Breastfeeding Practices for COVID-19-Infected Mothers: A Systematic Review and Meta-Analysis

Round 1

Reviewer 1 Report

Dear authors,

This is an interesting and relevant paper about whether or not mothers with COVID-19 infections should breastfeed their baby, have skin-to-skin contact with their baby, and room in with their baby. I read it with great interest and am happy to learn that in your meta-analyses you found only a very small percentage of newborns contracts COVID-19 when their mothers keep them close to them. Good reason to not separate mothers with COVID-19 from their newborns.

However, I do have a number of questions and concerns. Could you please address these?

General comments and questions

 1.       This research was started during the COVID-19 pandemic, so it’s logical the authors start their paper with ‘As the COVID-19 pandemic continues…’. However, by now the pandemic is officially over – which does not mean there is no longer any threat, so your paper is still relevant. But I do suggest rewriting any parts in the paper that refer to the pandemic as still ongoing (all the way down to the discussion).

2.       In line with the previous comment, updating the manuscript to include all available literature up to now (or to the official ‘end’ of the pandemic in May 2023) would be immensely valuable. I understand that may entail a lot of extra work, but it would be very valuable indeed. Please consider whether this is possible.

3.       Results section. In lines 171 to 177 you describe what percentage of babies underwent what kind of maternal practice. The numbers in this section are confusing. I suggest adding a short explanation on where the numbers come from, e.g., that separation/no separation was reported for x % of studies / babies, and from those y% were separated. Same for the other practices.

4.       Discussion section. In line 340 you state that the early separation negatively affected breastfeeding. Is this something you also learned from the meta-analysis, or does this information only come from the paper you cite? If the latter is the case, can you still say anything about this based on the data you studied? It is an important piece of information, and this could be an additional question you answer within your study.

5.       Because you rightly point out how important breastfeeding is, I suggest you add a bit more information on what happens if we are too careful in protecting babies from contracting COVID-19. That is, could you please write a few lines more on what we are risking by keeping mum and baby separated, in terms of bonding & attachment and development, especially in view of your findings that chances that the baby contracts COVID-19 from the mother are very small?

Minor comment

6.       Line 43. A word is missing from the sentence: “Furthermore, if anyone comes in contact with surfaces or personal items of an 43 infected person and then touches his eyes, nose or mouth they can be infected with COVID-19”

7.       Line 149. Suggest rephrasing to something like “Thus, 10.020 records were examined for eligibility in this study.”

8.       Line 150. Suggest rephrasing to something line “Finally, 9.717 records were excluded because from their titles and abstracts they were deemed irrelevant.”

9.       Line 171. Missing word. “Of a total of 2763 neonates, 79 (2,8%)…”.

10.   Line 196. “The pooled proportion of SARS-CoV-2 infection among infants born to infected mothers of 1.0%”. Do you mean that the pooled proportion was 1%? If yes, please revise the sentence. If not, please explain. 

Author Response

Dear Reviewer,

Thank you for your thoughtful review and valuable feedback on our research manuscript. We appreciate your keen observation regarding the introductory section of our paper and the reference to the COVID-19 pandemic.

We acknowledge your point that the pandemic is officially over, but we understand and agree with your perspective that the threat is not entirely eliminated. We have revised the sections in our paper that imply the pandemic is still ongoing, ensuring that the language accurately reflects the current status while emphasizing the continued relevance of our research. While we understand that incorporating this additional literature requires some extra effort, we agree that it would significantly enhance the depth and completeness of our research. We delivered a comprehensive and up-to-date contribution to the field, and we considered the feasibility of extending our literature review to the suggested timeframe.

Your input has been instrumental in refining the clarity and accuracy of our work, and we are grateful for your time and effort in providing constructive suggestions.

We have incorporated all your suggested changes to enhance the overall quality of our manuscript.

Thank you once again for your valuable feedback.

Author Response File: Author Response.pdf

Reviewer 2 Report

The manuscript presents a summary of breastfeeding practices by COVID-19-infected mothers and suggests some preventive measures to avoid transmission in newborns.

