What are the AAP guidelines for the management of infants born to mothers with coronavirus disease 2019 (COVID-19)?

Answer

The American Academy of Pediatrics Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases initially issued guidance on the management of infants born to mothers with coronavirus disease 2019 (COVID-19) on April 2, 2020.^[21] These guidelines have since been revised as more data have emerged.^[71]

Early evidence has shown low rates of peripartum severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission and uncertainty concerning in utero viral transmission. To date there does not seem to be any conclusive evidence indicating vertical transmission of COVID-19 from infected pregnant mothers to their neonates.^[20]

Neonates can be infected by SARS-CoV-2 after birth. Because of their immature immune systems, they are vulnerable to serious respiratory viral infections. SARS-CoV-2 may be able to cause severe disease in neonates. A recent review of neonates born to mothers with perinatal confirmed COVID-19 infection showed that severe maternal disease can lead to fetal distress, premature delivery, and other adverse outcomes. These small case series are predominantly out of China.^[72]

Another case series of 33 infants born to mothers with COVID-19 from China also described a varying course of the disease with an overall favorable outcome, including a 31-weeks' gestation infant who developed Enterobacter sepsis; however, the baby recovered.^[73]

Infection-control measures for birth attendants

Staff attending deliveries involving women with COVID-19 should observe airborne, droplet, and contact precautions owing to the increased risk of aerosolized virus and the potential requirement for administering resuscitation to newborns with SARS-CoV-2 infection.

Separation of mother and newborn

A pilot study suggests that rooming in for term or near term neonates may be considered for mothers with asymptomatic COVID-19 infection. Infection control measures still need to be followed strictly.^[74]

A more recent study looking at 49 infants (36 weeks' gestational age) who were allowed to room in with their mothers with asymptomatic COVID-19 infection did not demonstrate any symptoms up to two weeks after discharge. One infant did have a positive reverse transcriptase polymerase chain reaction (RT_PCR), but repeat RT-PCR at 48 hours was negative.^[75]

Breastfeeding

As of April 2, 2020, SARS-CoV-2 has not been detected in breast milk. Mothers with COVID-19 may express breast milk after appropriate hand and breast hygiene to be fed to the newborn by caregivers without COVID-19.

Breastfeeding guidelines from AAP are available for post hospital discharge for mothers or infants with suspected or confirmed SARS-CoV-2 infection.^[76]

Neonatal testing for COVID-19

Following birth, newborns born to mothers with COVID-19 should be bathed to remove virus from the skin. Newborns should undergo testing for SARS-CoV-2 at 24 hours and 48 hours (if still at the birth facility) after birth. Centers with limited testing resources can make testing decisions on a case-by-case basis.^[71]

Follow-up

Newborns who have documented SARS-CoV-2 infection or who are at risk for postnatal transmission because of testing inability require frequent outpatient follow-up (via telephone or telemedicine) or in-person assessments for 14 days after discharge.

Precautions following discharge

After discharge from the hospital, mothers with symptomatic COVID-19 should stay at least 6 feet away from their newborns. If a closer proximity is required, the mother should wear a mask and observe hand hygiene for newborn care until (1) her temperature has normalized for 72 hours without antipyretic therapy and (2) at least 1 week (7 days) has passed since the onset of symptoms.

Ongoing in-hospital neonatal care

Mothers with COVID-19 whose newborns require ongoing hospital care should maintain separation until (1) her temperature has normalized for 72 hours without antipyretic therapy, (2) her respiratory symptoms have improved, and (3) a minimum of 2 consecutive nasopharyngeal swab tests collected at least 24 hours apart are negative for SARS-CoV-2.

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