All Things Neonatal, by Michael Narvey

A blog by AllThingsNeonatal

SARS-CoV-2 Just Might Be In Breastmilk After

AllAfter several reports providing reassurance to breastfeeding mothers, two very recent
reports are giving me reason to pause. The Canadian Pediatric Society has been
recommending breastfeeding if a mother has COVID19 with precautions in
place; Breastfeeding when mothers have suspected or proven COVID-19. It would be heresy
to suggest that a mother not be permitted to breastfeed her infant but what follows are two
reports that at the very least may need to enter the discussion when a COVID19 positive
mother gives birth and is deciding about route of feeding.

Toronto Case Report

The first report was notable not so much for breastmilk but rather that a mother with a chronic
immunodeficiency and pneumonia from COVID19 had placental surfaces that tested positive
on PCR for COVID19. This was the main focus of the paper Probable congenital SARS-CoV-2
infection in a neonate born to a woman with active SARS-CoV-2 infection. In the same paper
though, testing of breastmilk in this mother demonstrated a positive PCR with a semi-
quantitative cycle time result (there are 40 cycles of amplification of RNA in PCR testing- the
further away from 40 cycles the more likely it is a true positive).

The results above were positive at 2 days and negative at 7 days. One could possibly excuse
this case as an anomaly since the mother in this case not only was sick but also has chronic
neutropenia but then along comes another report.

Second Research Report

This week a second report emerged that adds to the uncertainty around breastmilk. Detection
of SARS-CoV-2 in human breastmilk looks at two mothers one of whom was negative on
testing of breastmilk but the other unfortunately tested positive. The authors included the
following timeline which is very informative.
From the timeline above you will note that in the second case the mother becomes positive at
11 days of age and the infant tests positive around the same time the milk comes back
positive. The infant in this case also develops RSV which likely explains the symptoms they
developed later in the course. What is concerning to me though is that in this case while the
mother was COVID19 positive, she was not acutely ill. When thinking of vertical transmission
this has been something that has been postulated in suspecting that those with more severe
illness have higher viral loads and therefore may be capable of vertical transmission. Not the
case here if the results are to be believed. Adding to the strength of the result are Ct values for
SARSCoV2 N peaked at 29∙8 and 30∙4 in whole milk and skimmed milk respectively so this
seems real.

How does this differ than past testing?

What intrigues me about this study in particular is that past research on transmission into
breastmilk has failed to detect the virus. It could be that previous testing close to delivery was
negative and that with time might the virus enter breastmilk? At eleven days I think this may be
the latest testing done. In virtually all cases reported about COVID19 positives in newborns the
authors have always explained the painstaking steps they took to prevent postnatal infection. I
do wonder now if some of these cases may be related to a small percentage of women
carrying the virus in their breastmilk. This leaves us in a tough spot. What do we tell women
who are thinking of breastfeeding and have COVID19? There will need to be discussion on this
but one option is to proceed with feeding accepting there may be a small risk of transmission.
A second option would be to test milk but if the transmission occurs late you may miss it in
hospital on initial sampling Finally it may be worth pumping and discarding milk until mothers
test negative and using donor breastmilk in the meantime (or formula for those who don’t have
DBM).

Regardless I think this information coming out will need to be digested and centres think about
how they will approach this issue. My guess is these will not be the last reports on this.