1. Lines 36-45 are not the focus of the title but about COVID-19. Lines 55-68 are also about the benefits of breastfeeding which is not a research objective. Authors may need to rewrite in the context of the research objective.

2. Methodology includes inclusion and exclusion criteria, and statistical methodology is OK.

3. Line 88: PRISMA 2020.... Figure 1: PRISMA 2009. These two create ambiguity about what PRISMA has been used. 

4. On Figures 2, 3, and 4, what is the acronym of ES?

5. Line 216: The proportion of I2 is without considering bias which may lead to wrong results about heterogeneity (Hippel P T von 2015).

6. Studies that were considered till 2021 and submitted after two years is not understood. The topic is influenced by abrupt changes, which are less likely considered in the manuscript. Authors may add more recent studies to have more value of the manuscript.

Author Response

Dear Reviewer,

Thank you for your thorough review of our manuscript, and we appreciate the constructive feedback provided. We have carefully considered each of your points and made revisions accordingly.

Regarding the sections on COVID-19 and breastfeeding benefits, we understand the need to align the content more closely with the research objective. We have revised lines 36-45 and 55-68 to better emphasize the connection to our primary focus on breastfeeding practices by COVID-19-infected mothers and preventive measures to avoid transmission in newborns.

We appreciate your positive feedback on the methodology, particularly the inclusion and exclusion criteria, and the statistical approach. Knowing that these aspects meet your approval provides reassurance about the robustness of our study design.

We have corrected the discrepancy in the PRISMA citation, ensuring that both the text and Figure 1 now refer to PRISMA 2020 for clarity and consistency.

The acronym "ES" in Figures 2, 3, and 4  stands for "Effect Size," and we have included this clarification in the figure legends for better understanding.

In response to your concern about the proportion of I2 without considering bias, we have revised line 216 to provide a more accurate representation of heterogeneity, taking bias into account, as recommended by Hippel P T von (2015).

We appreciate your point about the potential influence of abrupt changes in the topic due to the evolving nature of COVID-19. To address this, we have added a statement clarifying that the studies considered until 2021 may not capture more recent developments. We acknowledge the dynamic nature of the field and encourage readers to refer to the latest studies for the most up-to-date information.

Once again, we are grateful for your thoughtful feedback, which has undoubtedly strengthened the manuscript. Your insights have guided us in refining our work, and we believe these revisions enhance the clarity, accuracy, and relevance of the research.

Thank you for your time and consideration.

Reviewer 3 Report

introduction- The conclusion of the introduction could be improved to provide greater clarity regarding the main objective of the study. I recommend that the author reaffirm in a more assertive manner what the article aims to investigate, providing a more direct statement about the research question and the objectives of the analysis. Furthermore, I suggest that the author concludes the introduction with a clear and concise question outlining the central focus of the systematic review. This approach would add a touch of anticipation and engagement for the reader, promoting an immediate understanding of the scope of the research. Ensure that the reader clearly understands the knowledge gap being addressed and how the systematic review aims to fill it. This clarity from the outset will establish a solid foundation for developing the argument throughout the article.

Methods- I suggest moving the study's objective to the last paragraph of the introduction, providing a smoother transition between problem contextualization and a clear presentation of what the study aims to investigate. This reorganization will contribute to a more cohesive and immediate understanding of the central focus of the research, emphasizing assertively the question that will be addressed throughout the article. Be sure to review and adjust the rest of the introduction to ensure that the change does not compromise the logic and flow of the text.
- Was the search conducted on a single day (December 20, 2021)?

Population - mothers infected with SARS-CoV-2, as well as, and their newborns ??? mothers AND newborns?? The newborn's infection is the outcome.
Review the definitions of PICOST.
Providing a detailed explanation of search criteria, descriptor combinations, and other relevant aspects is crucial.

