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. 2022 Oct 26;30(8):4064–4070. doi: 10.1111/jonm.13854

Protective measures feasibility for infants of low‐income SARS‐CoV‐2 positive breastfeeding mothers: A prospective multicentre cohort study

Walusa Assad Gonçalves‐Ferri 1,✉, Kelly Pereira Coca 2, Fábia Pereira Martins‐Celini 1, Yan‐Shing Chang 3, Raquel Santos Ferreira 4, Jamil Pedro de Siqueira Caldas 5, Rodrigo Duarte Ferreira 6, Patrícia Franco Marques 7, Thaise Cristina Branchee Sonini 8, Viviane Christina Cortez Moraes 9, Simone Manso de Carvalho Pelicia 10, Leandro Meireles Nunes 11, Bruno Antunes Contrucci 12, Edson Koji Suzuki 13, Maurício Magalhães 14, Paulo de Jesus Hartmann Nader 15, Daniela Marques de Lima Mota Ferreira 16, Juliane Barleta Javorsky 17, Laura de Fátima Afonso Dias 18, Bruna Pinto Dias Cavasin 1, Ana Ruth Antunes de Mesquita 1, Rebecca Meirelles de Oliveira Pinto 1, Luciana Mara Monti Fonseca 19, Edilaine Cristina da Silva Gherardi‐Donato 20, Davi Casale Aragon 1, Anelise Roosch 1; the BRACOVID Project Collaborative Group
PMCID: PMC9874786  PMID: 36205220

Abstract

Aim

The aim was to evaluate the feasibility of protective measures for infants of low‐income SARS‐CoV‐2 positive breastfeeding mothers.

Background

Breastfeeding mothers with SARS‐CoV‐2 positive should avoid exposing the infant through protective measures (PM), but it could be challenging in a low‐income population.

Methods

A prospective, multicentre study was conducted between July and October 2020 (BRACOVID). The participants were recruited at birth and interviewed through a structured questionnaire at 7 and 14 days in the home environment. The feasibility of PM during breastfeeding at home was defined by guidelines recommendations (mask using, handwashing, and distancing from newborn when not breastfeeding). Three groups according to the feasibility of guidelines: complete guidelines feasibility (CG): all PM; partial guidelines feasibility (PG): at least one PM feasible; no guidelines (NG): infeasibility to all of PM. Flu‐like neonatal symptoms and breastfeeding practices were analyzed. We evaluated the association between PM feasibility and socioeconomic factors.

Results

One hundred seventeen infected mothers from 17 Brazilian hospitals were enrolled. Forty‐seven (40%) mothers followed all recommendations, 14 (11.9%) could not practice at least one recommendation, and 50 (42.7%) did not execute any of them. The breastfeeding rate was 98%. Factors associated with infeasibility were monthly family income <92.7 dollars/person, high housing density (>1 inhabitant/room), teenage mothers, responsive feeding, and poor schooling. Regarding infants' flu‐like symptoms, 5% presented symptoms at 14 days (NG group).

Conclusion

The guidelines were not applied to infants of SARs‐CoV‐positive mothers in 54.6% of the dyads since the recommendations were unviable in their environments. During pandemics, we should look for feasible and effective guidelines to protect neonates from low‐income populations.

Implications for Nursing Management

Poor socioeconomic conditions lead to the unfeasibility of protective measures for infants of low‐income SARS‐CoV‐2 positive breastfeeding mothers during the isolation period in the pandemics. The orientations and the support provided to dyad should consider the socioeconomic factors to guide feasible measures in the home environment and promote adequate protections; only an individual approach will allow a safe environment for low‐income infants. The Research Ethics Committee approved the project of the Medicine School in Ribeirão Preto, University of São Paulo, Brazil (CAAE: 31357320.9.1001.5440‐4.066.741/2020) and Brazilian hospitals and maternal services.

Keywords: breastfeeding, COVID‐19 pandemic, developing country, low‐income population, SARs‐CoV‐2

1. INTRODUCTION

COVID‐19, caused by severe acute respiratory syndrome coronavirus‐2 (SARs‐CoV‐2), is a significant public health concern and has caused thousands of deaths worldwide (Coronavírus Brasil, 2021; WHO, 2021).

