Safety of Breastfeeding by Mothers
With COVID-19: New Evidence
From Israel
Genevieve G. A. Fouda, MD, PhD,a Jesse J. Kwiek, PhD,b Marcel Yotebieng, MD, MPH, PhDc
Human milk is the ultimate food to
promote healthy growth and
development of children aged ,2
years.1 Optimal breastfeeding practices,
as recommended by the World Health
Organization (WHO), include initiation
of skin-to-skin contact with
breastfeeding within 1 hour of birth,
exclusive breastfeeding (EBF) for 6
months, then continued breastfeeding
with appropriate complementary foods
for up to 2 years and beyond.1 The
WHO also recommends that mothers
with suspected or confirmed
coronavirus disease 2019 (COVID-19)
should be encouraged to initiate or
continue to breastfeed.2 However,
concerns have been raised about
whether mothers with COVID-19 can
transmit severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2)
to their infant or young child through
breastfeeding or horizontally.
In a case series of 53 women infected
with SARS-CoV-2 and their 55 mostly
breastfed infants reported in this issue
of Pediatrics, Shlomai et al3 report no
neonatal SARS-CoV-2 infections, neither
at delivery nor at 2 to 3 weeks
postdelivery. The lack of transmission
in these mother-infant pairs is
consistent with the 9% prevalence of
vertical transmission reported in
a recent meta-analysis of almost 200
infants.4 Although Shlomai et al3
did not use reverse transcription
polymerase chain reaction to screen the
breast milk for SARS-CoV-2 RNA, SARS-
CoV-2 RNA is uncommon in breastmilk5
and it is unlikely to be transmitted
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PEDIATRICS Volume 147, number 5, May 2021:e2020049772
through breast milk. The study by
Shlomai et al3 lends further support to
the continued breastfeeding of infants
born to mothers living with SARS-CoV-
2 while respecting infection control
measures.
Even if vertical transmission of SARS-
CoV-2 rarely occurs, maternal COVID-
19 infection can still have an impact on
infant health. Notably, maternal
antibodies transferred to the infant
across the placenta and during the
breastfeeding period are critical to
protect neonates and young infants
from common infections until they are
able to mount their own responses. In
a few recent studies, researchers have
investigated the transplacental transfer
of SARS-CoV-2–specific antibodies.6,7
These studies revealed that antibodies
against the SARS-CoV-2 spike protein
and nucleocapsid are transferred
across the placenta, although lower
transfer efficiency was observed in
women infected with SARS-CoV-2
during the third trimester of gestation
compared with women infected earlier
in pregnancy. Whereas the levels of
anti-spike and anti-nucleocapsid
antibodies in cord samples were highly
variable and their neutralization
potential was not assessed, these
results suggest that infants born to
SARS-CoV-2–infected women could
have some degree of protection. SARS-
CoV-2–specific antibodies have also
been detected in the breast milk of
infected lactating women.8 The fact that
none of the infants were infected,
despite being surrounded by an
a
Department of Pediatrics, Duke University, Durham, North
Carolina; bDepartment of Microbiology, The Ohio State
University, Columbus, Ohio; and cDivision of General Internal
Medicine, Department of Medicine, Albert Einstein College of
Medicine, Bronx, New York
Opinions expressed in these commentaries are
those of the authors and not necessarily those of the
American Academy of Pediatrics or its Committees.
DOI: https://doi.org/10.1542/peds.2020-049772
Accepted for publication Feb 23, 2021
Address correspondence to Marcel Yotebieng, MD,
MPH, PhD, Division of General Internal Medicine,
Department of Medicine, Albert Einstein College of
Medicine, 3300 Kossuth Ave, Bronx, NY 10467.
E-mail: marcel.yotebieng@einsteinmed.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2021 by the American Academy of
Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated
they have no financial relationships relevant to this
article to disclose.
FUNDING: Dr Yotebieng is supported by the following
grants from the National Institutes of Health:
R01HD087993, U54CA254568, and U01AI096299. The
other authors received no external funding. Funded
by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have
indicated they have no potential conflicts of interest
to disclose.
COMPANION PAPER: A companion to this article can
be found online at www.pediatrics.org/cgi/doi/10.
1542/peds.2020-010918.
To cite: Fouda GGA, Kwiek JJ, Yotebieng M. Safety
of Breastfeeding by Mothers With COVID-19: New
Evidence From Israel. Pediatrics. 2021;147(5):
e2020049772
COMMENTARY
ongoing transmission of SARS-CoV-2,
suggests that it is possible that these
maternally acquired antibodies
contributed to the protection of
breastfed newborns post discharge in
the study by Shlomai et al,3 lending
additional support for continued
breastfeeding.