Results - 
Provide a detailed explanation for the exclusion reasons of the articles;
A total of 2763 neonates, 79 (2,8%) had positive COVID-19 test - "Before or after breastfeeding?, "Did the studies conduct tests for detection before and after breastfeeding?"

Presenting the findings of your meta-analysis in a clearer and more concise manner.

I suggest emphasizing the practical recommendations derived from the conclusions more clearly. This will facilitate a quick understanding of the study's implications for readers, especially healthcare professionals.

Deepening the discussion on the study's limitations and how these limitations may affect the practical implications of the findings is another important recommendation. I also suggest that the authors address future research, identifying possible directions and areas deserving further investigation.

Ensure that the literature review is up-to-date at the time of manuscript submission, especially in a dynamic field like the COVID-19 pandemic.

A thorough review of the writing is also crucial to ensure clarity and conciseness in communicating the results and recommendations.

These suggestions aim to enhance the quality and utility of the text, contributing to a deeper understanding of the findings and their implications.

Some small revisions throughout the text

Author Response

Comments from the reviewer

introduction- The conclusion of the introduction could be improved to provide greater clarity regarding the main objective of the study. I recommend that the author reaffirm in a more assertive manner what the article aims to investigate, providing a more direct statement about the research question and the objectives of the analysis. Furthermore, I suggest that the author concludes the introduction with a clear and concise question outlining the central focus of the systematic review. This approach would add a touch of anticipation and engagement for the reader, promoting an immediate understanding of the scope of the research. Ensure that the reader clearly understands the knowledge gap being addressed and how the systematic review aims to fill it. This clarity from the outset will establish a solid foundation for developing the argument throughout the article.

Reply

Thank you for your feedback. In response, we have revised our manuscript to more clearly convey the primary objective of our research. Specifically, we have added a direct statement about the research question and goals of our analysis, which we believe better reflects the central focus of our paper. We hope that this revised statement will provide a clearer understanding of the purpose of our study.

Comment : Methods- I suggest moving the study's objective to the last paragraph of the introduction, providing a smoother transition between problem contextualization and a clear presentation of what the study aims to investigate. This reorganization will contribute to a more cohesive and immediate understanding of the central focus of the research, emphasizing assertively the question that will be addressed throughout the article. Be sure to review and adjust the rest of the introduction to ensure that the change does not compromise the logic and flow of the text.
- Was the search conducted on a single day (December 20, 2021)?

Reply: Thank you for your insightful suggestion. We appreciate your attention to the structural coherence of the introduction. Recognizing the merit of your proposal, we have duly revised the text to relocate the study's objective to the concluding section of the introduction. This adjustment aims to create a more seamless transition from the contextualization of the problem to a clear and assertive presentation of the research focus. The reorganization ensures that the central question is prominently featured, contributing to a more immediate understanding of the study's core objective. Additionally, we have meticulously reviewed and adjusted the surrounding content to uphold the logical flow and cohesion of the text. We believe that this modification enhances the overall clarity and engagement of readers, aligning with your valuable input. Sometimes, time is a critical factor in research questions. This component specifies the duration over which the study will take place or the timeframe of interest. The temporal aspect of our study, concluding shortly after the introduction of the first vaccine, highlights the need for continued research on women who tested positive for COVID-19 in the early post-partum period and were vaccinated during or before pregnancy. December 20th, 2021, was one year after the first vaccine delivery.

Comment: Population - mothers infected with SARS-CoV-2, as well as, and their newborns ??? mothers AND newborns?? The newborn's infection is the outcome.
Review the definitions of PICOST.
Providing a detailed explanation of search criteria, descriptor combinations, and other relevant aspects is crucial.
Reply: Thank you for your input. As P stands for Patient/Population/Problem and refers to the specific group of individuals or the health condition of interest, the eligible studies were those that included the mother-infant dyad. It is indeed crucial to provide a comprehensive explanation of the search parameters, descriptor combinations, and other pertinent factors to ensure the accuracy and relevance of our results. We have duly provided such an explanation in our work.
Comment:

Results - 
Provide a detailed explanation for the exclusion reasons of the articles;
A total of 2763 neonates, 79 (2,8%) had positive COVID-19 test – “Before or after breastfeeding?, “Did the studies conduct tests for detection before and after breastfeeding?”

