The COVID-19 Mother-Baby Outcomes (COMBO) Initiative at Columbia University has been researching the effects of the pandemic on moms and babies since March of 2020. Preliminary results show that one of the most affected aspects of the mother-baby relationship has been breastfeeding. The benefits of breastfeeding are more impactful than most people realize, and disrupting this physical and emotional connection between moms and babies can have repercussions that last a lifetime.
Here, Dr. Martha G. Welch (Director of the Nurture Science Program at Columbia University) and Dr. Dani Dumitriu (Director of Translational Research at the Nurture Science Program, and Chair of the COMBO Initiative) discuss the study’s findings, and their perspectives on breastfeeding during COVID-19.
Why Is Breastfeeding So Important?
Dr. Dumitriu: As a pediatrician working with newborns in the hospital, breastfeeding is probably the most important work I do. There is absolutely nothing that matches the long-term benefits for an infant, but also for a mom, as breastfeeding.
Breast milk changes throughout the day to perfectly suit a baby’s nutritional and immunological needs. It protects against numerous diseases: anything the mom has ever been exposed to, any vaccine the mom has ever gotten (including the COVID-19 vaccine)—those antibodies go into the breast milk and protect the baby. Breastfeeding lowers the baby’s risk of sudden infant death syndrome (SIDS), obesity, asthma, and ear infections, and reduces pain. It protects the whole GI system—the baby’s stomach and gut are protected by breast milk, whereas formula can really disturb the baby’s GI tract (especially premature babies).
There are also benefits for mom: lower risk of postpartum depression and anxiety, and decreased risk of developing breast and ovarian cancer, high blood pressure, and diabetes. Breastfeeding mothers have better cardiometabolic function… the benefits just keep going and going!
Dr. Welch: And then there’s how important breastfeeding is in establishing and nurturing emotional connection between mothers and babies.
We’ve done over a decade of research on connection in the especially-vulnerable population of preterm babies and their moms. Our studies have found that when these moms and babies connect through sensory and emotional interactions, the results are remarkable:
Moms have less anxiety and depression, and they feel more confident in their caregiving. Babies have better brain and nervous system development, better cognitive and language scores, and lower risk for attention issues and socioemotional difficulty. Both moms and babies have better nervous system regulation (which is related to their stress response and overall health) that lasts long term. So connection is really important in a multitude of ways, and breastfeeding is a wonderful way to achieve this connection.
But since the start of COVID, preliminary results have indicated extremely low rates of emotional connection between moms and babies at four months, possibly due to increased stress and increased separation (in the immediate postpartum period and over the course of the baby’s infancy). We’ve also noticed some mothers avoiding close contact with their babies for fear of passing the virus to their child. Whatever the reason, this drop in emotional connection is a true crisis.
Dr. Dumitriu: Parents need to know how important connection is, and they need to know that the rate of vertical and horizontal transmission (passing COVID-19 from mother to baby before or shortly after birth) is very, very low. And even when it happens, it does not tend to cause severe disease in the infant.
Dr. Welch: Breastfeeding involves lots of those crucial sensory and emotional interactions. It also causes the release of oxytocin (the “love hormone”) in the mother and the baby, and there’s oxytocin in breast milk, so the baby’s getting it by mouth, too.
Oxytocin syncs mom and baby’s metabolism, which ensures mom and baby will have the same nutritional requirements. If they live in a land of plenty where it’s safe to grow, they’ll have more nutrient absorption. If mom doesn’t have access to much, her and her baby’s metabolism will adjust not to need as much. This is how breastfeeding mothers can still feed their babies in times of starvation. This metabolic relationship is very, very important to our survival (and thriving), and it’s determined by breastfeeding.
Dr. Dumitriu: Babies who have been breastfed, on average, have two IQ points higher than babies who have never been breastfed. They also go to college more often (whether that’s from the milk itself or from the emotional connection, of course that’s unknown). The important thing is that there are numerous long-term benefits to breastfeeding.
COMBO Found Breastfeeding Rates Went Down During the Pandemic. Can You Tell Us More About That?
Dr. Dumitriu: Interestingly, at the beginning of breastfeeding (just after birth), the rates in our hospital only dipped very slightly. But what we’re finding in COMBO is that by the time the baby is four months old, those rates are dropping much faster for moms who had COVID during pregnancy than moms who did not. Now, keep in mind, most of these moms don’t have any symptoms by four months. They had the virus a long time ago. So what’s happening?
Well, we found that our COVID-positive group is much, much higher in minority populations. Up to 75% of moms in our COVID-positive group self-identify as Hispanic, versus about 45% in the COVID-negative group. And we know that the Hispanic population in our area, the Dominican population, tends to have lower breastfeeding rates in general.
So COVID is affecting them more in terms of numbers, and in terms of stopping breastfeeding sooner. Which is a double whammy for already-marginalized communities.
The other really important factor is that the pandemic caused some big disruptions in the birthing process. And moms were incredibly nervous to breastfeed, despite the fact that in many cases, they didn’t have COVID.
How Does Disrupting the Birth Process Hurt Breastfeeding?
Dr. Welch: When birth is undisturbed and the baby is placed on the mother’s naked belly, it will naturally crawl to the breast and latch. If you wash the breast, the baby does not find the breast. If you then put the mother’s amniotic fluid on one of her breasts, the baby will make a beeline for that breast. The trip to the breast gets the sucking apparatus ready in the baby’s mouth, and causes a milk letdown in the mother as the baby crawls up—all guided by the sense of smell.