The guidelines currently recommend that breastfeeding should be maintained if infected mothers want to. However, before that, they should wash their hands, use a mask, and maintain a minimum distance of 2 m from the baby after breastfeeding (Gonçalves‐Ferri et al., 2021; Nota Técnica, 2020).

Measures to prevent COVID‐19 can be challenging to breastfeeding mothers in the home environment, especially in situations with poor socioeconomic factors that may interfere with the proper feasibility of recommendations. Also, the vulnerability of women during the postpartum period and the establishment of actions to breastfeed in the first 14 days after birth can be an additional burden on mothers executing preventive measures at home (Dorn et al., 2020; Gonçalves‐Ferri et al., 2021; Krishnan et al., 2020).

Alternatives to prevent COVID‐19 infection in low‐income populations must be studied since the no viability of protective measures accelerates virus dissemination, increases mortality, and promotes the development of different virus variants (Chung et al., 2020; Corburn et al., 2020; Mallapaty, 2021).

Breastfeeding is responsible for saving thousands of lives. Moreover, there are no available data on the feasibility and effectiveness of the recommended protective measures in infants in unfavourable socioeconomic situations (Gonçalves‐Ferri et al., 2021; van Oosterhout et al., 2021).

Therefore, assessing breastfeeding mothers with COVID‐19 from low‐income populations is imperative. Our study evaluated the feasibility of protective measures during the isolation period according to the socio‐economic‐cultural factors in the infected breastfeeding mothers. Also, we assessed the impact of this situation, characterized by the rate of flu‐like symptoms and hospitalization in their infants during the first 14 days of life.

2. METHODS

2.1. Study design and study population

We performed a prospective, multicentre study enrolling mothers and newborns, started on delivery until 14 postpartum days, at 17 university hospitals and/or maternity services in Brazil, from July to October 2020.

All pregnant women with mild symptoms tested positive for SARS‐CoV‐2 confirmed by reverse transcription‐polymerase chain reaction (RT‐PCR) at hospital admission were included. Women who refused to participate or lacked information or posterior phone contacts were unavailable were excluded. Asymptomatic and severe symptomatic pregnant women were excluded from the study. Written informed consent was obtained from the hospital. This study followed the STROBE statement.

2.2. BRACOVID study

This study is part of the Brazil COVID (BRACOVID) project, developed to follow mothers and their infants, focusing on breastfeeding aspects. The participation invitation addressed COVID‐19 referral hospitals in five Brazilian geographic regions (non‐probabilistic sampling technique).

2.3. Instrument and data collection

We prepared a structured questionnaire on breastfeeding practices to perform a follow‐up of 14 days (postpartum period). A specific investigator was identified and trained in each centre to make a phone call to the mothers included in the study on the seventh and fourteenth days after delivery. The purpose of the contact was to investigate mothers' practices on protective measures to prevent SARs‐COV‐2 infection in neonates while breastfeeding in their home environment for 14 days. Data regarding the clinical evolution of newborns were also collected.

2.4. Measures

The variables evaluated were the three most common early pandemic national and international recommendations during breastfeeding: the use of masks, washing of hands, and mother–neonate distancing after breastfeeding.

The participants were categorized into three groups: the CG group (complete guidelines feasibility) mothers who entirely executed the guidelines, the PG group (partial guidelines feasibility) mothers who partially followed the guidelines, with at least one not executed, and the NG group, which did not take any of the measures (no guidelines feasibility). We evaluated these recommendations in the first 7 days after birth.

Masks were described as using all types of masks during breastfeeding. Hand‐washing was characterized by hygiene before breastfeeding and before handling the baby. Regarding distancing measurements, the dyad should have maintained at least 2 m of distance during periods of non‐breastfeeding.

