals can be achieved.
Why is it important to continue to promote and support breastfeeding in a family with suspected or confirmed COVID-19?
Breastfeeding protects infants from infection. Human milk has natural bioactive factors, antibodies and targeted immunologic mediators; although it is unknown if or to what extent breastfeeding protects the infant against acquiring or becoming symptomatic from SARS-CoV-2, we know it is safe to breastfeed and that breastfed infants are less likely to develop other viral infections. In addition to other health benefits for the breastfeeding parent and infant, the release of oxytocin during breastfeeding promotes wellness and relieves stress and anxiety in the lactating person. Breastfeeding is also sustainable, which is particularly important during a time of potential shortages of formula, bottles and other feeding supplies. Counsel families to consider delaying weaning and extending the duration of breastfeeding to maximize the protection conferred via human milk during the pandemic.
If a breastfeeding parent and/or infant has COVID-19, how can I support breastfeeding?
Every effort should be taken to provide infection-prevention education to all caregivers of the infant, which includes not only written education but also verbal education in person, via telephone or virtually. Interpreter services should be utilized where appropriate. Although challenging in the home environment, caregivers who test positive for COVID-19 should maintain reasonable precautions as specified in the CDC Guidance.
- Parent wants to breastfeed directly
Encourage proper hand washing with soap and water prior to handling the infant and advise the parent to wear a mask while nursing. Holding the baby skin-to-skin helps with latching and hormonal responses that trigger milk release. When not nursing, the infant can be cared for by a healthy caregiver, if available. To minimize possible exposure, additional precautions such as wearing a mask during any close contact (ie, less than 6 feet) with the child and cleaning their hands frequently (ie, before and after touching their child) can be recommended. Once the parent has met time and symptom-based criteria for being noncontagious, these precautions can be discontinued.
- Parent wants to express milk
Prior to expressing milk, the parent should put on a mask and thoroughly wash hands as well as any pump parts, bottles and artificial nipples. Optimal milk expression is facilitated by use of an efficient electric double pump. Milk should be expressed as often as the baby is eating or at least 6 to 8 times per 24 hours. Hands can be used for simultaneous breast massage/compression during pumping to improve milk flow, breast emptying and likely calorie content of breast milk. The expressed milk can be fed to the infant by a healthy caregiver. Support should be provided to the breastfeeding parent to reintroduce direct breastfeeding when well.
Milk supply is established in the first few weeks postpartum, so this is a critical time to support milk production. Families should be reassured that breast milk is safe and important for baby.
- Parent chooses not to breastfeed during the first weeks after birth
During the first week postpartum, consider asking family whether they might reconsider this choice, and engage in a discussion about the importance of breastfeeding and expressed human milk in protecting against infections and other diseases during this most vulnerable time.
What are important considerations for clinical management of breastfeeding, including telemedicine, during this pandemic?
- All newborn infants should be seen by their medical home provider and have an in-person visit within 1 to 2 days of birth hospital discharge. Avoid use of waiting rooms to decrease infectious exposures. Useful strategies may include scheduling newborn appointments for first thing in the morning; using separate entrances for well and sick patients; placing families in examination rooms immediately at the time of arrival; or if available and appropriate, having families wait in their car until appointment time. Consistent with Bright Futures recommendations, visits should include infant physical examination and weight check as well as direct observation of latch and feeding. Pediatric offices should consider making arrangements for assessment by a lactation specialist as needed.
- If additional breastfeeding support is necessary, consider providing lactation consultation via video-based telemedicine or telephone in the office or in the family home. Telehealth visits for lactation support may include breastfeeding latch assessment, observation of milk transfer, baby weight check (if family has access to a food scale, postal scale or a baby scale) and assessment of infant’s voiding, stooling and stool color transition. Lactation evaluation should also include assessment of breast engorgement and nipple integrity as well as advice on medications and diet. Use of a baby doll, breast model or breast diagram during telehealth visits is beneficial. At any time, if the health care professional triaging or providing advice has any concerns, the infant should be referred for urgent in-person evaluation, recognizing that poor feeding or a change in feeding behavior can be a symptom indicating serious illness. For guidance on coding and telehealth issues, please refer to the Breastfeeding and Lactation Coding Factsheet and the Coding for COVID-19 and Non-Direct Care.
- Investigate other community lactation support for families. Consider home health visit options. Check with your state and/or local breastfeeding coalitions and your AAP Chapter Breastfeeding Coordinator as many areas have breastfeeding hotlines and updated resource guides of currently available support – both virtually and in-person.
Should individuals who are breastfeeding receive the COVID-19 vaccine?
Yes, breastfeeding individuals should be fully vaccinated and receive booster(s) with the COVID-19 vaccine(s). All FDA-approved or -authorized COVID-19 vaccines are safe to receive while breastfeeding. Parents should not stop breastfeeding if they choose to be vaccinated. Antibodies to SARS-CoV-2 have been identified in human milk among breastfeeding parents who have received the vaccine, with high levels following both doses of the 2-dose mRNA vaccine primary series and even higher levels following a third booster dose. The AAP recommends vaccination among all persons eligible to receive the COVID-19 vaccine.
Pediatricians should be aware of the resources in their own community and reach out to learn what kind of services they are providing during the pandemic.
- La Leche League International (LLLI) – 1-877-4-LALECHE (1-877-452-5324) (messages will be returned by an LLL Leader in 24-48 hours).
- Perinatal mood disorders – Postpartum Support International COVID-19 resources
- 4th Trimester Project – COVID-19 resources for new moms
- AAP Breastfeeding Resources
- Infant Feeding in Disasters and Emergencies: Breastfeeding and Other Options (also available in Spanish)
- Coronavirus Disease and Breastfeeding (CDC)
- Resources to Address Coronavirus Disease (Academy of Breastfeeding Medicine)
Interim Guidance Disclaimer: The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing. Guidance will be regularly reviewed with regards to the evolving nature of the pandemic and emerging evidence. All interim guidance will be presumed to expire on June 30, 2023 unless otherwise specified.
American Academy of Pediatrics