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COVID-19: Separating Infected Mothers from Newborns: Weighing the Risks and Benefits

https://trends.hms.harvard.edu/2020/03/31/covid-19-separating-infected-mothers-from-newborns-weighing-the-risks-and-benefits/

This important article by By Melissa Bartick, MD, MS, FABM March 31, 2020

Current guidelines around whether infected mothers with COVID-19 should be separated from their newborn infants are conflicting. While the current guidelines for COVID-19 allow breastfeeding, this is not being clearly conveyed in the media. Reportedly, many US hospitals are routinely separating infected mothers from their newborns. Separation makes establishing breastfeeding difficult, even if breastfeeding is allowed and encouraged. The virus has not been found in breastmilk in limited studies of it1 and the related virus that causes SARS,1,2 but it’s not known with absolute certainty that the virus is not transmitted through breastmilk. The March 28 announcement of the death of an Illinois infant of undisclosed age may raise anxiety.

What Are the Guidelines?

WHO: At this writing, the World Health Organization advises that infected mothers can share a room with their infant and breastfeed but should practice “respiratory hygiene.” They should wash their hands and wear a mask, acknowledging that a mask might not be available.

CDC and ACOG: The Centers for Disease Control and Prevention (CDC) advises that facilities should “consider temporarily” separating mothers and newborns after “discussing the risks and benefits with the mother and health care team.”2 Mothers can breastfeed with respiratory hygiene. A separated infant must be isolated from other infants. The CDC makes provisions for rooming in if “it is in accordance with the mother’s wishes” or if it is unavoidable due to facility limitations. In such cases, the infant should be kept more than 6 feet (2 meters) from the infant with a curtain or barrier separating them if possible, and respiratory hygiene measures apply. The American College of Obstetricians and Gynecologists (ACOG) refers to CDC guidelines.3 ACOG is not recommending routine COVID-19 testing for pregnant women.

ABM: The Academy of Breastfeeding Medicine emphasizes mothers’ choice and notes that breastfeeding and rooming in are “reasonable” choices, and also refers to CDC and WHO guidelines.1 Wearing a mask, and washing hands as well as pump parts are advised.

Chinese Consensus: The Chinese Expert Consensus on Perinatal and Neonatal Management from February 7 recommended no breastfeeding or breast milk feeding and full separation,4 as authors said “virus may be excreted into the milk.” This has not yet been updated.

 Reconciling Conflicting Information

With conflicting recommendations, it is important to examine the primary information needed to make an informed decision. Since the virus has not been found in breastmilk, we need to look at the risk of transmission to an infant and balance that with the risks of separation.

  1. Risks from separation

I will start with the risks of separation, since that is rarely discussed. Breastfeeding is the safest, most reliable method of infant feeding in an emergency. There have been widespread reports of shortages of retail supplies of infant formula due to hoarding.6 Given the risk that novel coronavirus infections can spread through formula factories and delivery warehouses,7 potentially shutting them down, there is a risk of supply chain interruption. Thus, providers are already recommending that women who are supplementing with formula transition to exclusive breastfeeding.8 Because of the scarcity of formula in many locales and concern for infant health, there have been efforts to re-establish lactation in mothers who have stopped breastfeeding.

In addition, breastfeeding reduces the risk of ear infections and diarrhea, thus reducing the chance that an infant and their caregiver will need to the leave their home to seek medical attention and expose themselves to the virus.

Finally, mothers routinely pass on antibodies in their milk to pathogens to which they are exposed,.

However, the initial hours and days after birth are vital for establishing breastfeeding, and part of that process involves mother and infant being in constant close physical proximity, especially with skin-to-contact.10

  1. Risk of passing COVID-19 to infants

Now, we need to balance the establishment of breastfeeding with the risks that the infant could acquire COVID-19 and become seriously ill. The data on this topic are also conflicting.

A study examining all laboratory confirmed cases in China from December 8, 2019 to February 6, 2020 suggests COVID-19 among hospitalized young infants is rare.11  There were only 9 hospitalized infants among 31,211 confirmed cases among all ages, and the youngest of these infants was 1 month.

A broader analysis of 2,143 pediatric cases of confirmed or suspected COVID-19 in China from January 16 to February 8, 2020 included only 731 laboratory-confirmed cases, and had a much larger number of infants (379, or 17.7% of all pediatric cases). However, the authors acknowledge that most of the severe cases were not confirmed to be COVID-19, so they suspect many could have been caused by other pathogens.12 Two outside authors commenting on this analysis noted previous studies found that children in whom coronavirus is found in the respiratory tract have viral co-infection in up to two-thirds of cases.13 In this sample, 83% of infants had severe or critical disease. Of all the children, 90% had mild-to-moderate disease, and there was one death in a 14-year-old boy.