Socio‐cultural variables were measured by educational level, defined as complete or incomplete primary education, complete or incomplete secondary education, and complete or incomplete tertiary education. Regarding household income per capita, the participants were classified as vulnerable families presenting less than 0.5 Brazilian basic wages per family member (522 reais/92.7 dollars). The participants were classified into two groups regarding dwelling conditions: person per room (less than or equal to 1 and more than 1). Sleeping during the isolated period in the parents' room was considered inadequate in the neonate room environment. In addition, teenage mothers (≤18 years) were considered a social risk population. The socioeconomic Vulnerability Index characterized the threshold for the poor socioeconomic situation (BRAZIL, 2005).

Flu‐like symptoms of neonates were evaluated at 7 and 14 after birth. SARs‐COV‐2 tests were not performed on the neonates due to a shortage of examination kits in Brazil during the early pandemic. Re‐hospitalization was also registered.

Breastfeeding practices were evaluated according to response feeding (on‐demand), breastfeeding every 3 h, and types of feeding (mixed feeding, only breastfeeding, and fully formula feeding).

2.5. Statistical analysis

After a complete exploratory analysis of the variables, associations were made through correspondence analysis, a multivariate technique that allows us to obtain a map of correspondences. Therefore, the closer one variable is to the other, the higher association between them. In this type of analysis, the total data variation is called inertia, decomposed into two dimensions (Dim) indicated on each map. The FactoMineR and factoextra packages of R 4.0.2 software were used.

3. RESULTS

Overall, 179 dyads were recruited for the BRACOVID project between July and September 2020 (117 mothers testing positive for SARs‐CoV‐2, while 62 mothers were excluded due to inconclusive or no PCR‐RT tests). The median mother's age was 27 (12–40 years), the monthly household income median was 403.5 dollars (87.7–3.157.8 dollars), and the person per room's median was 2 (SD 0.40), and 9% of mothers had tertiary education. The neonates' median birth weight was 3230 g (2.94–3.51 g), and the mean gestational age was 39 weeks (38–39 weeks).

In the first 7 days, 47 (40%) mothers followed all recommendations, 14 (11.9%) could not practice at least one recommendation, and 50 (42.7%) did not execute any of them. Six participants (5%) refused to provide information about the implementation of the guidelines. The association between social‐cultural conditions and guideline execution in the first 7 days is presented in Figure 1.

FIGURE 1.

FIGURE 1

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Correspondence analysis map between the variables and the studied groups collected through the BRACOVID questionnaire applied 7 days after birth. The graphic representation obtained through correspondence analysis makes it possible to visualize the distribution of variables among all others. A point represents each variable category. The distances between the points represent the association between the variables; points closer have a stronger association. Variables: Groups: CG; PG; NG: Complete guidelines; Partial guidelines; No guidelines. PE; SE; TE: Primary education; Secondary education; Tertiary education. Teen; NTeen: Teenager mother; No teenager mother. RBF; NRBF: Response breastfeeding; no response breastfeeding. PNR > 2; Person per neonate room > 2; PNR ≤ 2: Person per neonate room ≤ 2. FMI > 0.5: Family monthly income > 0.5 Brazilian minimum wage per person (>92.7 dollars); FMI ≤ 0.5: Family monthly income ≤ 0.5 Brazilian minimum wages per person (≤92.7 dollars). PR ≤ 1: Person per room ≤ 1; PR > 1: Person per room > 1

At less than 7 days, there was an association between the viability of guidelines and poor schooling; partial execution was associated with teenage mothers, poor living conditions, and response feeding. Complete viability of the guidelines was associated with a higher degree of schooling and breastfeeding every 3 h.

Breastfeeding rates (exclusive or mixed) at 7 days after birth were 97% and 98% at 14 days. In the first 7 days, approximately 20% of the mothers in all groups were experiencing mixed feeding.

Neonates did not present flu‐like symptoms during the first 7 days. At 14 days, 5% of neonates from the NG group presented symptoms.

The infants were tested for SARs‐CoV‐2 before discharge, and all showed negative results. Due to a shortage of tests in Brazil, the recruited infants were not tested for SARs‐CoV‐2 at 7 and 14 days. There were no babies hospitalized after discharge, considering any cause.

4. DISCUSSION

This study evaluated a cohort of mothers infected with SARS‐CoV‐2 delivered in reference hospitals from Brazilian regions, following the same guidelines to avoid COVID‐19. They were instructed by the health care hospital team about the necessity of practicing preventive measures to avoid infection in infants over 14 days from the day of delivery.

