Since December 2019, we have been capturing Twitter data and employing social network analyses to examine the diffusion of pseudoscience and misinformation related to breastfeeding. We focused on breastfeeding as the death of 800,000 infants and 20,000 mothers may be prevented annually with universal, exclusive, and sustained breastfeeding (1, 2) . Recently, we were reviewing our latest capture and realized we had data on COVID-19 and breastfeeding, and as such this commentary relates to our "just in time" findings that may be of importance to the many agencies (governmental and non-governmental) and research groups who focus on diffusing information related to the pandemic.
The spread of health (mis)information particularly in times of crisis may cost human lives (3) . As such, it becomes even more critical to track and evaluate the extent to which messages from health authorities are accurately diffused. However, in-depth tracking is challenging at scale especially in online dynamic spaces. On Twitter alone, one of the largest social media platforms worldwide, estimates indicate that more than 410 Million tweets with #Covid19 or #Coronavirus have been shared to date. Collecting, analyzing, and reporting data of this breadth and depth is difficult given both the amount of data and the dynamic evolution of data over time. Rather than present the totality of data, we present findings about the diffusion of information related to "breastfeeding and COVID-19" that were unintentionally captured.
We have been harvesting all tweets and general user profile information from common breastfeeding hashtags (e.g. #breastfeeding, #normalizebreastfeeding, #breastmilk etc) resulting in a large dataset from which we now have two papers under review. The hashtags were a starting point that made sure we were locating our work in the correct research "location". In the midst of that work, on March 16 th , the WHO released its interim guidelines for breastfeeding during the COVID-19 outbreak (4), followed by UNICEF UK Baby Friendly Initiative on March 17 th (5) . As such, we ended up quite by accident capturing all tweets related to breastfeeding and #COVID-19 and #coronavirus. We conducted a social network analysis including several network metrics, structural communities (users who interact more frequently among each other than others) and key diffusers (top 5% of users with highest degree centrality), and then categorized users and tweets using inductive qualitative coding (6-8).
Our findings indicate a "breastfeeding and COVID-19" social network totaling 756 unique users, 880 tweets and 28 distinct communities (Figure 1 ; Table 1 Table 2 ). However, despite diffusion of accurate information, we did identify 6% of the tweets that contained scientifically unfounded recommendations and tweets for commercial use (e.g. promoting brands of breast pumps and feeding bottles).
In these difficult times when anecdotal health recommendations and misinformation may overwhelm the health care system and cause large numbers of preventable illness and death, it is heartening to learn that there is evidence of the flow of accurate information that supports the health of mothers and infants.
However, we must stand vigilant in our information battle with COVID-19 and continue to leverage analytical approaches that help identify if and when guidelines are tampered with before the problem and consequences become too big to fix.
Legend: Each dot represents a unique user that tweeted to the network until March 27, 2019. The lines between the dots reflect exchanged tweets (tweets, retweets, or mentions). The size of selected user names reflect central diffusers and brokers based their overall degree centrality and betweenness respectively. The color of the lines represent communities based on interaction behavior in the network. Map represents n=756 users, 880 tweets and 28 communities. Key diffusers: WHO, World Health Organization; Unicef UK, UNICEF UKbaby Friendly Initiative; United Nations news service; ihealth Visiting, Institute of Health Visiting in the United Kingdom, users 2 and 3, two academic researchers involved in public health policy with leadership positions; user 1 and 4, two international board certified lactation consultants (IBCLC). Key brokers: Bf USA, non-governmental agency Breastfeeding USA; California Coal., Breastfeeding Coalition; Kansas Coal., Kansas Breastfeeding Coalition; users 6 and 7, academic researchers in nursing and midwifery, user 3, one academic researcher in public health policy and leadership; user 5, a medical anthropologist, user 1, an IBCLC. 