Providing breastfeeding support during the COVID-19 pandemic: Concerns of mothers who contacted the Australian Breastfeeding Association

Concerns of mothers seeking breastfeeding support during the COVID-19 pandemic, and the experiences of Australian Breastfeeding Association (ABA) volunteers who assisted them, were explored via an online survey. Surveys were completed 16 th March to 18 th of May 2020 and described the COVID-19 related concerns of 340 individuals. One hundred and thirty six mothers (64%) sought support to protect their infants by continuing breastfeeding, increasing milk supply, or restarting breastfeeding. Mothers were commonly stressed, isolated and ne eding reassurance. Thirty four (10%) rais ed concerns about CO VID-19 and breastfeeding safety. One hundred and twenty nine (61%) informed volunteers they were unable to access face-to-face health servi ces because of fear or unavailability. Most common breastfeeding concerns were related to insufficient milk or weight gain, painful breas ts , relac tation, and reduc ing supplemental milk. Volunteers reported mothers were worried stress had reduced milk supply, that milk supply concerns were exacerbated by the inability to weigh infants, and that seeking medical treatment was bein g delayed. ABA volunteers stated they f elt supported and confident assisting mothers while also expressing distress at mothers’ situation. ABA’s role in emergency response should be recognised and n ational planning for infant and young child feeding in emergencies, must be urgently developed, funded, and implemented.

COVID-19, Australian Breastfeeding Association, relactation, infant feeding in emergencies, volunteer . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 3

On 11 March 2020, the World Health Organization (WHO) declared the spread of the novel c or onavir us SARS-Co V-2, a pandemic ( Ghebreyesus, 2020). In Australia, the first confirmed case of COVID-19, the disease caused by the virus, was identified on 25 January 2020 (Department of Health, 2020c). While virus spread was initially slow, by 24 March there were 2051 cases (Department of Health, 2020a) . In the thir d and fourth week of March, Aus tr alian governments imposed a variety of public health measures to reduce transmission. These included banning international travel, closure of clubs, gyms, and restaurants,

of individual movement outside the home, and gathering restrictions. Schools and un iversities also shifted to remote learning. At the same time, health services reduced in-person antenatal, postnatal, and child health appointments, and cancelled mothers’ groups. The Australian Breastfeeding Association (ABA) remained operational and continued to support women with breastfeeding. Formed in 1964, ABA aims to provide women with practical mother-to-mother support to enable them to breastfeed their infants and young ch ildren (Australian Breastfeed ing Association, 2019). AB A is a registered training organisation and its volunteers und ertake competency-based training to receive a Certificate IV in Breastfeed ing Education (Counselling or Community). AB A has more than 1000 volunteer breastfeeding counsellors and community educators who deliver antenatal breastfeeding education classes, run mothers’ groups, facilitate social media groups, p rovi de text-based support via the ABA L iveChat service, and provide telephone counselling through the ABA National Breastfeeding Helpline. The Nation al Breastfeeding Helpline received more than . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 4 70,000 calls in 2018–19, operates 24 hours a day, 365 days of the year, and receives funding support from the Australian Government (Australian Breastfeeding Association, 2019). WHO made it clear even before the pandemic was declared, that mothers with COVID-19 should be supported to breastfeed their infants (World Health Organization, 2020c). While early research indi cated SARS-CoV-2 infection causes serious disease in 20% of people, significant illness in children was rare (Wei et al., 2020; World Health Organization, 2020d). Experience with other resp iratory viruses suggested SAS-CoV-2 transmission via breastmilk was unlikely (World Health Organization, 2020c). The role of breastfeeding in protecting infant health required breastfeeding not be impeded (World Health Organization, 2020c). WHO publish ed detailed guidance on COVID-19 and neonatal care on 13 March 2020 (World Health Organi zation, 2020a). This guidance stated that infants born to women who are su spected or confirmed as h aving COVID-19 should be placed skin-to-skin with their mothers immediately after birth, initiate breastfeeding within an hour of birth, be kept proximate to their mothers day and night, and exclusively breastfeed. These breastfeeding practices should be maintained alongside infection prevention and control practices including respiratory hygiene, hand hygiene, and the cleaning of surfaces (World Health Organization, 2020a). WHO also advised that all mothers should receive support to initiate and establish breastfeeding and to manage breastfeeding difficulties from . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 5 appropriately trained health professionals and lay breastfeeding counsellors (World Health Organization, 2020a). From the end of the f irst week of March, ABA volunteers started report ing mothers were delaying ceasing breastfeeding because of COVID-19 and an increasing number of women wanting relactation assistance. It appeared the pandemic might be changing the feeding practices of mothers and the support ABA volunteers were being asked to provide. ABA national management team members decided to launch an ABA volunteers survey to assess whether ABA was providing volunteers, mothers, and other service users with the support they needed during the COVID-19 p andemic.

Data was collected via an online survey using the SurveyMonkey® platform accessed via a password-protected section of the ABA website between 16 March and 18 May 2020. ABA volunteers were sent an email informing them of the survey, and were also given a message about the survey when they logged into the National Breastfeeding Helpline to take calls. They were asked to co mplete a survey if people contacting them for assistance as an ABA volunteer raised concerns about COVID-19 or menti oned COVID-19 as a reason for seeking support from ABA. The survey consisted of nine open-ended questions. Respondents were asked to provide non-identifying information about how and when they were contacted, and the concerns of the person seeking support, noting relactation and . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 6 increasing milk supply as potential areas of concern.They were also ask ed whether there was anything they would like to share in relation to their volunteer role and CO VID-19 such as whether they felt they had the needed knowledge and skills. R espondents could describe more than one contact in a survey completion and could also complete the survey more than once. No identifying information was collected from respondents. Survey responses were exported into Excel® and coded using conventional content analysis (Hsieh & Sh annon, 2005). The process of coding involved the authors each reading all survey responses and two authors independently undertaking open coding to identify the main ideas being expressed. The three authors then discussed the coding outcomes and finalised a coding framework. The full data set was then re-coded by one author using the finalised framework which was then checked by another author. Where there was ambiguity, the authors determined the appropriate code through discussion. Codes were arranged into themes encompassing the data. Since the data was pre-existing, contains no identifying information, and i s of negligible risk, the research was determined to be exempt from the need for ethical revi ew by the West ern Sydney University Human Research Ethics Committee.

