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FREQUENTLY ASKED QUESTIONS: COVID-19Breastfeeding and COVID-19 and breastfeedingFor health care based workers on WHO interim(12 May 2020) recommendations (August 2021)

Clinical management of severe acute respiratory (SARI) when COVID-19 is suspected: Interim guidance V 1.2.

Preface

Clinical management of severe acute

respiratory infection (SARI) when COVID-19

disease is suspected.

TheseThis FAQFrequently complements Asked Questions the WHO interim(FAQs) have guidance: been developed Clinical management jointly by the of severeIFE Core acute Group respiratory, UNICEF , the World Interim guidance Health 13 March 2020

This is the second edition (version 1.2) of this document for the novel coronavirus SARS-CoV-2, causing COVID-19 disease. It was originally adapted from the publication Clinical management of severe acute respiratory infection when Organizationinfection (SARI) (WHO when) and COVID-19 the COVID-19 disease is suspected Feeding Working Group based on the most recent recommendationsMERS-CoV infection is suspected (WHO, 2019). from the This document is intended for clinicians involved in the care of adult, pregnant and paediatric patients with or at risk for severe acute respiratory infection (SARI) when a SARS-CoV-2 infection is suspected. Considerations for paediatric patients and pregnant women are highlighted throughout the text. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen clinical management of these patients and to provide up-to-date guidance. Best practices for infection prevention and control (IPC), triage and optimized supportive care are included. This document is organized into the following sections: 1. Background WHO Strategic Advisory Group of Experts (SAGE) on : 2. Screening and triage: early recognition of patients with SARI associated with COVID-19 (13 March 2020 - www.who.int/publications-detail/clinical-management-of-severe-acute- 3. Immediate implementation of appropriate infection prevention and control (IPC) measures 4. Collection of specimens for laboratory diagnosis 5. Management of mild COVID-19: symptomatic treatment and monitoring 6. Management of severe COVID-19: oxygen therapy and monitoring 7. Management of severe COVID-19: treatment of co- 8. Management of critical COVID-19: acute respiratory distress syndrome (ARDS) 9. Management of critical illness and COVID-19: prevention of complications 10. Management of critical illness and COVID-19: septic shock 11. Adjunctive therapies for COVID-19: corticosteroids 12. Caring for pregnant women with COVID-19 respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected ) and provides responses 13. Caring for and with COVID-19: IPC and breastfeeding 14. Care for older persons with COVID-19 15. Clinical research and specific anti-COVID-19 treatments Appendix: resources for supporting management of severe acute respiratory infections in children

These symbols are used to flag interventions: •  Interim recommendations for use of the Pfizer–BioNTech COVID-19 , BNT162b2, under Emergency Do: theUse intervention is beneficial (strong Listingrecommendation) OR the intervention is a best practice statement. Don’t: the intervention is known to be harmful. to questions that have arisen about the recommendations. Consider: the intervention may be beneficial in selected patients (conditional recommendation) OR be careful when considering this intervention.

This document aims to provide clinicians with updated interim guidance on timely, effective and safe supportive management of patients with suspected and confirmed COVID-19. It is organized by the patient journey. The definitions  Interim recommendations for use of the Moderna mRNA-1273 vaccine against COVID-19 for mild and severe illness are in Table 2, while those with critical illness are defined as patients with acute respiratory • distress syndrome (ARDS) or sepsis with acute organ dysfunction. The recommendations in this document are derived from WHO publications. Where WHO guidance is not available, we refer to evidence-based guidelines. Members of a WHO global network of clinicians, and clinicians who have treated SARS, MERS or severe patients, have reviewed the recommendations (see Acknowledgements). For queries, please email: [email protected] with “COVID-19 clinical question” in the subject line.