And the mother needs to smell her baby, too! It triggers a release of oxytocin and lights up the reward centers in mom’s brain, which helps jumpstart this intense emotional connection. (Smell is foundational to building a strong connection, but even for parents who’ve lost their sense of smell after having COVID, there’s plenty you can do to connect.) Oxytocin is also what moves the milk from the breast to the nipple! So for breastfeeding to go well, you need a big bubble of oxytocin around mom and baby.
Touch also needs to be stimulated. The pressure receptors on the baby’s body are stimulated by the pressure of crawling up the mother’s body. If the mother hugs the baby, the pressure receptors get even more stimulated. When a baby’s born, it needs touch to be alerted. A mother is programmed to do light feather touch. Why? She’s checking: when I touch my baby like this, does it alert? Then she transitions to full-palm touch, which comforts the baby. It’s very interesting to watch the natural evolution of mom’s touch in the first hour after birth.
In the NICU, where we care for preterm and very sick babies, mothers might have a hard time believing that the baby is going to live, let alone be alert. They cannot make the transition from feather touch to complete palm touching. Even if you tell them, and even if you hold their hand, they still do light touch—until they get emotionally connected. Then, they’re able to do full touch. I found that to be really fascinating.
And for the babies, you can see from the monitor that it’s calming to taste the mother’s nipple. Even for preterm babies who haven’t coordinated suck-breathe-swallow (the mechanisms needed to breastfeed), just tasting the mother’s nipple is an important activity and primes the baby for breastfeeding.
So in an undisturbed birth, the baby is skin-to-skin, smelling the mother. The baby crawls to the mother’s breast because they smell the mother’s milk. The baby knows that smell, because it’s exactly the same as the amniotic fluid that the baby has tasted for months (taste and smell are very close together). And then the baby tastes the mother’s breast. If you don’t put the baby on the mother’s belly and let the baby make that trip, chances are, you’re going to have some suckling difficulties at the onset of breastfeeding.
In normal hospital birthing practices, the baby is taken away, separated from mom, and washed of their wonderful scent so important to this whole process. It’s terrible. Separation is a really big problem for emotional connection, and it can have terrible effects on breastfeeding.
Dr. Dumitriu: Even wearing clothes can be a form of separation. My routine when I walk into a room is to take those baby shirts off. They really interfere with things. The babies should be naked, moms and their partners should be shirtless, and they should just constantly do skin-to-skin with the baby. That there’s no better place for a baby than on mom’s skin when mom is awake, and the other parent’s skin when they’re awake. Skin-to-skin is calming for mom and baby’s nervous systems. It allows the baby to breastfeed whenever they want, and it also regulates their blood pressure, blood sugar, and temperature.
Dr. Welch: Yes! The natural mechanism for keeping a baby warm is to be on the mother’s chest. The breasts can modulate the amount of heat they provide, depending on the baby’s needs. The breasts even know how to heat differentially for twins: if the mother is holding two babies, each of her breasts heats to meet the needs of the baby on that breast.
The mother’s body is finely-tuned to answer the needs of the baby, and the baby is finely-tuned to elicit the proper mechanisms from the mother. But we are interrupting them at every turn, taking babies away from their mothers. We have these normal protective factors that have been cast aside for so-called “modern” birthing methods. Dr. Dumitriu, you can say what the usual hospital routine is.
Dr. Dumitriu: The baby is often taken off of the mom and put on a warmer, where all the routine care normally happens.
Dr. Welch: But isn’t it ridiculous to have a baby on a warmer, when the mother could have the baby? The routine stuff can be done with the baby on the mother!
Dr. Dumitriu: Yes! Actually, this is a really good change since the pandemic: we used to have moms and babies come down [to the postpartum floor] separately. This was mostly for practical reasons. One team would bring the baby down, and another team would bring the mom down. So there was this separation between moms and babies, even in the absence of any medical problems.
But now, one team generally brings mom and baby down together, because we’re trying to minimize traffic in the hospital during the pandemic. And even though the baby is in a warmer, at least they’re not separated longer than the elevator trip.
How Can Moms Protect Their Breastfeeding Relationship and Emotional Connection with Their Babies?
Dr. Dumitriu: Parents can advocate to keep the baby with them throughout their stay in the hospital. And there are lots of things parents can do when they get home. They can respond to all of their baby’s needs during those first few months. Don’t let the baby cry. Soothe them. You can’t spoil a baby that young. Being responsive is absolutely critical—not only for emotional connection, but also for the growth of the baby’s brain (which doubles in size during the first year). Moms can wear their baby all day long, and take turns with their partner.
Dr. Welch: We see babies whose hair is rubbed off their heads when they come back for a check. It’s because they’re lying by themselves all the time. We don’t want to see that. Babies should always face in when they’re being carried so they can see their parents’ faces, and so they can breastfeed while in the carrier!
Dr. Welch: Mothers should understand the importance of breastfeeding for their own and for their child’s physical and emotional health, and get support from experienced relatives or trained lactation professionals when needed. Whenever possible, mothers should take their baby’s shirt or onesie off while they feed. When the baby is naked (or just wearing a diaper), you build in extra skin-to-skin time, which is so important for the short and long-term health of both mother and baby.
Dr. Dumitriu: There are so many benefits to breastfeeding—for both health and connection, for both mother and baby, in the short term and long term. There really is nothing that matches it. This pandemic has caused a dangerous drop in rates of breastfeeding and emotional connection between mothers and babies. But breastfeeding builds emotional connection, and emotional connection supports the breastfeeding relationship. Moms and babies can heal together, by engaging in both of these fundamental processes of early life and development.