The online survey was completed 211 times and described the concerns of 340 individual contacts, including 336 mothers, two fathers, and one grandmother, regarding 341 infants and young ch ildren, and one pregnant woman. Respondents stated 207 times they were reporting on contacts made via the . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 7 National Breastfeeding Helpline, 22 times via LiveChat, and 16 times via other means (eg email counselling, group meetings, social media, breast pump hire). Respondents reported on contacts made between 11 March and 18 May 2020. The most common COVID-19 related issues identified by ABA volunteers and their frequen cy are summarised in Table 1. Table 1. Type and frequency of C OVID-19 related issues rai sed with ABA volunteers Themes and sub-themes Frequency Seeking suppo rt to p rot ect infa nt s b y br eas t f eedin g in th e CO VID-19 pan de m ic To continue breastfeeding 64 To increase milk supply or reduce infant formula supplementation 39 To restart breastfeeding 33 Total 136 Why b r ea stfeedi ng was viewed as prot ec t iv e Breastmilk provides protection against infections 55 Concern that infant formula may become inaccessible 10 Total 65 In ability t o a c ce s s to face-t o-face ser vices b ecau se of COV ID - 19 Normal services cancelled 69 Afraid of attending in person 60 Total 129 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 8 Safet y conc e r n s rela ted t o CO VID-19 Transmission of SARS-CoV-2 and breastfeeding/milk 25 Health professional managing working and breastfeeding 9 Total 34 Em otional wel lbei ng co nce rn s r e l at e d to CO VID-19 Needing reassurance 63 Anxiety/Stress 53 Isolation 31 Total 147 Seeking support to protect infant s by breastfeeding in the COVID-19 pandemic One hund red and thirty-six mothers (64% of contacts) were reported to have sought support to continue breastfeeding, to increase their milk supply or to restart breastfeeding to protect their infants. Support to continue breastfeeding Sixty-four of these women had contacted ABA seeking support to continue breastfeeding or avoid using infant formula. Children of these women ranged from the very young, to older babies and toddlers. For example, ‘Bab y was 1 2 days o l d… Had p re viou s poo r b re a stf e edin g expe rie nces and happil y u sed formula for othe r 3 babi es. This tim e mot he r i s co nc e rn ed a bout t h e vi r u s a nd wa n ts the baby to receive b r e a s t milk’, ‘I ha d tw o mothe rs of n ewbo rn s und er 10 d ays old . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 9 Bot h had significant a nx i e t y a bo ut k eeping b rea s t feedi ng g oing t o help prot ect t he baby f rom CO VID-19’, and ‘M oth er th in king of w eani ng at 1 2 month s b ut due t o pandemi c had d ecided to co nt inu e breastfe eding’ . Support to increase milk supply to avoid or eliminate supplementary formula feeds Thirty-nine mothers sought assistance to increase their milk supply or reduce infant formula supplementation because of COVID-19. Often infants were young and mothers had been supplementing becau se of breastfeeding ch allenges. For example, ‘ Nin e-day-old b aby who ha d been m o s tl y formu la -fed in ho spita l due to lat c hin g difficult ie s and jaun dice . .. w an ting t o g e t the ba by back ont o th e br eas t fully’, and ‘Mot her was st rug glin g wi th att achment, had sta rted… formu l a but want e d t o g et br e astf eedin g right ’. T here were also instances where reversal of a planned weaning was desired, ’10- month -old baby . Mothe r had b egu n t h e weani ng p roc ess , bu t du e to CO VID-19, wa s k een to i n crea s e suppl y so t ha t she could c ontin u e t o b reastfe ed’. Support to restart breastfeed ing Finally, 33 women were reported to have sought assistance with restarting breastfeeding. In some cases, it had been a short time since breastfeeding had ceased and they were reinitiating breastfeeding with a likely existent milk supply, in other cases relactation was necessary. For example, ‘ 8 da ys . L ost weight at birth s o fo rmul a . B aby will ing to br eas t fe ed . Lo ve s it! !’ , ‘Moth er c eas ed br eas t fe e di ng whe n bab e w a s 3wks o f ag e . No w 10 w ee k s…with th r eat of c o r ono vir us, w a nt s to tr y to r e l a c t ate ’ , and ‘ B aby boy 10 w e ek s old , bo r n . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 10 prematu r e, mum de cided to fo rmula -f e ed from t h e sta rt in h ospit al . . . wa nted t o know if she co uld sta rt b r eas t fe eding ’. Why breastfeeding was viewed as protective In almost half of cases (n=65, 48%) where women had sought support to protect their infants by breastfeeding, ABA volunteers recorded why mothers viewed breastfeeding as protective. In the majority of instances (n=55), it was because of the anti-infective properties of breastmilk. For example, ‘Ni ne day o ld b aby who had bee n mo stly fo rmula fed in hospi tal … T he mothe r wa s a war e o f COVI D - 19 and want e d t he immun e system b en efit s of br eas t milk’ , ‘M othe r w a nted to k e ep he r 11 day old b rea s t fee di ng to s u ppo rt his im mune s yst em .. . fo r th e b est prot ec tion again s t t he c o rona vi rus ’ , and ‘Mum h as a 9 mont h o ld and stopp ed b r east fee d ing 6 we eks ag o .. . h opin g to r elac t at e b ec aus e she feels b re a stm ilk is impo rt an t for immu ne f ac t o rs with t he COVI D 19 c ris i s’. A small number of of women (n=10) told volunteers they wanted to breastfeed because they were concerned they might not be able to access infant formula. For example, ‘Baby 4 w eek s o ld…Mo t her now wa nt ing to dit c h f or m u la a nd exc lu s ively b r ea stfeed ‘in ca s e he b eco mes r e l iant on t h e fo r m ul a and I ca n no longe r get it’, and ‘5 1/2-mo nth-ol d b aby … hig hly a nxio us and t ea r y , w o rried that if baby co ntin u es to refu se an d w ea n s anytim e o ve r the n ext fe w u ncerta i n months tha t s he w on't b e ab l e t o get formu la ’. