Infant and Young Child Feeding in the Context of the COVID-19 Pandemic - Eastern, Central and Southern Africa
Infants born to mothers with suspected, probable, or confirmed COVID-19 should be fed according to standard infant feeding guidelines
This joint note aims to consolidate the current recommendations on Infant and Young Child Feeding in the context of the COVID-19 pandemic in Eastern, Central and Southern Africa. This guidance is not intended to replace national guidance, rather to serve as a resource that is based on the latest evidence. The contents are adapted to the African region from Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected, Interim Guidance, 13 March 2020 WHO 
1. Caring for infants and mothers in the context of COVID-19: Infection prevention and control (IPC) and Breastfeeding
Published research  based on nine Chinese mothers, found no evidence of vertical transmission of COVID19 during pregnancy. Further, all breastmilk samples taken from the mothers’ after the first lactation were also found to be negative for the COVID-19 virus.
Remarks: Breastfeeding protects against morbidity and death in the post-neonatal period and throughout infancy and childhood. The protective effect is particularly strong against infectious diseases that are prevented through both direct transfer of antibodies, other anti-infective factors and long-lasting transfer of immunological competence and memory . In settings where diarrhea, respiratory infections and infectious morbidity are common in infants, any possible risk of transmission of COVID-19 through breastfeeding (not reported to date) is outweighed by the known risks associated with replacement feeding. Therefore, standard infant feeding guidelines should be followed with appropriate respiratory hygiene during feeding. i.e.
Always wash hands with soap and water before and after contact with the infant.
Routinely clean surfaces, which the mother has been in contact with, using soap and water.
If the mother has respiratory symptoms, use of a face mask when caring for the infant is recommended, if available.
Maintain physical distancing with other people and avoid touching eyes, nose and mouth.
2. Infants born to mothers with suspected, probable, or confirmed COVID-19 should be fed according to standard infant feeding guidelines , while applying the necessary hygiene precautions listed above.
Remarks: Breastfeeding should be initiated within 1 hour of birth. Exclusive breastfeeding should continue for 6 months with timely introduction of adequate, safe and properly fed complementary foods at age 6 months, while continuing breastfeeding up to 2 years of age or beyond. Because the health and survival benefits of breastfeeding are dose-response and because neonatal mortality is reduced by early initiation of breastfeeding, mothers who are not able to initiate breastfeeding during the first hour after delivery should be actively supported to breastfeed as soon as they are able5.
3. As with all probable, confirmed or suspected COVID-19 cases, symptomatic mothers who are breastfeeding or practicing skin-to-skin contact or Kangaroo Mother Care (KMC) should practice respiratory hygiene, including during feeding (for example, if the mother has respiratory symptoms it recommended to use of a face mask when near a child, if possible), perform hand hygiene before and after contact with the child, and routinely clean and disinfect surfaces with which the symptomatic mother has been in contact.
4. Breastfeeding counselling, basic psychosocial support, and practical feeding support should be provided to all pregnant women and mothers with infants and young children, whether they or their infants and young children have suspected, probable or confirmed COVID-19 .
5. In situations when severe illness in a mother with COVID-19 or other health complications, prevents her from caring for her infant or prevents her from continuing direct breastfeeding, mothers should be encouraged and supported to express milk , and safely provide breastmilk to the infant, while applying appropriate hygiene measures.
Remarks: If the mother is able to express breastmilk, the milk can be given to the infant using a cup with a wide mouth, or a cup and spoon. Using a bottle is not advised as it requires sterilization prior to each use and makes it more difficult for the baby to return to the mother’s breast when she becomes well again. Expressed breastmilk (EBM) can be stored in a closed container or covered with a cloth or plate at room temperature for up to 8 hours. If stored in a sterile container, expressed breastmilk can be kept for 24 hours at 18o–20oC in a shady place, for about 72 hours in a refrigerator (at 4o–5oC) and for about four months in a freezer (at -18o to -20oC). 
If the mother is too unwell to breastfeed or express breastmilk, an appropriate breastmilk substitutes , informed by cultural context, acceptability to the mother, and service availability should be provided. There should be no promotion of breastmilk substitutes, donation of feeding bottles and teats, pacifiers or dummies or donations of breastmilk substitutes in any part of facilities providing maternity and newborn services, or by any of the staff. Health facilities and their staff should teach mothers/caregivers how to safely prepare milk and how to give milk using a cup with a wide mouth or a cup and spoon. Health facilities and staff should not give feeding bottles and teats or other products within the scope of the International Code of Marketing of Breast-milk Substitutes and its subsequent related WHA resolutions, to breastfeeding infants.10 Please note wet nursing is not recommended in contexts of high HIV prevalence and donor milk should only be considered if appropriate screening and pasteurization services are included.
6. Mothers and infants should be enabled to practice skin-to-skin contact, kangaroo mother care and to remain together and to practice rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding, whether they or their infants have suspected, probable, or confirmed COVID-19.