• The Interim interim recommendations guidance and forFAQ use reflect: of the AZD1222 (ChAdOx1-S [recombinant]) vaccine against COVID-19 developed-1- by Oxford University and AstraZeneca i. the available evidence regarding risks of COVID-19 through breastmilk; •  Interim recommendations for the use of the Janssen Ad26.COV2.S (COVID-19) vaccine •  Interimii. the recommendations protective effects for of use breastfeeding of the inactivated and skin-to-skin COVID-19 vaccine contact, BIBP and, developed by China National Biotec Group August 2021 August |

(CNBG),iii. the Sinopharm harmful effects – Interim of inappropriate guidance use of . •  Interim recommendations for use of the inactivated COVID-19 vaccine, CoronaVac, developed by Sinovac The FAQ also draws on other WHO recommendations on Infant and Young Child Feeding and the Interagency TheWorking FAQs are Group intended Operational to provide Guidance answers on Infantto health and care Young providers Child Feedingand the public,in Emergencies. including Amothers decision who tree are shows breastfeeding orhow expressing these recommendations milk, on breastfeeding may be and implemented the following by healthCOVID-19 workers vaccines in maternity: services and community settings, as part of daily work with mothers and . •  Pfizer-BioNTech www.who.int/news-room/q-a-detail/q-a-on-covid-19-and-breastfeeding BNT162b2 •  Janssen Ad26.COV2.S

 Moderna mRNA-1273  Sinopharm – BIBP vaccine www.who.int/news-room/q-a-detail/q-a-on-covid-19-and-breastfeeding

• • •  Oxford University – AstraZeneca AZD1222 •  Sinovac – CoronaVac | 1. Can COVID-19 be passed through breastfeeding? regulation of newborns and several other physiological outcomes, and is associated with reduced neonatal Active COVID-19 ( that can cause infection) has not, COVID-19 and breastfeeding mortality. Placing the newborn close to the to date, been detected in the breastmilk of any mother FREQUENTLY ASKED QUESTIONS: Breastfeeding and COVID-19 also enables early initiation of breastfeedingFor health care workers which Breastfeedingwith confirmed/suspected is safe for infants COVID-19. and young It appears children unlikely, even when mothers are suspected or known (12 May 2020)

Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance V 1.2.

Preface

Clinical management of severe acute

respiratory infection (SARI) when COVID-19

disease is suspected.

This FAQ complements the WHO interim guidance: Clinical management of severe acute respiratory Interim guidance 13 March 2020

This is the second edition (version 1.2) of this document for the novel coronavirus SARS-CoV-2, causing COVID-19 disease. It was originally adapted from the publication Clinical management of severe acute respiratory infection when infection (SARI) when COVID-19 disease is suspected MERS-CoV infection is suspected (WHO, 2019). This document is intended for clinicians involved in the care of adult, pregnant and paediatric patients with or at risk for also reduces neonatal mortality. severe acute respiratory infection (SARI) when a SARS-CoV-2 infection is suspected. Considerations for paediatric patients and pregnant women are highlighted throughout the text. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen clinical management of these patients and to provide up-to-date guidance. Best practices for infection prevention and control (IPC), triage and optimized supportive care are included. This document is organized into the following sections: 1. Background 2. Screening and triage: early recognition of patients with SARI associated with COVID-19 (13 March 2020 - www.who.int/publications-detail/clinical-management-of-severe-acute- 3. Immediate implementation of appropriate infection prevention and control (IPC) measures 4. Collection of specimens for laboratory diagnosis 5. Management of mild COVID-19: symptomatic treatment and monitoring 6. Management of severe COVID-19: oxygen therapy and monitoring 7. Management of severe COVID-19: treatment of co-infections 8. Management of critical COVID-19: acute respiratory distress syndrome (ARDS) to have COVID-19. The numerous benefits of breastfeeding substantially outweigh the potential 9. Management of critical illness and COVID-19: prevention of complications 10. Management of critical illness and COVID-19: septic shock 11. Adjunctive therapies for COVID-19: corticosteroids 12. Caring for pregnant women with COVID-19 respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected ) and provides responses 13. Caring for infants and mothers with COVID-19: IPC and breastfeeding 14. Care for older persons with COVID-19 15. Clinical research and specific anti-COVID-19 treatments Appendix: resources for supporting management of severe acute respiratory infections in children