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 11 Inability to access to f ace-to-face services because of COVID-19 An inability to access face-to-face health servi ces was mentioned by 129 (61%) of those who sought support from ABA. In about half of these cases, mothers expressed an unwillingn ess to go to their General Practitioner (GP) or to see their Maternal and Child Health Nu rse (MCHN) because of a fear of exposure to COVID-19. For example, ‘ M othe r of 3 w e ek old having di fficulty seei ng h er GP an d rel uc t ant t o s e e oth er he a lth p rofe s si onals , even r e f used a v isit f rom a ma ter nal and child healt h nu rse becau se of b ei ng w or r i ed ab ou t COV ID-19,’ an d ‘Whil s t t he mot her ne eded help s he di dn 't want to g o o u t of the hous e’. In the other half of cases, volunteers reported mothers had been unable to access health services because of service reductions. For example, ‘ E a r ly d is c h ar ge d ue to CO VID19 but n o a s sociat ed ext ra supp or t . T his mot h er wa s in a r u ral lo cati on with a 1- day-old ba by r ec ei ving no s upport at a ll’, ’10 day old ba by , mot h e r not received a ny midwife/ MCHN v isit s s i n c e bein g dis char g ed f rom hospita l d ue t o CO VID-19’, and ‘Mum wit h 8-w eek-o l d, co nc e r ned about h er milk supply… s he co uld not g et any loc a l a ssis t a nce from h er health s ervic e b e cau se a ll thei r facili ties a re closed’. Safety concerns related to COVID-19 Volunteers reported 34 instances where contacts raised safety concerns regarding COVID-19. Most concerns were general in nature regarding whether breastfeeding was safe when mothers are infected with SARS-CoV-2. For example, ‘Co nce rn s a bout fe eding he r 3 we ek ol d bab y if s h e wa s to cont r act Covid19 an d w h e t he r she s houl d w ea n’. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 12 In a few instances, the concern was more specific. For example, ‘A mot her in NSW who has b een t es t ed fo r the co rona vi r u s and wa nt ed t o kno w if s he co uld conti nu e BF… Ve ry a nxiou s a nd didn't wa nt to feed if it wou ld ha r m he r bab y’ and ‘ Grandmot h er ma de cont ac t a s he r d aught e r had b een advi se d by car e p r ovide r s at a major te rtia ry ho s pi tal to stop b re as t feedin g whil e s elf- is o lat ing aft er a pos s ible exposur e event ’ . Although relatively small in number (n=9), it was nonetheless striking that health professionals who were breastfeeding themselves, contacted ABA to ask for information. For example, ‘Mum wo rks i n healt hca r e with C o vi d-19 pat ie n ts , want e d t o kn ow th e s af e t y of con tinu ing t o ex p re s s at w ork v of fe r ing b ab y formula’ and ‘ H e a l t h c a re w or k er ... p r e p ar i n g to w or k w i t h C OV I D - 1 9 c a s es . .. looking fo r info a b out s a fel y cl eanin g h er pumpi ng e q uipment i n a shar e d s ink ’. Emotional wellbeing needs ABA volunteers described 31 mothers who were finding isolation because of COVID-19 difficult, 53 mothers who were anxious or stressed, and 63 instances of mothers needing reassurance or providing mothers with reassurance. For example, ‘Two mot he r s with ba bie s unde r 1 w eek who were fee ling ve r y i s o late d and ins ecu re . I wa s a b le t o give t h em informat ion and reas s u r an ce’, ‘W a s ve r y anxious and s t r e ssed a s a res ult of fe eling isolat ed f rom he r mothe r s ' g ro up and other contact s an d felt like she w a s a lone and stuck i n g ro und hog day’ , and ‘Feeling very i s o lat ed with 10 we ek o ld baby . She wa s v e r y g rateful for i nfo r e onlin e A BA servic es ’ . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 13 Sometimes volunteers described mothers just wanting to have someone to talk to, ‘Mum f e elin g is o lat ed a nd j us t wa nted to t alk’, an d ‘ M a ny m o t h ers a ppe ar t o want t o talk and be list en ed to an d a r e on the li ne fo r mu ch long e r than n ormal . They ju st want t o talk abo ut the bi rt h, what' s happeni ng wit h b r ea stfeedi ng a nd their baby a nd t hei r hom e life’ . In some circumstances, stress and the need for reassurance was related to being unable to access informal or health professional supports, ‘Mot he r was very str e s sed as he r n o rmal s uppo rts coul d not he lp he r . ..[gave] r eassu ran ce ’ , and ‘Mother of 6 day old had no in pe r s o n con sult s s ched uled and h ad a bab y wi th s i gn s of inadequ at e inta ke . Wa s st r e s s e d a s did not kn o w ho w ba b y wou ld b e a s s e ssed and ca red f or app rop riate ly’. Some mothers were stressed about the direct threat of COVID-19 and needed reassurance, for example, ‘B oth t h e mo thers w e r e very anxi ous about t he ir ba b ies cont racting t h e c o ro navi ru s ’, and ‘B ot h pare nts C OVI D positi ve a nd in is olati on at home. M uch re a ssu r a n c e’ . Infant feeding concerns raised with ABA volunteers There were 292 separate breastfeeding concerns raised with ABA volunteers and reported in the survey. The four most common were regarding insufficient milk or inadequate weight gain, painful breasts or nipples, relactation, and infant formula supplementation (Table 2 ). In many instances, COVID-19 was a factor in why mothers had these concerns and how these concerns presented. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 14 Table 2. Most common breastfeeding concerns raised with ABA volunteers Concern Frequency (n=292*) Insufficient milk supply or inadequ ate weight gain 80 Painful breast or nipples 49 Relactation 27 Reducing infant formula supplementation 15 *Volunteers could report more than one concern for each individu al Insufficient milk supply or inadequ ate weight gain Eighty mothers (38%) sought assistance from ABA volunteers because they believed their milk supply or infant’s weight gains were inadequate. Many mothers stated they believed the stress of the COVID-19 pandemic had negatively impacted their milk supply. For example, ‘Mot her i ndicat e d s he felt he r supply may have b e en aff e ct e d d u e t o he r l ev els of an x iet y a rou nd C OVI D ’ , and ‘Mother wa s in cr edibl y anxio us a bou t th e im pact of Covid-1 9. H e r pa rt ner was a high risk of expo su re in hi s wo rkplac e s o s h e was se lf-isolat ing with he r 4- we ek - old . .. w orr i e d th a t th e s tr es s w as a ls o a f f e c t i n g he r s u pp l y ’ . Concerns around weight gain were driven or exacerbated by the inability of mothers to access face-to-face health services and to have their infant weighed. For example, ‘W o r ried about not bei ng abl e to w eigh bab y p rope r l y a s u n able t o see [h e al th pr ofessional s] and usi ng bat hr oom scal es i nst ead’, and ‘Ba b y 17 da y s old. Low sup ply , n ot su re if ba by i s g e t ting e nough , a s bab y c a n 't b e we i gh ed. Expre ssing a nd supplem enti ng with f ormula wit h n o ext r a s upport’ . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 15 Painful breasts and nippl es Forty-nine women (23% of contact s) sought assistance from ABA volunteers with symptoms of mastitis or other breast infections. Many mothers had avoided seeking medical attention for symptoms because of COVID-19. For example, ‘All in r elatio n t o ma s t itis/b locke d du c t s. They s a id they wo uld have u s ual l y g one t o their GP , but the y wer e too sc a r ed to becau se of C ovi d-19’ and ‘ M o the r be li e ves s he has mas t itis (cold chills , b rea st pain etc o ve r 24 hou rs) conc erned abo ut l eaving the house to s e e GP t o g et anti bi otics ’ . In one case, access to a doctor was prevented by infection control policies not accounting for mothers having multiple children, ‘Mother had what sound ed like a b re as t i nfec t io n… I sugg es t e d G P vis it . S he said she ha d t wo child ren an d wa s u nabl e t o take both of t hem to he r c lini c b e cause they a re l imited t o on ly 2 p eopl e in e ach consu lt .’ In other instances, concerns regarding the overlap of symptoms between mastitis and COVID-19 jeopardised access to medical care, ‘Mu m with m astit is … GP refu sed t o s e e he r i n pe r son du e t o tempe ratu r e and flu -lik e sympt oms ’ and ‘Mu m had a block ed duct and w as w or ri ed tha t her d oct o r would n't t r eat he r a p pr op riat e l y if it b ec om es mastit i s, d ue to th e flu- like s ympt oms … b eing CO VID sy mpt oms’ . As previously described, concerns related to relactation and reducing infant formula supplementation were connected to mothers wanting to protect their infants in the COVID-19 pandemic. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 16 ABA volunteer’s feelings about their work Fifty-nine surveys (28 %) included comments from volunteers about their ABA role. As shown in Table 3, these comments mos t commonly (n=21) reflected that volunteers felt supported and equipped to assist mothers and others who contacted ABA for assistance, ‘I felt I h ad the know ledg e , skills and c onfidenc e to answ er and rea s su r e t hem’ , and ‘I fel t confident m y t r a inin g had st ood m e in go od stead fo r this crisi s ’. They sometimes mentioned ABA COVID-19 resources as of assistance, ‘I felt the ne w re sou r c e s r elea s ed by AB A for u s help ed me to fe el mo re confident a nswe rin g any inq uiri es ’ . Some volunteers (n=9) described being happy and gaining p ersonal satisfaction through helping mothers during the crisis. One reported, ‘I t felt good t o be ab le t o rea s s u r e ot her mot her s in s u ch a challengi ng t ime’ , and another said, ‘Pe rsonall y , I felt so happy to b e a ble to do s omethin g helpful rathe r than sitt i ng at ho me t rying not t o get i nfected !’ In seven surveys, volunteers expressed distress of various kinds at what mothers and infants were experiencing, For example , ‘Fee l a bit helpl es s,’ ‘ I am wo r ri ed about ba bie s fal ling thro ugh t he c ra cks ’, and ‘ I felt furio us that the ca re provid e r s had said this to t he m othe r’. The feelings of distress were sometimes lin ked to satisfaction in helping women, ‘I fee l reall y sad for t he s ca re d m othe rs. I f eel frust rat ed that supp ort i sn't get tin g t hr ou gh to them. I feel s o pl e a sed tha t we exi st. I feel ab le t o make a sig nificant differen c e to mu m s ’. Four volunteers described seeking support for themselves, ‘ I am d e br i e f i n g w i th m y pe ers a nd c o nti n u i n g t o take H elplin e s hi fts and offe r wha t su ppor t I can’. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 17 Four volunteers suggested resources or actions that could help mothers or themselves including one volunteer who mentioned the need for the National Breastfeeding Helpline to be better advertised, ‘I 'd like t o see some ad ve rtisi ng of our se rvices . T he TV me nti on s Life lin e , Be yond B lu e a nd othe r s b ut I have n't hea rd Helpli ne at all . M ot hers need t o kno w we' r e her e and wait ing for t hem’. Three volunteers said they lacked knowledge, for example, ‘I wis h I 'd kno wn more abo ut what G Ps a r e doi ng t o m inimise ri sk and meet the ne eds of b r ea stfee ding women’ . Finally, one volunteer noted sh e was working beyond her capacity , ‘A TM I am volunt eeri ng a rou nd 6 hou r s a da y t o s upp ort ou r volu nt ee rs t hrou gh trainin g/h e l plin e/on line be c a use I k now everyo ne ne eds ext ra s up po r t r i ght now . This is n ot su s ta i nable’ . Table 3. ABA volunteers’ feelings about their volunteering work and the resources available to them Feeling Frequency (n=59) Well supported and equipped to assist 21 Happy or s atisfied 9 Distressed for mothers 7 Made suggestions for additional resources 4 Lacked knowledge 3 Working beyond capacity 1

The findings of this study suggest that the COVID-19 pandemic may have increased the perceived importance of breastfeeding and altered th e infant feeding practices of Australian women. Australian Infant Feeding Guidelines . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 18 recommend infants be fed only breastmilk for the first 6 months and continue breastfeeding into the second year of life (National Health and Medical Research Council, 2012). Nin ety-three percent of Australian women initiate breastfeeding but premature cessation of exclusive and any breastfeeding is common (Australian Bureau of Statistics, 2019). In the early postnatal period, as many as 22% of inf ants are fed supplementary infant formula and a further 16% cease breastfeeding entirely (Ogbo et al., 2017). By 1 year of age, only 40% of infants rec eive any br eastmilk ( Australian Bureau of Statistics, 2019). H owe ver, our study show s, because of the COVID- 19 pandemic, mothers who had not initiated or had stopped breastfeeding, or who were supplementary formula-feeding contacted ABA for assistance to start/restart breastfeeding or increase t heir milk supply. Infectious disease risk and concerns regarding infant formula availability motivated women to breastfeed. It was parti cularly notable how many women sought assistance with relactation. Under normal circumstances, support for relactation is an un common reason for women to contact ABA. The 2019 ABA client survey (n=395) included only three mothers who nominated relactation as their contact reason. However, the heightened importance of immune protection and food security provided by breastfeeding was a motivation for mothers to restart breastfeeding in the COVID-19 pandemic (Salmon, 2015; Victora et al., 2016). With the exception of relactation, the most common breastfeeding concerns related to COVID-19 were not different from those encountered under non- emergency conditions. Sore nipples or breasts are consistently the most common concern reported in the annual ABA client survey. Similarly, concerns about low . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 19 milk supply (which may include concern about weight gain or a desire t o decrease formula supplementation) have been in the top four concerns of mothers contacting ABA over the last 3 years. However, lack of access t o health care because of COVID-19 had an impact on how these concerns presented. Many mothers described experiencing breast pain and other symptoms likely caused by mastitis but were unable or afraid to visit their doctor to obtain treatment. If left untreated, mastitis can result in tissu e destru ction and development of abscesses requiring hospitalisation and surgery (Boakes, Woods, Johnson, & Kadoglou, 2018). Anecdotally, La Leche League Italia reported an increase in breast abscesses during the COVID-19 wave of March–April 2020 because mothers had similarly delayed medical treatment (A. Venturini, personal communication, July 10, 2020) . Concerns about milk supply and infant weight gain were also exacerbated by lack of health care access and the in ability of infants to be weighed. Similar concerns associated regarding lack of ability to weigh infants has been reported by the Association of Breastfeeding Mothers in the UK (E. Pi ckett, personal communication, July 17, 2020). Feeding infant formula because of unresolved milk supply concerns would adversely impact infant health (Quigley, Carson, Sacker, & Kelly, 2016). Unidentified dehydration or failure-to-thrive could have serious n egative consequences (Jang et al., 2020; Livingstone, Willi s, Abdel- Wareth, Thiessen, & Lockitch , 2000; Payn e & Quigley, 2016 ). In two hospitals in Italy, an 84% reduction in paedi atri c presentations and a 75% decline in admissions occurred in March and April of 2020 raising concerns that fear of seeking medical treatment could imperil child health (Manzoni, Militello, Fiorica, . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 20 Manzionna, & Cappiello). It seems possible fear or inability to access health care because of COVID-19 could be affecting mothers and infants in many contexts. Some mothers were concerned stress had affected their milk supply. The erroneous belief that stress reduces milk production is common and, in emergencies, women often perceive milk insufficiency (Gribble, 2014). Changes in infant behaviour such as increased fussiness, more frequ ent feeds, night waking, and an intolerance of maternal separation are commonly interpreted by mothers as signifying milk supply problems. However, none of these behaviours are reliable indicators of insufficient milk. Rather, such behaviour chan ge is most likely in response to altered circumstances and maternal d istress in emergencies and is to be expected. Stress can result in some temporary slowing of oxytocin release and milk flow (but not milk production) also making infants fussy at the breast (Ueda, Yokoyama, Irahara, & Aono, 1994). Breastfeeding counselling can enable women who believe their milk supply is reduced due to stress, to regain confidence in their ability to breastfeed and avoid infant formula use (UNICEF, 2008). For thi s reason, international infant feeding in emergency guidance requires that emergency plans include provision for breastfeeding counselling (IFE Core Group, 2017). Inability to access health care, isolation from others, and concerns directly related to COVID-19 were difficult for many mothers. Women were often in need of not only practical assistance and information regarding breastfeeding but reassurance and someone to talk to. The year following the birth of a child is a time of transition as women experience changes to their body, the physical and . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 21 emotional demands of infant care, and changes in relationships, self-perception, and employment (Fahey & Shenassa, 2013). During this time, social su pport assists women to develop parenting self-efficacy and facilitates good mental health (Leahy- Warren, McCarthy, & Corcoran, 2012 ). The pandemic reduced mothers’ access to formal support mediated by the health system and informal support from friends and rel atives. Research from Belgium found high rates of symptoms of anxiety and depression in new mothers during COVID-19 lockdown (Ceulemans, Hompes, & Foulon, 2020). Contact with ABA provided women with a form of social support as well as other components of breastfeeding support, like emotional support and reassurance, practical assistance, and informational support (McFadden et al., 2017). The mother-to-mother support ABA provides, may have been p articularly salient as volunteers had the shared experience of isolation from family and friends, often were also caring for infants and young children, and all had breastfed themselves (Rossman et al., 2011). Proactive telephone support by ABA counsellors in creases breastfeeding rates at 6 months of age (Forster et al., 2019). However, it may be the emotional support provided by volunteers was especially significant to the wellbeing of mothers who were isolated because of COVID-19. ABA launched the survey reported on in this study partly in order to ascertain whether volunteers were adequately supported. It was reassuring that the majority of those who commented on their volunteer role, stated they felt supported and confident. Their comments noted their general training and the specific ABA COVID-19 resou rces as of assistance. In March and April 2 020, ABA produced COVID-19 resources for volunteers, parents, and health professionals. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 22 Resources regarding the safety of breastfeeding and COVID-19 were targeted at all groups and based on WHO guid ance (World Health Organization, 2020a, 2020b). Support materials for volunteers focused on accessing government- funded telehealth services (Department of Health, 2020b), and relactation. A video for health professionals on assessing infant milk intake during telehealth consultations without the ability to weigh was produced (Australian Breastfeeding Association, 2020). Volunteers reported feeling distressed for mothers and satisfaction in providing assistance. Cultivation of empathy with mothers is core to breastfeedi ng counselling (World Health Organization, 1993). However, empathic response to individuals in difficulty can lead to helpers experiencing traumatic stress (Regehr, Goldberg, & Hughes, 200 2). Alternatively, where assistance is effective, it can lead to compassion satisfaction (Wagaman, Geiger, Shockley, & Segal, 2015). Comments from ABA volunteers reflected some had experienced compassion satisfaction but the distress and workload pressure noted by others underlines the importance of supporting volunteers. It is noteworthy that female ABA volunteers were und ertaking their ABA work often alongside paid employment, and a d isproportionate burden of household management, childcare, and education sup ervision noted as impacting women in the pandemic (McLaren, Wong, Nguyen, & Mahamadachchi, 2020). This research highlights the role of ABA in Australia’s COVID-19 health response. Particularly during the early stages of the pandemic, health service pro vision suffered as major adjustments had to be made. However, ABA service design . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 23 meant support to mothers continued largely uninterrupted during the March– May lockdown. ABA volunteers staffing the National Breastfeeding Helpline and LiveChat work from home and no adjustments for isolation measures were necessary. ABA has run online mother support groups (particularly in remote or rural areas) for many years and ABA support groups moved more broadly to online provision from 17 March. Demand for services increased; in April 2020, the National Breastfeeding Helpline received 500–1000 calls in excess of that expected. It is undoubtedly the case that ABA’s services provided a safety net that helped protect mothers and inf ants. However, as noted by one survey respondent, lack of promotion of ABA’s services may have resulted in under- utilisation. It may have also left a gap for commercial expoitation. The infant formula manufacturer (Nutricia) targeted doctors with advertisements for their helpline stating they were ‘here to help … share the load’ during the crisis. Doctors were invited to direct patients with feeding concerns to their helpline which begins each call with an advertisement for their infant formula st ore. The exploitation of the pandemic by the baby food industry appears to be an international ph enomenon (Cullinan, 2020) which Australia is not immune to. Despite the role ABA played in supporting mothers and infants during the COVID-19 pandemic, ABA is not mentioned in any Australian emergency plans. More broadly, this pandemic has highlighted again that Australia lacks emergency planning for infants. Th e National Pandemic Influenza Preparedness Plan recognises infants as a vulnerable group and advises specific strategies be implemented to protect them (Department of Health, 2019). However, neither it nor any state or territory pandemic plan contains infant feeding content. A . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 24 recent audit of Australian emergency plans and gu idance revealed a dearth of planning for infants at all levels of government and in all emergency types (Gribble, Peterson, & Brown, 2019 ). Nonetheless, the Australian Government’s funding support for the National Breastfeeding Helpline was a measu re that contributed to resilience in Australi a’s health systems in the COVID-19 pandemic to the benefit of mothers and infants. The Council of Australian Governments’ National Breastfeeding Strategy states that skilled breastfeeding support should be available to mothers and infants during emergencies and that a national policy on infant and young child feeding in emergencies should be developed. The shortcomings of the emergency response in the 201 9–20 Black Su mmer of Bushfires and the COVID-19 pandemic has mad e it clear such planning must be urgently d eveloped, funded, and implemented. Study Limitations It is a limitation of this study that not all ABA volunteers w ho were contacted by individuals with concerns related to the COVID-19 pandemic may have completed the study su rvey. In addition, not all individuals whose breastfeeding concerns were related to the pandemic may have mentioned this to ABA volunteers or fully explained their concerns.

Mothers are responsive to aw areness of heightened risks to infants in emergencies and are willing to change feeding practices as a result. Exclusive and continued breastfeeding provides infants with a safe and secure food and water supply and protection from i nfection and should be promoted as an . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 25 emergency preparedness activity promoting community resili ence. Mothers were negatively impacted by the reduction or removal of formal and in formal supports for breastfeeding and mothering during the pandemic. However, ABA services continued to provide support and were able to rapidly deploy key information to mothers, ABA volunteers, and health professionals. The role ABA can play in emergency response should be recognised and reflected in emergency planning. There i s an urgent need for the Federal Department of Health to convene and fund a national advisory committee to adapt international infant and young child feeding emergency planning and gu idance (IFE Core Group, 2017) for the Australian context.