However, maternal antibodies can
also interfere with the development
of infant immunity after infection or
vaccination. Notably, it has been
revealed that maternal antibody
interference contributes to lower
the rotavirus vaccine efficacy in low-
and middle-income compared with
high-income countries.9 In recent
studies, researchers have also
reported that infants born to women
who received a tetanus toxoid,
reduced diphtheria toxoid, and
acellular pertussis, adsorbed
vaccine during pregnancy tend to
have lower levels of pertussis-
specific antibodies after primary
immunization,10,11 suggesting that
this phenomenon occurs with live-
attenuated vaccines as well as with
protein vaccines. Whether SARS-
CoV-2 maternal antibodies will
impact infant response to
vaccination remains unknown, and
interference will probably depend
on the vaccine construct used for
infant immunization. Thus, studies
to better understand the dynamics
of SARS-CoV-2 immune responses in
maternal-infant dyads are critically
needed.
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2 FOUDA et al
This large case series lends additional
evidence to support the WHO
recommendation that mothers with
suspected or confirmed COVID-19
should be encouraged to initiate or
continue to breastfeed.
ABBREVIATIONS
COVID-19: coronavirus disease
2019
EBF: exclusive breastfeeding
SARS-CoV-2: severe acute
respiratory syndrome
coronavirus 2
WHO: World Health Organization
REFERENCES
1. World Health Organization; United
Nations International Children’s
Emergency Fund. Global Strategy for
Infant and Young Child Feeding. Geneva,
Switzerland: World Health Organization;
2003
2. World Health Organization. Clinical
Management of COVID-19: Interim
Guidance, 27 May 2020. Geneva,
Switzerland: World Health Organization;
2020
3. Shlomai NO, Kasirer Y, Strauss T, et al.
Neonatal SARS-CoV-2 infections in
breastfeeding mothers. Pediatrics.
2021;147(5):e2020010918
4. Raschetti R, Vivanti AJ, Vauloup-Fellous
C, Loi B, Benachi A, De Luca D. Synthesis
and systematic review of reported
neonatal SARS-CoV-2 infections. Nat
Commun. 2020;11(1):5164
5. Chambers C, Krogstad P, Bertrand K,
et al. Evaluation for SARS-CoV-2 in
breast milk from 18 infected women.
JAMA. 2020;324(13):1347–1348
6. Atyeo C, Pullen KM, Bordt EA, et al.
Compromised SARS-CoV-2-specific
placental antibody transfer. Cell. 2021;
184(3):628–642.e10
7. Edlow AG, Li JZ, Collier AY, et al.
Assessment of maternal and neonatal
SARS-CoV-2 viral load, transplacental
antibody transfer, and placental
pathology in pregnancies during the
COVID-19 pandemic. JAMA Netw Open.
2020;3(12):e2030455
8. Fox A, Marino J, Amanat F, et al. Robust
and specific secretory IgA against SARS-
CoV-2 detected in human milk. iScience.
2020;23(11):101735
9. Otero CE, Langel SN, Blasi M, Permar
SR. Maternal antibody interference
contributes to reduced rotavirus
vaccine efficacy in developing
countries. PLoS Pathog. 2020;16(11):
e1009010
10. Barug D, Pronk I, van Houten MA, et al.
Maternal pertussis vaccination and its
effects on the immune response of
infants aged up to 12 months in The
Netherlands: an open-label, parallel,
randomised controlled trial. Lancet
Infect Dis. 2019;19(4):392–401
11. Ladhani SN, Andrews NJ, Southern J,
et al. Antibody responses after primary
immunization in infants born to women
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comparator. Clin Infect Dis. 2015;61(11):
1637–1644
Safety of Breastfeeding by Mothers With COVID-19: New Evidence From Israel
Genevieve G. A. Fouda, Jesse J. Kwiek and Marcel Yotebieng
Pediatrics 2021;147;
DOI: 10.1542/peds.2020-049772 originally published online April 13, 2021;

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Safety of Breastfeeding by Mothers With COVID-19: New Evidence From Israel
Genevieve G. A. Fouda, Jesse J. Kwiek and Marcel Yotebieng
Pediatrics 2021;147;
DOI: 10.1542/peds.2020-049772 originally published online April 13, 2021;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/147/5/e2020049772

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2021
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