The feasibility of preventive measures was low: Only 40% of the mothers practiced all recommendations in the first 7 days. The participants presented low‐medium household incomes for the Brazilian pattern and low scholarly.

Besides the health care team instructions, the feasibility of recommendations to prevent COVID‐19 infection is a warning finding, leading to a higher exposure of the neonate, greater viral dissemination, and worsening health rates (Corburn et al., 2020; van Oosterhout et al., 2021; Passarinho & Barrucho, 2021; Robertson et al., 2020).

Approximately 10% of the participants could not take at least one preventive measure. As reported in other studies with low‐income populations, distancing between the infected person and their relatives is challenging to maintain in their home environment (Dorn et al., 2020; Ortelan et al, 2021; Robertson et al., 2020; Siegel & Mallow, 2021; Villar et al., 2021).

Therefore, poor habitational conditions, high density of inhabitants, and even co‐habitation of many families and children in the same house can impact PM feasibility (Esposito & Principi, 2021; Dorn et al., 2020; Heck et al., 2021; Siegel & Mallow, 2021; Wasdani & Prasad, 2020).

In our study, partial feasibility was also associated with maternal age because teenagers are more likely to live with their families and share their rooms with siblings.

Mothers' low scholarly was related to the no viability of all preventive measures. Health education is fundamental to a country's development and population safety. Since antiquity, ignorance and lack of proper information have led to numerous diseases, raising the need for strong public health measures for disease prevention and improving the health's quality (de Oliveira, 2020; Rollins, 2021).

Complete guideline execution was associated with a higher college degree, higher maternal age, and breastfeeding every 3 hours.

Responsive feeding (on‐demand) is widely recommended in Brazil, leading to lactation stimulation and mother–child bond strengthening (Unicef UK, 2021). However, we can note in our data that COVID‐positive mothers feeding their baby every 3 hours could support better the PM.

We observed a breastfeeding rate of 98%, which was higher than that reported in Brazil (70%) in previous periods (ENANI, 2019). We attribute this response to health care professionals' campaigns to promote breastfeeding during the COVID‐19 pandemic. Also, the BRACOVID project could have influenced studied mothers' support.

In the group that did not take the measures (NG), 4.9% of neonates sick had symptoms on the fourteenth day, but did not require hospitalization.

The study's limitations included that RT‐PCR tests were not performed for symptomatic neonates because of the shortage of tests at the time of the study. The studied population belonged to major cities and was assisted in referenced hospitals in the country, which may not represent rural areas, riverside communities, and small Brazilian towns. Furthermore, being “watched” and surveyed for 7 days could modify the answers (Hawthorne bias). Thus, the rate of PM execution could be lower than registered in the BRACOVID study.

Also, we should consider the role of single parents in caring for neonates, which could impact the isolation practices. The PM is less feasible without a partner or family member dedicated to caring for the neonate in the hours between breastfeeding. Unfortunately, we did not evaluate these data in our study.

The period of isolation has been reduced. However, we collected the data regarding the 7 days after the delivery, therefore, a time comparable with the current recommended period of isolation (5 days). Thus, we consider that our data have translational aspects nowadays.

In addition, these findings raise some questions: Are we adequately protecting all the infants during the pandemic? Assuming that the neonatal infection rate in the Brazilian population could be close to 5%, as found in our study, in a scenario with thousands of monthly births, it could cause concerns (Fiocruz analisa mortes em crianças por COVID‐19, 2021; Martins‐Filho et al., 2021; Sánches‐Luna et al., 2021; Solis‐Garcia et al., 2021).

Therefore, initiatives must protect infants in poor socioeconomic situations worldwide. In developed and developing countries, the support should have government‐paid support, spaces for housing dyads with adequate housing conditions, food supply, availability of masks cost free, health promotion education, and juridical accountability for the disseminator's disinformation and discharge after the isolation period (Armitage & Nellums, 2020; Modi et al., 2022).

The results reinforce the importance of public policies that recognize and implement diagnosis and actions to guarantee protection to low‐income infants against the SARs‐CoV‐2 infection.