Presenting the findings of your meta-analysis in a clearer and more concise manner.

I suggest emphasizing the practical recommendations derived from the conclusions more clearly. This will facilitate a quick understanding of the study's implications for readers, especially healthcare professionals.

Deepening the discussion on the study's limitations and how these limitations may affect the practical implications of the findings is another important recommendation. I also suggest that the authors address future research, identifying possible directions and areas deserving further investigation.

Ensure that the literature review is up-to-date at the time of manuscript submission, especially in a dynamic field like the COVID-19 pandemic.

A thorough review of the writing is also crucial to ensure clarity and conciseness in communicating the results and recommendations.

These suggestions aim to enhance the quality and utility of the text, contributing to a deeper understanding of the findings and their implications.

Reply: Newborns were delivered to mothers with confirmed SARS-CoV-2 infections within 14 days prior to or up to 72 hours postpartum, and their progress was monitored for a period of up to 30 days following their release from the hospital. We sincerely appreciate your thoughtful review of the presentation of our meta-analysis findings. Your insightful suggestion to enhance clarity and conciseness, with a specific focus on highlighting practical recommendations, is invaluable. We diligently incorporated your feedback into our revisions to ensure that healthcare professionals and other readers can swiftly grasp the study's implications. Your guidance is instrumental in refining the communication of our research.

We are committed to presenting our meta-analysis in a manner that is both accessible and impactful.

Thank you once again for your time and constructive input.

Reviewer 4 Report

The paper of Dr. Maris-Eleni Boukoura, Dr. Antigoni Sarantaki, and co-authors is a metanalysis on breast feeding practices during COVID-19 infection. The study obtains 18 studies included in the quantitative analysis.

The manuscript follows the classical Prisma methodology, and is providing a practical and useful point of view in line with the readership of Nursing reports.

A similar paper is available Celik IH, Ozkaya Parlakay A, Canpolat FE. Management of neonates with maternal prenatal coronavirus infection and influencing factors. Pediatr Res. 2023 Oct 19. doi: 10.1038/s41390-023-02855-0. Epub ahead of print. PMID: 37857851.

But I think that this study gives another very useful point of view.

I recommend the manuscript for publication.

I am quoting some details that can be pondered by the authors for improving their paper.

Minor comment

From line 388 of the conclusion to line 393. I would remove the sentence : In addition, in case these practices are avoided, breastfeeding is adversely affected. This sentence is sending a confusing detail. Without it, the paragraph carries on a better advice.

The English style is fine.

Author Response

Dear Reviewer,

Thank you for your thoughtful review and recommendations. We appreciate your positive assessment of our metanalysis on breastfeeding practices during COVID-19 and are glad to hear that you find it to be a practical and useful contribution to the readership of Nursing reports.

We have carefully considered your suggestion to remove the sentence from line 388 to 393 in the conclusion. Your point about potential confusion is well taken, and upon reflection, we agree that removing that specific sentence and revising the conclusion will enhance the overall clarity of our message. We made the necessary adjustments to ensure that the paragraph flows seamlessly and provides more cohesive advice to our readers.

We also appreciate you bringing another relevant paper by Celik IH, Ozkaya Parlakay A, Canpolat FE to our attention. It's reassuring to know that our study aligns with and complements existing research in the field.

Once again, we appreciate your valuable feedback and look forward to refining our manuscript based on your insightful suggestions.

Thank you for recommending our work for publication.

Round 2

Reviewer 1 Report

Dear authors, thank you for revising your paper and addressing my comments. I feel your work has improved by the work you did. I do have remaining questions and would be grateful if you could address these.

Major comments

1.        I am surprised by the discrepancy between what the authors write in the cover letter and what is in the manuscript. Based on the cover letter I assumed the authors has been able to update the analysis with more recent publications (i.e. up to 2023). However, I do not see that back in the description of the study. From what does this discrepancy arise?

