New AAP guidance released today addresses the care of infants whose mothers have suspected or confirmed coronavirus disease 2019 (COVID-19).
The report “Initial Guidance: Management of Infants Born to Mothers with COVID-19” along with a Q&A covers precautions for birth attendants, rooming-in, breastfeeding, testing, neonatal intensive care, visitation and hospital discharge.
“Although evidence is accumulating to inform adult care, relatively little published data is currently available to guide the care of infants born to women who have — or are suspected to have — COVID-19 around the time of delivery,” said Karen M. Puopolo, M.D., Ph.D., FAAP, a lead author of the guidance and member of the AAP Committee on Fetus and Newborn. “Despite this, neonatal clinicians are currently faced with managing this scenario on a daily basis.”
Members of the AAP Section on Neonatal-Perinatal Medicine, Committee on Infectious Diseases and Committee on the Fetus and Newborn evaluated published reports from China that describe deliveries from pregnant women with COVID-19 and provide information on neonatal outcomes.
The groups combined this information with “the evolving understanding of how the SARS-CoV-2 virus is transmitted person-to-person and how long infected persons are infected, and with current guidance provided by the Centers for Disease Control and Prevention,” Dr. Puopolo said.
They will continue to follow published reports and update guidance as needed.
Key initial guidance
Precautions for birth attendants: Staffattending a birth when the mother has COVID-19 should use gown and gloves, with either an N95 respiratory mask and eye protection goggles or with an air-purifying respirator that provides eye protection. The protection is needed due to the likelihood of maternal virus aerosols and the potential need to perform newborn resuscitation that can generate aerosols.
Rooming-in for mothers and well newborns: While difficult, temporary separation minimizes the risk of postnatal infant infection from maternal respiratory secretions. If possible, admit the infant to an area separate from unaffected infants, and wear gowns, gloves, eye protection goggles and standard procedural masks for newborn care.
If the center cannot place the infant in a separate area — or the mother chooses rooming-in despite recommendations — ensure the infant is at least 6 feet from the mother. A curtain or an isolette can help facilitate separation.
Breastfeeding: Because studies to date have not detected the virus in breast milk, mothers may express breast milk after appropriate breast and hand hygiene. Caregivers who are not infected may feed the breast milk to the infant. Mothers who request direct breastfeeding should comply with strict preventive precautions that include use of a mask and meticulous breast and hand hygiene.
Intensive care: Infants requiring neonatal intensive care ideally should be admitted to a single-patient room with the potential for negative room pressure or other air filtration system. If unavailable, or if the center must cohort multiple COVID-exposed infants, there should be at least 6 feet between infants and/or they should be placed in air temperature-controlled isolettes.
For the care of infants requiring continuous positive airway pressure or any form of mechanical ventilation, staff should wear a gown and gloves, with either an N95 respiratory mask and eye protection goggles, or with an air-purifying respirator that provides eye protection.
Testing for COVID-19: If available, testing of well newborns can facilitate plans for their care after hospital discharge. Bathe newborns after birth to remove virus potentially present on skin surfaces. Test first at around 24 hours of age and repeat at around 48 hours of age unless the infant has been discharged home, as follows:
Use one swab to sample first the throat and then the nasopharynx. Place single swab in one viral transport media tube and send it to the lab for molecular testing.
For infants who are positive on their initial testing, follow-up testing of combined throat/nasopharynx specimens should be done at 48- to 72-hour intervals until there are two consecutive negative tests.
Hospital discharge: Newborns should be discharged based on a center’s normal criteria.
Infants who cannot be tested should be treated as if they are positive for the virus for the 14-day observation period. The mother should continue to maintain precautions until she meets the criteria for non-infectivity.
Positive test results:If an infant tests positive for COVID-19 but does not display symptoms, plan for frequent outpatient follow-up (phone, telemedicine or in-office) through 14 days after birth. Follow precautions to prevent household spread from infant to caregivers.
Negative test results:Discharge the infant, ideally, to the care of a designated healthy caregiver. The mother should maintain a 6-foot distance when possible and use a mask and hand hygiene when directly caring for the infant until either a) she has been afebrile for 72 hours without use of antipyretics and b) at least seven days have passed since her symptoms first appeared; or she has negative results from a COVID-19 test from at least two consecutive specimens collected 24 or more hours apart.
Other caregivers in the home who are persons under investigation (PUIs) for COVID-19 should use standard procedural masks and hand hygiene when they are within 6 feet of the newborn until their own status is resolved.
Education should be provided to all caregivers and include written as well as verbal education in person, via telephone or virtually. Utilize interpreter services when appropriate.
Visitation in neonatal intensive care units (NICUs): Mothers who have COVID-19 should not visit their infants in NICUs until all of the following conditions are met:
- resolution of fever without the use of antipyretics for at least 72 hours and improvement (but not full resolution) in respiratory symptoms, and
- negative results of a COVID-19 test from at least two consecutive specimens collected 24 or more hours apart.
Non-maternal parents who are PUIs should not visit infants requiring ongoing hospital care until they are determined to be uninfected by molecular testing and/or clinical criteria. Non-maternal parents who develop symptoms of disease and are confirmed to have COVID-19 also must meet the requirements above before visiting infants in the NICU.
This initial guidance does not address management of pregnant women. The American College of Obstetricians and Gynecologists has issued a Practice Advisory addressing management of pregnant women at https://bit.ly/2UAoZxu.
Clinicians are asked to participate in the National Registry for Surveillance and Epidemiology of Perinatal COVID-19 Infection. Register at https://redcap.ctsi.ufl.edu/redcap/surveys/?s=FY44J48D9F.
Copyright © 2020 American Academy of Pediatrics, via AAP News (April 2, 2020).