These symbols are used to flag interventions: Do: the intervention is beneficial (strong recommendation) OR the intervention is a best practice statement. Don’t: the intervention is known to be harmful. to questions that have arisen about the recommendations. Consider: the intervention may be beneficial in selected patients (conditional recommendation) OR be careful when considering this intervention.

therefore, that COVID-19 would be transmitted through This document aims to provide clinicians with updated interim guidance on timely, effective and safe supportive management of patients with suspected and confirmed COVID-19. It is organized by the patient journey. The definitions for mild and severe illness are in Table 2, while those with critical illness are defined as patients with acute respiratory distress syndrome (ARDS) or sepsis with acute organ dysfunction. The recommendations in this document are derived from WHO publications. Where WHO guidance is not available, we refer to evidence-based guidelines. Members of a WHO global network of clinicians, and clinicians who have treated SARS, MERS or severe influenza patients, have reviewed the recommendations (see Acknowledgements). For queries, please email: [email protected] with “COVID-19 clinical question” in the subject line.

The interim guidance and FAQ reflect: -1- i. the available evidence regarding transmission risks of COVID-19 through breastmilk; ii. the protective effects of breastfeeding and skin-to-skin contact, and, risks of illness associated with the virus. Breastfed children have not been shown to be at risk of iii. the harmful effects of inappropriate use of infant formula milk. The FAQ also draws on other WHO recommendations on Infant and Young Child Feeding and the Interagency breastfeeding or by giving breastmilk that has been Working Group Operational Guidance on Infant and Young Child Feeding in Emergencies. A decision tree shows The numerous benefits of skin-to-skinhow these recommendations contact may be implemented by health workers in maternity servicesand and community settings, as part of daily work with mothers and families. www.who.int/news-room/q-a-detail/q-a-on-covid-19-and-breastfeeding www.who.int/news-room/q-a-detail/q-a-on-covid-19-and-breastfeeding