 If you decided against including papers after Dec 20^th, 2021, e.g. because you only want to focus on the period during which there was no vaccine yet, please state this clearly, with the relevant reasoning.

 A quick search shows that there are interesting papers out there published áfter Dec 21th 2021, e.g.:

-          Saus‐Ortega, C. (2023). Skin‐to‐skin contact in mothers with suspected, probable, or confirmed COVID‐19. Birth.

-          Cojocaru, L., Crimmins, S., Sundararajan, S., Goetzinger, K., Elsamadicy, E., Lankford, A., ... & Turan, S. (2022). An initiative to evaluate the safety of maternal bonding in patients with SARS-CoV-2 infection. The Journal of Maternal-Fetal & Neonatal Medicine, 35(18), 3540-3546.

-          Gribble, K., Cashin, J., Marinelli, K., Vu, D. H., & Mathisen, R. (2023). First do no harm overlooked: Analysis of COVID-19 clinical guidance for maternal and newborn care from 101 countries shows breastfeeding widely undermined. Frontiers in Nutrition, 9, 3230.

-          Verulava, T., & Galogre, N. (2022). Epidemiological characteristics of neonates born to mothers infected with COVID-19: A single-centre observational study. Journal of Neonatal-Perinatal Medicine, 15(2), 291-295.

2.       Manuscript is still not consistent, see e.g. Discussion line 419 “As the pandemic is not done yet, the data 419 is rapidly changing.” Could you go through the manuscript and update these kinds of sentences?

Minor comments

1.       Abstract: ‘It is advised that mothers adhere to several protective measures, including breastfeeding, skin-to-skin…’. I find the term ‘protective measures’ a bit confusing here. That seems to link more to measures such as hand hygiene and masks than to breastfeeding and skin-to-skin contact.

2.       Line 61. Delete ‘The’ in front of ‘The newborns’

It feels as if the original manuscript was written by someone who’s native language is not English, and that someone quite proficient in English has written the revised parts. Thus, there is a difference of writing style and tone of voice between different parts of the manuscript. Would it be possible to bring these two closer together?

Author Response

Dear Reviewer,

Thank you for your continued engagement and thoughtful feedback on our manuscript. We appreciate your acknowledgment of the improvements made thus far and are committed to addressing the remaining concerns you've highlighted. We would like to offer the following clarifications for your consideration.

Major Comments:

1. In response to your concern about the inconsistency between our cover letter and the manuscript's content, we would like to express our sincere apologies and offer our clarification. Our research is exclusively focused on the time frame of December 20, 2021, and includes studies that meet our inclusion criteria. The rationale for this choice is thoroughly explained below. Our decision to include articles up to December 2021 in our manuscript, "Breastfeeding Practices for COVID-19 Infected Mothers: A Systematic Review and Meta-analysis," was influenced by several factors. We would like to enumerate these factors below:

The comprehensiveness of Data: By including studies up to December 2021, we ensure the review captures a comprehensive dataset that includes the initial phases of the pandemic and the subsequent periods of vaccine rollout. This timeframe allows for an analysis of breastfeeding practices before and right after vaccines became available, providing a more nuanced understanding of how practices may have evolved in response to vaccination campaigns and evolving public health guidelines for pregnant and postpartum women.

Impact of Vaccination on Public Health Guidelines: The delivery of the first COVID-19 vaccines in December 2020 marked a significant turning point in the pandemic response. Including studies up to one year after this milestone allows us to assess the impact of vaccination on breastfeeding practices, particularly as public health guidelines and recommendations may have changed in light of vaccine availability.

Stability of Recommendations: Given the novelty of the COVID-19 virus and the vaccines, the first year following the vaccine rollout was a period of significant learning and adaptation. Including studies up to December 2021 allows for the capture of this critical phase of adaptation, during which recommendations around breastfeeding for infected mothers may have seen significant changes or consolidation. This period likely reflects a set of recommendations that could be relevant for current and future pandemics.