Remarks: Mothers should not be separated from their newborns, unless medically indicated. Minimizing disruption to breastfeeding during the stay in the facilities providing maternity and newborn services will require health care practices that enable a mother to breastfeed for as much, as frequently, and as long as she wishes .
7. Parents and caregivers who may need to be separated from their children, and children who may need to be separated from their primary caregivers, should have access to appropriately trained health or non-health workers for mental health and psychosocial support.
Remarks: Given the high prevalence of common mental disorders among women in the antenatal and postpartum period, and the acceptability of programmes aimed at them, interventions targeted to these women need to be more widely implemented. Prevention services should be available in addition to services that treat mental health difficulties .
8. Mothers and health workers should be counselled/ advised to continue breastfeeding should the infant or young child become sick with suspected, probable, or confirmed COVID-19 or any other illness
Remarks: During an illness, breastfeeding infants need to breastfeed more often. After an illness, babies need to be offered more food than usual, such as more frequent meals, to replenish the energy and nourishment lost due to the illness. Withholding breastmilk during an illness increases the possibility that baby will get sick and deprives the baby of the superior nutrition from breastmilk including the immunological benefits. Caregivers should increase children’s fluid intake during illness (including by frequent breastfeeding) and encourage the child to eat (for example, by offering soft, appetizing or favorite foods). After illness, caregivers should provide meals more frequently than usual and encourage the child to eat more.
9. Caregivers and health workers should be counselled/ advised on the importance of healthy diets during complementary feeding  and safe food preparation/ handling to reduce risk of transmission of COVID-19.
Remarks: Parents should be supported to ensure that children 6-23 months of age are fed the minimum number of meals per day to ensure dietary adequacy and from at least 5 out of the 8 food groups to ensure dietary diversity. Young children need to consume a variety of foods to meet their nutrient needs and expose them to various tastes and textures. A diverse diet includes meals consisting of foods from a variety of food groups each day: (1) breastmilk; (2) grains, roots and tubers; (3) legumes, nuts and seeds; (4) dairy (milk, yoghurt, cheese); (5) flesh foods (meat, fish, poultry, and liver or organ meats); (6) eggs; (7) vitamin A-rich fruits and vegetables (carrots, mangoes, dark green leafy vegetables, pumpkins, orange sweet potato); and (8) other fruits and vegetables. To promote a healthy diet, caregivers should avoid providing drinks or foods with low nutritional value, such as sugar-sweetened beverages, candy, chips and other foods high in sugar, salt and trans fats.
Before preparing or eating food, caregivers should ensure they implement the recommended hygiene practices such as handwashing with soap and regular cleaning and disinfecting of food preparation areas.
Those engaged in the COVID-19 response, therefore, need to be aware of and sensitized as to the importance of Infant and Young Child Feeding (IYCF) and the continued protection and promotion of breastfeeding.
 Chen H et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet published online February 12, 2020. doi.org/10.1016/S0140-6736(20)30360-3
 WHO Essential newborn care and breastfeeding (apps.who.int/iris/bitstream/handle/10665/107481/e79227.pdf).
 WHO Essential newborn care and breastfeeding (apps.who.int/iris/bitstream/handle/10665/107481/e79227.pdf). 5 apps.who.int/iris/bitstream/handle/10665/42590/9241562218.pdf), as endorsed by the Fifty-fifth World Health Assembly, in resolution WHA54.2 in 2002
 Ensuring all health workers practice recommended precautionary measures e.g. wearing masks, social distancing, when providing counselling and other support
 Ensuring recommended precautionary hygiene measures are applied while handling breastmilk
 Where breastmilk is not accessible, appropriate breastmilk substitutes include: Ready to Use Infant Formula if the infant is <6 months of age, and ultra-heat treated (UHT) milk and complementary feeding if the infant / baby is 6-23 months of age. 10 This recommendation is consistent with the WHO guidance Acceptable medical reasons for use of breast-milk substitutes (apps.who.int/iris/bitstream/handle/10665/69938/WHO_FCH_CAH_09.01_eng.pdf;jsessionid=709AE28402D49263C8D F6D50048A0E58?sequence=1).
 WHO Guideline: protection, promoting and supporting breastfeeding in facilities providing maternity and newborn services (apps.who.int/iris/bitstream/handle/10665/259386/9789241550086-eng.pdf).
 IASC Reference group for Mental Health and Psychosocial Support in Emergency Setting 2020 Briefing note on addressing mental health and psychosocial aspects of COVID-19 outbreak – version 1.1
(https://interagencystandingcommittee.org/system/files/2020-03/MHPSS%20COVID19%20Briefing%20Note%202%20March%202020-English.pdf) and the Improving early childhood development: WHO guideline (https://www.who.int/publications-detail/improving-early-childhood-development-whoguideline).
 Improving Young Children’s Diets During the Complementary Feeding Period, Programming Guidance, UNICEF, Feb 2020. https://www.unscn.org/en/news-events/recent-news?idnews=2030
Distributed by APO Group on behalf of UNICEF South Africa.