transmission of SARS-CoV-2 through breastmilk. Consequently, WHO and other organizations | 1. Can COVID-19 be passed through breastfeeding? regulation of newborns and several other physiological outcomes, and is associated with reduced neonatal expressed by a mother who is confirmed/suspected to Active COVID-19 (virus that can cause infection) has not, mortality. Placing the newborn close to the mother breastfeeding substantially outweighto date, beenthe detected in the breastmilk potential of any mother risks also enables early initiation of breastfeeding which with confirmed/suspected COVID-19. It appears unlikely, also reduces neonatal mortality. therefore, that COVID-19 would be transmitted through such as the Centers for Disease Control and Prevention (CDC), UNICEF and the Royal breastfeeding or by giving breastmilk that has been The numerous benefits of skin-to-skin contact and expressed by a mother who is confirmed/suspected to breastfeeding substantially outweigh the potential risks have COVID-19. Researchers continue to test breastmilk of transmission and illness associated with COVID-19. have COVID-19. Researchers continue to test breastmilk from mothers with confirmed/suspected COVID-19. of transmission and illness associated with COVID-19.4. If a mother is confirmed/suspected to have 2. In communities where COVID-19 is prevalent, COVID-19, should she continue breastfeeding? College of Obstetricians and Gynaecologists recommend that mothers continue to breastfeed should mothers breastfeed? Yes. High quality evidence shows that breastfeeding Yes. In all socio-economic settings, breastfeeding reduces neonatal, infant and including in improves survival and provides lifelong health and high resource settings and improves lifelong health and development advantages to newborns and infants. development in all geographies and economic settings. Breastfeeding also improves the health of mothers. The transmission of COVID-19 through breastmilk and from mothers with confirmed/suspected COVID-19. In contrast, transmission of COVID-19 through breastmilk breastfeeding has not been detected. Among the few and breastfeeding has not been detected. There is no cases of confirmed COVID-19 infection in children from reason to avoid or stop breastfeeding. their infants if suspected or known to have COVID-19. Refer to FREQUENTLY ASKED QUESTIONS: other sources, most have experienced only mild or 3. Following delivery, should a baby still be asymptomatic illness. For health care workers Questions: Breastfeeding and COVID-19. Frequently Asked immediately placed skin-to-skin and breastfed While breastfeeding, a mother should still implement if the mother is confirmed/suspected to have appropriate hygiene measures, including wearing a 4. If a mother is confirmed/suspectedCOVID-19? to have medical mask if available, to reduce the possibility of Yes. Immediate and continued skin-to-skin care, droplets with COVID-19 being spread to her infant. including kangaroo mother care, improves thermal Breastfeeding and COVID-19 for health care workers 1 2. In communities where COVID-19 is prevalent, COVID-19, should she continue breastfeeding? should mothers breastfeed? Yes. High quality evidence shows that breastfeeding WHOYes. SAGE In all Interim socio-economic settings,Pfizer– breastfeedingModerna AstraZenecareduces neonatal,Janssen Ad26. infant andSinopharm child mortality Sinovac-including in COVID-19 vaccines and breastfeeding based on WHO interim recommendations COVID-19 recommendationsimproves survival and providesBioNTech lifelong health and AZD1222high resourceCOV2.S settings andBIBP improves vaccine lifelongCoronaVac health and development advantages toBNT162b2 newborns and infants. development in all geographies and economic settings. Breastfeeding also improvesvaccine the health of mothers. The transmission of COVID-19 through breastmilk and In contrast, transmission of COVID-19 through breastmilk Ok for breastfeeding breastfeeding has not been detected. Among the few mothers?and breastfeeding has not been✓ detected. There✓ is no ✓ ✓ ✓ ✓ cases of confirmed COVID-19 infection in children from reason to avoid or stop breastfeeding. other sources, most have experienced only mild or asymptomatic illness. 3.1. Should Following women delivery, currently should breastfeeding a baby still be or Breastfeeding is vital to the health of infants and their Breastfeeding and COVID-19. For health care workers Questions: Breastfeeding and COVID-19. Frequently Asked Frequently Asked Questions: Frequently Asked providingimmediately expressed placed skin-to-skin milk receive and the breastfed vaccines? mothers.While breastfeeding, Research on COVID-19a mother shouldvaccines still did implement not include Yes.if the WHO mother recommends is confirmed/suspected the use of COVID-19 tovaccines have in breastfeedingappropriate hygiene women measures,or consider including the effects wearing of mRNA a or lactatingCOVID-19? women as in other adults. Therefore, healthy non-replicatingmedical mask if vaccines available, on to them reduce or on the the possibility breastfed of individualsYes. Immediate currently and continuedbreastfeeding skin-to-skin or expressing care, milk child.droplets However, with COVID-19 the absence being of data spread does to not her mean infant. that CANincluding receive kangaroo the vaccines. mother care, improves thermal the vaccine is not safe for lactating women or their 1 children. WHO recommends that mothers who are breastfeeding child,” and for AZD1222 and Janssen Ad26. vaccinated continue breastfeeding after . COV2.S “as the vaccine is a non-replicating vaccine, it is unlikely to pose a risk to the breastfeeding child”. For countries facing insufficient vaccine supplies, the Mothers who are vaccinated should be encouraged to 1 WHO Prioritization Roadmap and the WHO Values continue breastfeeding to protect their infants. 2 Framework are recommended to guide the prioritization of target groups. 4. Does the ability to continue breastfeeding or 2. What advice should women currently provide expressed milk change after a mother is breastfeeding or expressing milk receive vaccinated? (i.e. Can/will the vaccine decrease regarding the vaccine? milk supply?) Lactating women considering receiving the COVID-19 It is highly unlikely that vaccination will have any vaccine should have access to information about the impact on women’s ability to make milk. WHO does NOT safety and efficacy of the vaccine including that: recommend stopping breastfeeding after vaccination. •  Breastfeeding is vital to the health of infants and their Women currently breastfeeding or expressing milk should mothers; and continue to do so after receiving the vaccine and can be •  Vaccine efficacy in lactating women is expected to be confident that vaccination will not affect their milk supply. similar to efficacy in non-lactating women. Taking the vaccine should not be an impediment to begin breastfeeding or a cause for its interruption. Although data are lacking on the potential benefits and risks of COVID-19 vaccines to breastfed children, they are 5. Should there be research undertaken on biologically and clinically unlikely to pose a risk: vaccination of breastfeeding women? •  Pfizer–BioNTech BNT162b2 and Moderna mRNA-1273 WHO acknowledges the lack of data on COVID-19 are not live virus vaccines and the mRNA does not enter vaccination of lactating women. Given the importance of August 2021 August the nucleus of the cell and is degraded quickly; | breastfeeding, researchers are encouraged to prioritize •  AZD1222 vaccine and the Janssen Ad26.COV2.S are not this topic and provide data on the safety of these vaccines live virus vaccines; and for breastfeeding mothers and their infants. •  Sinopharm BIBP and Sinovac-CoronaVac use an with an adjuvant that is routinely used in many other vaccines with a documented good In accordance with the International Labour Standards5, safety profile, including in pregnant women. governments and employers must continue to respect and uphold the right of women to breastfeed. Workers Two recent small studies support these expectations, who are currently breastfeeding should not be forced finding comparable antibody and T-cell response against to leave employment if not vaccinated. They should SARS-CoV-2 after COVID-19 mRNA vaccination.3,4 be supported to remain employed and incentivized to continue breastfeeding whether they receive the It is important to continue to provide the necessary vaccine or not. counselling and support for breastfeeding women to build confidence in the safety and adequacy of breastfeeding and risks of not breastfeeding in the Feedback context of COVID-19. Refer to FREQUENTLY ASKED This guidance will be periodically QUESTIONS: Breastfeeding and COVID-19 for health updated as new evidence care workers. on these vaccines emerges, additional vaccines are approved 3. Is it safe for mothers to breastfeed after they and new questions arise. You can are vaccinated? pose questions to the moderated Yes. For Pfizer-BioNTech, Moderna mRNA-1273, online forum https://www.en-net. Sinopharm BIBP and Sinovac-CoronaVac, WHO clarifies