The children need urgent measures for adequate guidelines for low‐income people and improvement in managing pandemics. Social inequality is a worldwide occurrence, the policies were unviable in most of the dyads in our study, and the initiative on protecting low‐income infants against SARs‐CoV‐2 is vital since the recommendations were not viable in poor socioeconomic situations.

5. CONCLUSION

Hand washing, masks, and distancing were unviable in low‐income dyads. Poverty, poor housing conditions, responsive feeding, and poor schooling are related to the unfeasibility of PM. Guidelines based on impracticable measures can drive thousands of poor children to a risk increase of infection by SARs‐CoV‐2. Therefore recommendations must be made considering the population characteristics; only an individual approach will allow a safe environment for low‐income infants.

6. IMPLICATIONS FOR NURSING MANAGEMENT

Poor socioeconomic conditions lead to the unfeasibility of protective measures for infants of low‐income SARS‐CoV‐2 positive breastfeeding mothers during the isolation period in the pandemics. The orientations and the support provided to dyad should consider the socioeconomic factors to guide feasible measures in the home environment and promote adequate protections; only an individual approach will allow a safe environment for low‐income infants.

ETHICS STATEMENT

The Research Ethics Committee approved the project of the Medicine School in Ribeirão Preto, University of São Paulo, Brazil (CAAE: 31357320.9.1001.5440‐4.066.741/2020) and Brazilian hospitals and maternal services.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

AUTHOR CONTRIBUTIONS

Walusa Assad Gonçalves‐Ferri conceived of and designed the study, developed study instruments, led the analysis, and wrote the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Fábia Martins Pereira‐Cellini developed study instruments, led the analysis, and wrote the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Raquel Santos Ferreira collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Jamil Pedro de Siqueira Caldas collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Rodrigo Duarte Ferreira collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Patrícia Franco Marques collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Thaise Cristina Branchee Sonini collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Viviane Christina Cortez Moraes collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Simone Manso de Carvalho Pelicia collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Leandro Meirelles Nunes collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Bruno Antunes Contrucci collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Edson Koji Suzuki collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Kelly Pereira Coca collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Mauricio Magalhães collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Paulo de Jesus Hartmann Nader, collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Daniela Marques de Lima Mota Ferreira collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Juliane Barleta Javorsky collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Laura de Fátima Afonso Dias collected data, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Bruna Pinto Dias Cavasin contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Ana Ruth Antunes de Mesquita collected data, developed study instruments, led the analysis, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Rebecca Meirelles de Oliveira Pinto collected data, developed study instruments, led the analysis, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Luciana Mara Monti Fonseca developed study instruments, led the analysis, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Edilaine Cristina da Silva Gherardi‐Donato, developed study instruments, led the analysis, contributed to write the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. Davi Casale Aragon developed study instruments, led the analysis, contributed to write the first draft of the manuscript, statistical analysis, coded the data, and contributed to thematic analysis. Anelise Roosch developed study instruments, led the analysis, and wrote the first draft of the manuscript, supervised data collection, coded the data, and contributed to thematic analysis. All authors had full access to all the study data and take responsibility for data integrity and reliability of the analysis. All authors had final responsibility for the decision to submit for publication. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Gonçalves‐Ferri, W. A. , Coca, K. P. , Martins‐Celini, F. P. , Chang, Y.‐S. , Ferreira, R. S. , de Siqueira Caldas, J. P. , Ferreira, R. D. , Marques, P. F. , Sonini, T. C. B. , Moraes, V. C. C. , de Carvalho Pelicia, S. M. , Nunes, L. M. , Contrucci, B. A. , Suzuki, E. K. , Magalhães, M. , de Jesus Hartmann Nader, P. , de Lima Mota Ferreira, D. M. , Javorsky, J. B. , de Fátima Afonso Dias, L. , … Roosch, A. (2022). Protective measures feasibility for infants of low‐income SARS‐CoV‐2 positive breastfeeding mothers: A prospective multicentre cohort study. Journal of Nursing Management, 30(8), 4064–4070. 10.1111/jonm.13854

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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