AND DISC LOSURES The authors would like to thank Nerida Haines for her work in laun chi ng and managing the survey and for supplying ABA statistics for use in the discussion of the paper, th e ABA volunteers who completed the study survey, and Libby Salmon for her helpful comments in the development of this paper. No financial assistance or funding was received from any sources towards this article. CONFLICTS OF INTEREST Naomi Hull is an Australian Breastfeeding Association volunteer Counsellor, Renee Kam is an Australian Breastfeeding Association volunteer Counsellor, Karleen Gribble is an Australian Breastfeed ing Association volunteer Community Educator and Counsellor and a member of the Infant and Young Child Feeding in Emergencies Core Group. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 26

Australian Breastfeeding Association. (2019). A nnua l Repo rt 20 18-2019 . Retrieved 19 July, 2020, from https://www.breastfeeding.asn.au/system/fil es/AnnualReport_2018- 19_FINAL.pdf Australian Breastfeeding Association. (2020). Assessing newborn intake in th e context of COVID-19. Retrieved 19 July, 2020, from https://abaprofessional.asn.au/assessing-newborn-intake-in-the- context-of-covid-19/ Australian Bureau of Statistics. (2019). Br ea s t feedin g . N at ional Hea lth Survey : Firs t Resul ts, 2017 -18 Retrieved 19 July, 2020, from https://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/436 4.0.55.0 01~2017-18~Main%20Features~Breastfeeding~10019 Boakes, E., Woods, A., Johnson, N., & Kadoglou, N. (2018 ). Breast infection: A review of diagnosis and management practices. Eu r opean Jou rna l of Br east H ea lt h, 14(3 ), 136-143. doi:10.5152/ejbh.2018.3871 Ceulemans, M., Hompes, T., & Foulon, V. Mental health status of pregnant and breastfeeding women during the COVID-19 pandemic: A call for action. Int erna tional Jou r na l of G y nec o log y & Ob stet ric s . doi: 10.1002/ijgo.13295 Cullinan, K. (2020). Infant formula companies are ‘exploiting’ COVID-19 pandemic. Retrieved 19 July, 2 020. https://www.opendemocracy.net/en/5050/infant-formula-companies- are- exploiting-covid-19-p andemic/ . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 27 Department of Health. (2019). A us t ral ian Healt h Manag eme nt Plan for P andemic Inf luenza (AHMPP I) . Retrieved 19 July, 2020, from https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp -ahmppi.htm Department of Health. (2020a). C or onavi ru s (CO VID-19 ) Cur r e nt Sit uat i on and Case Num b e r s. Retrieved 19 July, 2020, from https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019- ncov-health-alert/coronavirus-covid-19-current-situation-and-case- numbers#daily-reported-cases Department of Health. (2020b). CO VI D - 19 N at ional H ealth P la n – P r im ar y Car e Package – MBS Tel ehealt h Ser vice s a nd In crea s ed P ractice In centi ve Payment s. Retrieved 19 July, 2020, from https://www.health.gov.au/resources/publications/covid-19-national- health-plan-primary-care-package-mbs-telehealth-services-and- increased-practice-incentive-paym ents Department of Health. (2020c). Fi rst c o nfirm ed c a se of novel co rona v ir u s in Aust ralia. Retrieved 19 July, 2020, from https://web.archi ve.org/web/20200215171557/https://www.health.go v.au/ministers/th e-hon-greg-hunt-mp/media/first-confirmed-case-of- novel- coron av iru s- in-au strali a Fahey, J. O., & Shenassa, E. (2013). Understanding and meeting the needs of women in the postpartum period: The perinatal maternal health promotion model. Jour nal of Midwif er y and W om en' s Heal th , 58 (6 ), 61 3 - 621. doi:10.1111/jmwh.12139 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 28 Forster, D. A., McLard ie-Hore, F. E., McLachlan, H. L., Davey, M.-A., Grimes, H. A., Dennis, C.-L., . . . Amir, L. H. (2019). Proactive peer (mother-to-mother) breastfeeding support by telephone (ringing up about breastfeeding early [RUBY]): A multicentre, unblinded, randomised controlled trial. ECli nicalM edicin e, 8 , 20-28. doi:10.1016/j.eclinm.2019.02.003 Ghebreyesus, T. A. (2020). WHO Dir e ct or-G en e r al' s op enin g re m a r ks at t h e m e di a bri efing on CO VID-19 - 11 M ar ch 20 20 . Retrieved 19 July, 2020 from https://www.who.int/dg/speeches/detail/who-director-general-s- opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 Gribble, K., P eterson, M., & Brown, D. (2019). Emergency preparedness for infant and young child feeding in emergencies (IYCF-E): An Australian audit of emergency plans and guidance. B M C Public H ealth, 19 (1), 1278. doi:10.1186 /s12889-019-7528-0 Gribble, K. D. (2014). Formula feeding in emergen ci es. In V. R. Preed y, R. R. Watson & S. Zibadi (Eds.), H an dbo o k of D i et ary and Nut rit io nal Asp ec t s of Bot tle Fee ding (pp. 143-161). Wageningen. The Netherlands: Wageningen Academic Publishers. Hsi eh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualit ative H e a lth Re sea r c h, 15 (9), 1277-1288. doi:10.1177 /1049732305276687 Infant and Young Child Feeding in Emergencies Core Group. (2017). In fant an d Young C hild F eedin g in Eme rge ncie s : O pe rat io nal Gui da nce for Eme rg enc y Relief St aff and Pr og ram Manag e rs, Ver s io n 3 . Oxford: IFE Core Group. Jang, M. J., Kim, Y. J., Hong, S., Na, J., Hwang, J. H., Sh in, S. M., & Ahn, Y. M. (2020). Positive association of breastfeeding on respiratory syncytial virus . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 29 infection in hospitalized infants: A multicenter retrospective study. Clini c al an d Expe r ime nt al P ediat rics, 63 (4), 135-140. doi:10.3345 /kjp.2019.00402 Leahy-Warren, P., McCarthy, G., & Corcoran, P. (2012). First-time mothers: social support, maternal parental self-efficacy and postnatal dep ression. J ou r nal of Clin ic al N u rs in g, 21 (3-4), 388-397. doi:10.1111/j.1365- 2702.2011.0 3701.x Livingstone, V. H., Willis, C. E., Abdel-Wareth, L. O., Th iessen, P., & Lockitch, G. (2000). Neonatal hypernatremic dehydration asso ciated with breast- feeding malnutrition: A retrospective survey. C anadian Medical Ass ociat io n Jou r nal 162 (5), 6 47-652. Manzoni, P ., Militello, M. A., Fiorica, L., Manzionna, M., & Cappiello, A. Impact of Covid-19 epidemics in pediatric morbidity and utilization of hospital pediatric services in Italy. Acta Paed iat ric a . doi:10.1111/apa.15435 McFadden, A., Gavine, A., Renfrew, M. J., Wade, A., Buchanan, P., Taylor, J. L., . . . MacGillivray, S. (2017). Support for healthy breastfeeding mothers with healthy term babies. Co chr an e Data ba s e of Sys t e m atic Re vie ws, 2 (2), CD001141. doi:10.1002/14651858.CD001141.pub5 McLaren, H . J., Wong, K. R., Nguyen, K . N. , & Mahamadachchi, K. N. D. (2020) . Covid-19 and women's triple burden: vignettes from Sri Lanka, Malaysia and Australia. Social Sci enc es, 9 (5), 87. doi:10.3390 /socsci9050087 National Health and Medical Research Council. (2012). Infan t F eedin g G uid e li n e s: Inf or ma tion fo r Healt h W o rk e rs . Retr ieved 19 July, 2020, fr om https://www.nhmrc.gov.au/about-us/publications/inf ant-feeding- guidelines-information-health-workers . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 30 Ogbo, F. A., Eastwood, J., Page, A., Arora, A., McKenzie, A., Jalaludin, B., . . . for the Early Years Research Group. (2017 ). Prevalence and determinants of cessation of exclusive breastfeeding in the early postnatal period in Sydney, Australia. I nte rnatio na l B r eastf e edin g Jou rn al , 1 2 , 16. doi:10.1186 /s13006-017-0110-4 Payne, S., & Quigley, M. A. (2016). Breastfeeding and infant hospitalisation: analysis of the UK 2010 Infant Feeding Survey. Mat e r na l a nd Child Nutriti on , 13(1), e12263. doi:10.1111/mcn.12263 Quigley, M. A., Carson, C., Sacker, A., & Kelly, Y. (2016). Exclusive breastfeeding duration and infant infection. Eu rop ean Jo u rnal of Clin ic a l Nut r it ion , 70 (12), 1420-1427. doi:10.1038/ejcn.2016.135 Regehr, C., Goldberg, G., & Hughes, J. (2002). Exposure to human tragedy, empathy, and trauma in ambulance paramedics. Ame rica n Jo ur nal of Orth ops ychiat ry , 72 (4 ), 505-513. do i:10.1037/0002-9432.72.4.505 Rossman, B., Engstrom, J. L., Mei er, P. P., Vonderheid , S. C., Norr, K. F., & Hill, P. D. (2011). “They’ve walked in my shoes”: Mothers of very low birth weight infants and their experiences w ith breastfeeding peer counselors in the neonatal intensive care unit. Jo u rna l of Huma n Lac t ation , 27 (1), 14-24. doi:10.1177 /0890334410390046 Salmon, L. (2015). Food security for infants and young children: An opportunity for breastfeeding policy? In t e r n atio nal B r ea stfe eding J ou r na l , 10 , 7. doi:10.1186 /s13006-015-0029-6 Ueda, T., Yokoyama, Y., Irahara, M., & Aono, T. (1994). Influence of psychological stress on suckling-indu ced pulsatile oxytocin release. O bst etric s a nd Gynec olog y, 84 (2), 259-262. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 31 UNICEF. (2008). Calmn es s a nd lo ve for di s pl aced b r eas t fee d in g mothe r s i n t he new tempo ra ry shelt e r . Retrieved 19 July, 2020, from https://web.archi ve.org/web/20090213232806/http://www.unicef.org /georgia/reallives_10695.html Victora, C. G., Bahl, R., Barros, A. J. D., França, G. V. A., Horton, S., Krasevec, J., . . . Rollins, N. C. (2016). Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lan c et , 387 (10017), 475-490. doi:10.1016 /S0140-6736 (15 )01024-7 Wagaman, M. A., Geiger, J. M., Shockley, C., & Segal , E. A. (2015). Th e role of empathy in bu rnout, compassion satisfaction, and secondary traumatic stress among social workers. Social Wor k , 60 (3), 201-209. doi:10.1093 /sw/swv014 Wei, M., Yuan, J., Liu, Y., Fu, T., Yu, X., & Zhang, Z. J. (2020). Novel Coronavirus infection in hospitalized infants under 1 year of age in China. JA MA. doi:10.1001 /jama.2020.2131 World Health Organization. (1993). B reastfe eding Cou n selling : A Traini n g Cou rs e, Traine r 's G u ide . Retrieved 18 July, 2 020, from https://www.who.int/maternal_child_adolescent/documents/who_cdr_9 3_3/en/ World Health Organization. (2020a, 27 May 2020). Cl i nical Managem en t of Sever e Acut e Re spi rato ry Infectio n ( SARI) when COV ID-19 Di s ea se is Suspec t e d : Int erim guidan ce . Retr ieved 17 July, 2020, fr om https://www.who.int/publications/i/item/clinical-management-of- covid-19 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint 32 World Health Organization. (2020b, 28 April 2020). Fr e que nt l y A s k e d Qu e s tio n s : Br eastfe eding and CO VID-19 Fo r H ea lth Car e W o rk ers . Retrieved 17 July, 2020, from https://www.who.int/docs/default-source/matern al- health/faqs-breastfeeding-and- covid-19.pdf?sfvrsn=d839e6 c0_1 World Health Organization. (2020c, 4 February 2020). Hom e Ca re for P at ients with Susp ected COV ID-19 Pr esent ing with Mil d Symp toms , an d Mana ge m en t of thei r C ont ac t s : In te rim Guidan c e . Retrieved 17 July, 202 0, from https://apps.who.int/iris/h andle/10665/331133?locale- attribute=es& World Health Organization. (2020d, 28 February 2020). Repo rt of t he WHO-C hina Joint Mi s sio n on Co rona vir us Dis e a se 2019 (C O VI D - 19 ) . Retrieved 17 July, 2020, from https://www.who.int/docs/default- source/coronaviruse/who-ch ina-joint-mission-on-covid-19-final- report.pdf . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2020. ; https://doi.org/10.1101/2020.07.18.20152256doi: medRxiv preprint