Newborns of COVID+ moms

Clinical Question

What are the current guidelines for caring for newborns of COVID positive moms?

Key Findings

  • Data is currently limited, however newborns born to COVID-19 positive mothers do appear at risk of adverse outcomes from acquiring infection.
  • There is very limited evidence suggesting that vertical transmission of infection can occur.
  • CDC official guidelines have recommended “considering temporarily separating” since “transmission after birth via contact with infectious respiratory secretions is a concern”
  • There is no evidence of viral transmission through breast milk
  • Best practices such as mask-wearing and hand hygiene can decrease risk of newborn infection.

Summary of Information

Knowledge regarding management of newborns to COVID19 positive mothers is not well established and continues to evolve. Although data are currently limited, in limited size studies neonates born to affected mothers appear to be at risk for adverse outcomes including but not limited to fetal/respiratory distress, thrombocytopenia, abnormal liver function, and death, with no existing evidence for vertical transmission (transmission directly from the mother to an embryo, fetus, or baby during pregnancy or childbirth) thus far.[1] CDC official guidelines have recommended “considering temporarily separating” since “transmission after birth via contact with infectious respiratory secretions is a concern”.[2] Official institution guidelines throughout the nation vary, with some including Johns Hopkins ultimately leaving the decision to the mother.

Mother-Baby Contact Guidelines

Consider using physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the ill mother. If no other healthy adult is present in the room to care for the newborn, a mother who has confirmed COVID-19 or is a PUI (person under investigation) should put on a facemask and practice hand hygiene before each feeding or other close contact with her newborn. The CDC does not specify which type of facemask to wear. The facemask should remain in place during contact with the newborn. These practices should continue while the mother is on transmission-based precautions in a healthcare facility.[2] Maternal-infant separation at birth may have long lasting consequences, though the effects on bonding and infant psyche are not entirely known. The health risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the healthcare team, with the decision left to the mother.

American Academy of Pediatrics Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases have outlined the following while OUTSIDE of a healthcare facility[3]:

For 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.
For 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.
For 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.

Breastfeeding Guidelines

Mother should be encouraged to express their breast milk to establish and maintain milk supply, with a dedicated breast pump if possible, with proper hand hygiene and disinfection of pump per instrument instructions. If the mother wishes to feed at the breast, she should put on a facemask and practice hand hygiene before each feeding.[2][4] In limited studies on women with COVID-19 and another coronavirus infection, Severe Acute Respiratory Syndrome (SARS-CoV), the virus has not been detected in breast milk.

Infant Testing

Clinical manifestations may mirror the adult presentation of infection with varying degrees of severity and an incubation period generally no longer than 14 days. Confirmation of infection requires detection of 2019-nCoV nucleic acid or viral gene sequencing in samples from the upper respiratory tract (pharyngeal swab, nasal swab) or lower respiratory tract (sputum, alveolar lavage fluid, tracheal intubation and secretion).[5]

Medical Management Guidelines

The first symptoms of the neonates of 10 (+) SARS-CoV2 mothers in a 10 case series after admission were mainly respiratory distress (n=6), followed by gastrointestinal symptoms (n=4), fever (n=2), increased heart rate (n=1), and vomiting (n=1). Thus, respiratory rate, body temperature, heart rate, and gastrointestinal symptoms and signs should be closely monitored, and there should be early intervention for patients with abnormal findings.[1][6]

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Selected Info of Neonates from 10+ SARS-CoV2+ mothers, Zhu et al.

For positive testing neonates, no effective anti-coronal drugs currently exist, and where appropriate IV Immunoglobulin may be used.[1][5] Suspected/confirmed neonatal cases should be isolated on the neonatal ward with appropriate contact precautions. For children with severe acute respiratory distress syndrome manifested by "white lung", high-dose lung surfactants, nitric oxide inhalation, and high-frequency oscillatory ventilation (HFOV) may be effective. Critical cases need to be implemented with continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) treatment when necessary.[5]

Discharge Guidelines

For infants with pending or negative testing for SARS-CoV2, caretakers should follow guidance on reducing risk of transmission to infants.

For infants with positive testing, China Contemporary Pediatrics Editorial Committee Working Group on Prevention and Control of Perinatal Neonatal Coronavirus Infection[5] proposed the following for discharge criteria depending on the presentation:

Asymptomatic infection: upper respiratory tract specimens (nasopharyngeal swabs + pharyngeal swabs) are collected every 2 days to detect 2019-nCoV, until the results are negative 2 times (at least 24 hours apart).

Upper respiratory tract infection: The body temperature returned to normal for more than 3 days, the symptoms improved, AND the upper respiratory tract secretion specimens (nasopharyngeal swabs + pharyngeal swabs) were negative for 2019-nCoV 2 consecutive times (at least 24 hours apart) .

Pneumonia: the body temperature returned to normal for more than 3 days, respiratory symptoms improved, and pulmonary imaging showed obvious absorption of inflammation. Both upper respiratory tract specimens (nasopharyngeal swabs + throat swabs) collected 2 consecutive times (at least 24 hours apart) and lower respiratory tract specimens (sputum) were tested negative for 2019-nCoV.

Author Information

Authors: Rohith Voora, MS3; Alex Qian, MS3; UC San Diego School of Medicine
Completed on: April 2, 2020
Last updated: not yet revised

Reviewed by: Gary Smithson MD
Reviewed on: April 7, 2020

This summary was written as part of the CoRESPOND Earth 2.0 COVID-19 Rapid Response at UC San Diego. For more information about the project, please visit http://earth2-covid.ucsd.edu

References

  1. Zhu H, Wang L, Fang C, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr. 2020;9(1):51-60.  [PMID:32154135]
  2. CDC. Coronavirus Disease 2019 (COVID-19): Consideration for Inpatient Obstetric Healthcare Setting. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html. Published February 11, 2020. Accessed April 19, 2020.
  3. Puopolo KM, Hudak ML, Kimberlin DW, Cummings J. INITIAL GUIDANCE: Management of Infants Born to Mothers with COVID-19. American Academy of Pediatrics
  4. CDC. Pregnancy and Breastfeeding. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html. Published February 11, 2020. Accessed April 19, 2020.
  5. Working Group for the Prevention and Control of Neonatal 2019-nCoV Infection in the Perinatal Period of the Editorial Committee of Chinese Journal of Contemporary Pediatrics. [Perinatal and neonatal management plan for prevention and control of 2019 novel coronavirus infection (1st Edition)]. Zhongguo Dang Dai Er Ke Za Zhi Chin J Contemp Pediatr. 2020;22(2):87-90.
  6. Chen Y, Peng H, Wang L, et al. Infants Born to Mothers With a New Coronavirus (COVID-19). Front Pediatr. 2020;8:104.  [PMID:32266184]