Both these studies apparently used the same Chinese national database and ended at the same time, yet they have very different results. While the second study’s data on infants is alarming, it is also much less reliable due to lack of clear diagnosis. We know from this database that no newborns or any infant under 1 month were hospitalized with confirmed COVID-19 during this time.

An analysis of 72,314 Chinese cases up to February 26, found fewer than 1% of cases were in children under 10. Of children treated in the only hospital in Wuhan assigned to treat children under 16, only 3 of 171 confirmed cases required intensive care and all 3 had underlying comorbidities.14 There was one death in a 10-month-old infant of intussusception, but it is unclear if this death was related to COVID-19.

There were media reports of one newborn contracting the virus on Feb. 5 in Wuhan, following infection of the infant’s nanny, then mother. She was thought to have gotten the infection from her nanny, mother, or hospital staff.15 It is unclear why she was not counted in the first study, but had few, if any, symptoms.14 The cause of death of the Illinois infant with COVID-19 is under investigation.16 As the infant’s age was not disclosed, we do not know if this was a newborn or neonate (ie, under 7- or 28-days old).

Beyond this there are case reports of older infants, including a 55-day-old infant who had multi-organ system failure.17 It is also unknown if affected sick infants had been breastfed, particularly by infected mothers who could have passed on protective antibodies.

Conclusion

To summarize, the CDC does not categorically recommend separating infants from infected mothers, and currently, there are insufficient data to support routinely doing so. Because the decision is ultimately up to the mother and family, they should be carefully educated about the clear risks of separation as well as its potential benefits. One must weigh the risk of the newborn getting severe COVID-19 infection, which is rare but likely finite, with the risk of undermining the establishment of breastfeeding and the consequences of breastfeeding failure, which can be significant, particularly in low-income settings. Failure to establish breastfeeding could put the newborn at risk of food insecurity and other infections. If an infected mother is not planning to breastfeed, then separation may make more sense if other factors allow, and separation seems more important if a newborn has underlying health conditions.

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Update: AAP Report on Initial Guidance: Management of Infants Born to Mothers with COVID-19

The AAP has recently published a new report, “Initial Guidance: Management of Infants Born to Mothers with COVID-19” addressing the care of infants whose mothers have suspected or confirmed coronavirus disease 2019 (COVID-19).
Key points:
  • Current evidence is consistent with low rates of peripartum transmission and is inconclusive about in utero transmission of SARS-CoV-2 from mothers with COVID-19 to their newborns.
  • Neonates can acquire SARS-CoV-2 after birth. Their immature immune system leaves newborns vulnerable to other serious respiratory viral infections, raising concern that SARS-CoV-2 may cause severe disease among neonates.
  • Airborne, Droplet, and Contact Precautions should be utilized when attending deliveries from women with COVID-19 due to the increased likelihood of maternal virus aerosols and the potential need to administer newborn resuscitation to infants with COVID-19 infection that can generate virus aerosol.
  • When the physical environment allows, newborns should be separated at birth from mothers with COVID-19.
  • SARS-CoV-2 has not been detected in breast milk to date. Mothers with COVID-19 can express breast milk to be fed to their infants by uninfected caregivers until specific maternal criteria are met.
  • Infants born to mothers with COVID-19 should be tested for SARS-CoV-2 at 24 hours and, if still in the birth facility, at 48 hours after birth. Centers with limited resources for testing may make individual risk/benefit decisions regarding testing. Note that there have been reports of neonates who test negative at 24 hours but positive at 48-72 hours.
  • A newborn who has a documented SARS-CoV-2 infection (or who remains at risk for postnatal acquisition of COVID-19 due to inability to test the infant) requires frequent outpatient follow-up via telephone, telemedicine, or in-person assessments through 14 days after discharge.
  • After hospital discharge, a mother with COVID-19 is advised to maintain a distance of at least 6 feet from the newborn, and when in closer proximity use a mask and hand-hygiene for newborn care until (a) she is afebrile for 72 hours without use of antipyretics, and (b) at least 7 days have passed since symptoms first appeared.
  • A mother with COVID-19 whose newborn requires ongoing hospital care should maintain separation until (a) she is afebrile for 72 hours without use of antipyretics, and (b) her respiratory symptoms are improved, and (c) negative results are obtained from at least two consecutive SARS-CoV-2 nasopharyngeal swab tests collected ?24 hours apart. These recommendations are based on the most conservative CDC recommendations for discontinuing transmission-based precautions for patients with COVID-19 in the hospital setting and are more stringent than the requirements for mothers and well newborns after hospital discharge.
For detailed information on the 2019 Novel Coronavirus (COVID-2019) outbreak, please visit the 2019 Novel Coronavirus (COVID-19) entry in the Red Book Online Outbreaks section.
Please note that this latest AAP report is specific for COVID-19. This information is NOT addressed in the Coronaviruses chapter (including SARS and MERS) in the current edition of Red Book.
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