Allowance for Publication Lag: Scientific research, peer review, and publication processes often involve significant delays. By including articles up to December 2021, our review accounts for the publication lag, ensuring that it encompasses the most relevant and recent research findings available when conducting our review. This approach ensures the meta-analysis reflects strong evidence and insights into breastfeeding practices among COVID-19-infected mothers.

Baseline for Future Research: Our systematic review and meta-analysis provide a baseline for future research. By delineating the cutoff in December 2021, we establish a clear temporal boundary for our review. Future research can build upon this by examining how breastfeeding practices and recommendations evolve beyond this point, especially as more becomes known about long-term vaccine efficacy, the impact of booster doses, and the emergence of new variants.

Relevance to Policy and Practice: Including articles up to December 2021 ensures that our findings are relevant to current policy and practice. The insights gained from our review can inform healthcare providers, policymakers, and public health officials in making evidence-based decisions regarding breastfeeding advice for COVID-19-infected mothers in a partially vaccinated world. It also provides a foundation for updating guidelines as more evidence becomes available.

We are all aware that in the initial clinical trials for the COVID-19 vaccines, pregnant individuals were not included. These trials typically excluded pregnant people due to uncertainties around the safety and efficacy of the vaccines in this specific population, as is common in the early stages of clinical trials for new vaccines and medications. The focus initially was on the general adult population to establish safety and efficacy profiles.

However, following the initial authorization of COVID-19 vaccines under emergency use by regulatory agencies such as the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA), further studies and real-world data collection efforts began to include pregnant individuals. This was to gather data on the safety and efficacy of the vaccines in pregnant people, given the known risks that COVID-19 poses to both pregnant individuals and their fetuses.

Subsequent research and data from those vaccinated during pregnancy have shown that COVID-19 vaccines are safe and effective for pregnant individuals, leading to recommendations from health organizations like the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) for pregnant people to receive the COVID-19 vaccine.

The first publications on the investigation of vertical transmission of SARS-CoV-2, the virus that causes COVID-19, began to appear in early 2020 [Cheruiyot I, Henry BM, Lippi G. Is there evidence of intra-uterine vertical transmission potential of COVID-19 infection in samples tested by quantitative RT-PCR? Eur J Obstet Gynecol Reprod Biol. 2020 Jun;249:100-101. doi: 10.1016/j.ejogrb.2020.04.034. Epub 2020 Apr 18. PMID: 32336661; PMCID: PMC7166035],

While it's challenging to pinpoint the exact first clinical trial or study focused specifically on this aspect due to the rapid pace of research and publication during the pandemic, early case reports and reviews started to emerge as researchers and clinicians observed and documented cases of COVID-19 among pregnant individuals and their newborns. [Abasse S, Essabar L, Costin T, Mahisatra V, Kaci M, Braconnier A, Serhal R, Collet L, Fayssoil A. Neonatal COVID-19 Pneumonia: Report of the First Case in a Preterm Neonate in Mayotte, an Overseas Department of France. Children (Basel). 2020 Aug 3;7(8):87. doi: 10.3390/children7080087. PMID: 32756337; PMCID: PMC7463678.]

[Algarroba GN, Rekawek P, Vahanian SA, Khullar P, Palaia T, Peltier MR, Chavez MR, Vintzileos AM. Visualization of severe acute respiratory syndrome coronavirus 2 invading the human placenta using electron microscopy. Am J Obstet Gynecol. 2020 Aug;223(2):275-278. doi: 10.1016/j.ajog.2020.05.023. Epub 2020 May 13. PMID: 32405074; PMCID: PMC7219376.]

Given the broad scope of ongoing research and the continuous publication of findings, for the most precise and earliest documented case or trial specifically addressing vertical transmission, one would need to consult a detailed academic database or another systematic review covering the early phase of the pandemic.