org/forum/31.aspx and send feedback on the FAQs to vaccines and breastfeeding based on WHO interim recommendations COVID-19 that: “As the vaccine is not a live virus vaccine , it is the IFE Core Group, [email protected] biologically and clinically unlikely there is a risk to the

1 WHO SAGE roadmap for prioritzing uses of COVID-19 vaccines in the context of A. G. (2021). Coronavirus disease 2019 vaccine response in pregnant and lactating limited supply. Geneva: World Health Organization 2021 (https://www.who.int/ women: a cohort study. American Journal of Obstetrics and Gynecology. publications/i/item/who-sage-roadmap-for-prioritizing-uses-of-covid-19-vaccines- 4 Collier, Ai-ris Y., Katherine McMahan, Jingyou Yu, Lisa H. Tostanoski, Ricardo in-the-context-of-limited-supply, accessed July 2021) Aguayo, Jessica Ansel, Abishek Chandrashekar et al. "Immunogenicity of COVID-19 2 WHO SAGE values framework for the allocation and prioritization of COVID-19 mRNA Vaccines in Pregnant and Lactating Women." Jama (2021) vaccination. Geneva: World Health Organization; 2020 5  International Labour Organization; 2020. ILO Standards and COVID-19 Questions: Frequently Asked (https://apps.who.int/iris/handle/10665/334299, accessed 04 June 2021). (coronavirus) FAQ. https://www.ilo.org/wcmsp5/groups/public/---ed_norm/--- 3 Gray, K. J., Bordt, E. A., Atyeo, C., Deriso, E., Akinwunmi, B., Young, N., ... & Edlow, normes/documents/genericdocument/wcms_739937.pdf

WHO/2019-nCoV/FAQ/Breast_feeding/Vaccines/2021.1 © World Health Organization 2021. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. Suggested citation: IFE-Core Group, UNICEF, WHO, COVID-19 Infant Feeding Working Group. Frequently asked questions: COVID-19 vaccines and breastfeeding based on WHO interim recommendations (August 2021). Geneva: World Health Organization; 2021 (WHO/2019-nCoV/FAQ/Breast_feeding/Vaccines/2021.1). Licence: CC BY-NC-SA 3.0 IGO. 2 https://www.ennonline.net/breastfeedingandcovid19vaccines