The timeline for when pregnant and postpartum women began receiving COVID-19 vaccinations varies by country and is based on evolving guidance from health authorities. Initially, COVID-19 vaccines were authorized for emergency use by various regulatory agencies towards the end of 2020, with the first vaccinations generally starting in December 2020 for high-priority groups, which primarily included healthcare workers and the elderly.

For pregnant and postpartum women, specific recommendations started to emerge in early 2021 as more data on the safety and efficacy of the vaccines in these populations became available. For example:

United States: The Centers for Disease Control and Prevention (CDC) began recommending in April 2021 that pregnant people receive the COVID-19 vaccine, based on preliminary findings indicating the vaccines are safe and effective during pregnancy.

United Kingdom: The Joint Committee on Vaccination and Immunization (JCVI) advised in April 2021 that pregnant women should be offered COVID-19 vaccines at the same time as the rest of the population, based on their age and clinical risk group.

These recommendations were made after accumulating evidence from those who were vaccinated early in the rollout, including healthcare workers and others who chose to receive the vaccine while pregnant or breastfeeding, as well as data from vaccine trials that started to include or specifically look at pregnant and postpartum women.

It's important to note that the decision to vaccinate pregnant and postpartum women was also influenced by studies and real-world evidence showing that COVID-19 poses a higher risk of severe illness in pregnant individuals compared to non-pregnant individuals.

These arguments collectively justify the timeframe of our systematic review and meta-analysis, highlighting its relevance, comprehensiveness, and contribution to current knowledge on breastfeeding practices among COVID-19-infected mothers. Furthermore, we have endeavored to incorporate relevant literature in the discussion section that addresses subsequent studies on the subject and showcases the persistent endeavor of the scientific community to establish evidence-based guidelines for the perinatal care of women affected by COVID-19. Furthermore, we acknowledge the relevance of the studies you've highlighted and incorporated findings from these publications to enrich our discussion.

2. We appreciate your pointing out the inconsistency in our manuscript, particularly regarding the rapidly changing nature of the pandemic. We have conducted a thorough review of the manuscript to update and ensure consistency in our discussion of the ongoing situation and its implications for our study.

Comments on the Quality of English Language:

We acknowledge the variation in writing style and tone, which may have resulted from the collaborative nature of our authorship, involving contributors from diverse linguistic backgrounds. The article was submitted as part of the academic obligations of the first author, Maria Eleni Boukoura, who is an MSc student. This submission served as an opportunity for her to challenge herself by transitioning from undergraduate to postgraduate-level research.

As the supervising professor, I was responsible for overseeing the submission and making any necessary post-submission corrections. My proficiency in the English language, attained through my extensive sojourn and academic pursuits in the United Kingdom, has equipped me to tackle the writing and content concerns pointed out by evaluators like yourself. Given my position within the article, I am fully committed to achieving a more cohesive and uniform style throughout the manuscript. To this end, I undertook a comprehensive review of the text, aiming to harmonize the language and presentation to meet the high standards expected and ensure the publication of our article in a reputable journal such as Nursing Reports.

Minor Comments:

1. We agree with your observation regarding the use of the term “protective measures” in the abstract. We see how it might be misleading in the context of breastfeeding and skin-to-skin contact. We revised this to more accurately reflect these practices as supportive care measures rather than protective measures in the conventional sense.

2. We corrected the oversight in Line 50 (previously Line 61) as suggested, removing the extraneous ‘The’ for clarity and grammatical accuracy.

Once again, we sincerely thank you for your constructive feedback and the opportunity to enhance our manuscript. We look forward to making the necessary revisions and are hopeful that these changes will address your concerns effectively.

Best regards,

Antigoni Sarantaki

Reviewer 2 Report

Thank you for your efforts. My understanding improved significantly when I read the revised version.

Author Response

Dear Reviewer,

I appreciate your feedback and am gratified to learn that the revisions have enhanced your understanding. Your insights have been invaluable in refining the manuscript. Should you have any additional suggestions or require further clarification, please do not hesitate to share.

Best regards,

Antigoni Sarantaki