Ambulatory Management of Neonates Born to SARS-CoV-2 -Infected Mothers

The infection prevention practices for neonates born to women with COVID-19 around the time of delivery, both during the birth hospitalization and in the days to weeks after hospital discharge, is an unresolved issue. In areas with community spread of SARS-CoV-2, hospitals may test all women presenting in labor for SARS-CoV-2 to optimize infection prevention practices. Testing identifies neonates born to women with symptomatic SARS-CoV-2 infection, as well as a larger group born to women with asymptomatic SARS-CoV-2 infection.1 In addition, some hospitals test the father of the infant or other person accompanying the woman during labor.

Available data indicate vertical transmission of SARS-CoV-2 infection is very uncommon, but the risk of infection from transmission in the delivery room or in the days after delivery has not been established.2 The Centers for Disease Control and Prevention (CDC) considers a neonate born to a SARS-CoV-2 PCR-positive woman to be potentially infected.3 As such, these neonates are potentially contagious. Preliminary data suggest 1-3% of infants born to SARS-CoV-2 PCR-positive women will test positive during the first 24-96 hours of life.4

In this white paper, we provide some basic guidance to help primary care and other ambulatory providers decide what infection prevention measures are most appropriate for patient visits. Local practice varies, and clinics and providers should discuss practices with their health system and local infection prevention or public health authorities.

Recommendations:

1.      Newborns of women with symptomatic or asymptomatic SARS-CoV-2 infection at the time of delivery should be considered potentially infected and should remain in quarantine, until at least 14 days of age. They may be at risk for SARS-CoV-2 infection longer because of postnatal exposure from the mother or exposures from close contacts including other members of the household. In healthcare, the need for COVID-19-specific personal protective equipment (PPE) and isolation should be 14 days after the last exposure to an infectious household member/close contact.

2.      Newborns of women with a history of symptomatic or asymptomatic SARS-CoV-2 infection with onset of symptoms or SARS-CoV-2 detection, respectively, longer than 10 days prior to delivery (or 20 days in cases of severe infection or an immunocompromised status) are no longer contagious. Thus, the newborn can be cared for using standard isolation precautions unless there is concern for exposure from other persons in the household/close contacts.  

3.      Birth hospitals should adopt a protocol to ensure the primary pediatrician/provider is informed in a timely manner when a neonate is born to a mother with SARS-CoV-2 infection.

4.      Health supervision visits during the first 2 weeks of life

A.    When scheduling the visit, the family should be informed that the caregiver bringing the infant to the ambulatory visit should be asymptomatic and ideally not in quarantine. Persons who have been exposed to the SARS-CoV-2-positive mother should also remain in quarantine for 14 days after their last exposure to the infectious person. An example of a preferred adult who may bring the infant to the visit is an asymptomatic person who is not a household or close contact of the mother or infant. If no such individual is available, an asymptomatic adult who is in quarantine but is not known to be SARS-CoV-2 infected is acceptable, providing the individual wears a face covering and performs hand hygiene. If no asymptomatic individual is available, the provider should assess the risks of transmission from a symptomatic caregiver with the benefits of an in-person evaluation for patient care. For example, an in-person visit may be necessary for an infant at risk of weight loss and dehydration based on feeding history and maternal breastfeeding status. In such a case, transmission risk can be mitigated by bringing in the infant as the last appointment of the day after all other patient and families have vacated the clinic, and by patient evaluation performed by staff members vaccinated for COVID-19 and with use of PPE. Upon arrival for the visit, the infant and adult should be escorted directly to an examination room and the door should be kept closed. The adult should wear a face covering for the duration of the visit and perform hand hygiene upon entry into the clinic.

B.     All ambulatory healthcare personnel should wear masks. Personnel who will be in the exam room with the neonate should also wear eye protection (i.e., eye shields, face shields, or safety goggles; regular eyeglasses are not sufficient), gown and gloves.5 A surgical mask is sufficient, but per the local health system and department of health guidelines, an N95 respirator or higher level of protection can be used.

C.     If needed, an oropharyngeal/nasopharyngeal swab can be obtained in the ambulatory office setting while wearing PPE recommended by your health system for test collection. Swabbing is not considered to be a procedure at high risk of generating infectious aerosols.5

D.    Few ambulatory offices have negative pressure rooms. The likelihood of viral particles being released and remaining in the air from an asymptomatic neonate is likely to be low unless the infant underwent an aerosol-generating procedure.

E.     Telehealth visits can be considered for 1 or more early visits but an in person visit during the first week of life may provide an opportunity for a more complete evaluation of the infant, particularly if there is a clinical concern that the infant may not be thriving. If an early telehealth visit is contemplated, providing a scale at time of hospital discharge for checking the weight of the infant should be considered.

5.      A SARS-CoV-2-positive mother may directly breast feed provided she is asymptomatic, hand hygiene is performed, and she wears a surgical mask. Symptomatic mothers may pump milk using the same precautions; expressed milk may be fed to the infant by an asymptomatic household member.3,6

6.      The need for SARS-CoV-2 testing of asymptomatic infants born to SARS-CoV-2-positive mothers following hospital discharge has not been established but a second test at 5-14 days of life may identify some infants with SARS-CoV-2 infection and inform infection prevention practices in the infant’s household.7,8

7.      If a neonate develops symptoms, in addition to testing/re-testing for SARS-CoV-2, alternative causes should be sought.

 

Repeat testing and potentially infected person status. CDC3 and the American Academy of Pediatrics (AAP)4,9 have recommended that infants born to women with COVID-19 should be managed like other potentially infected persons.  In the medical office setting this includes use of the appropriate PPE. The AAP recommends that infants be tested for SARS-CoV-2 using a combined oropharyngeal/nasopharyngeal swab (or using separate swabs or only a nasopharyngeal swab) at 24 hours of age and if continued hospitalization, re-test at 48 hours of age. If both tests are negative the AAP states that isolation precautions can be downgraded to standard precautions. However, it is plausible that an infant may acquire SARS-CoV-2 in the delivery room, from the mother while rooming-in, or from another person in the household or close contact following hospital discharge. Therefore, infants should be considered potentially infected until at least 14 days after the last exposure to an infectious household member/close contact.

Advice for handling potentially infected infants at home. Hand hygiene and masking of caretakers when within 6 feet of the infant including when holding or feeding the infant are important to reduce the risk of the baby becoming infected or the baby infecting other close contacts.3,4 As much as is feasible, the mother of the infant and other household members who have COVID-19 should be isolated if they are infectious. Adults, including grandparents, >65 years or those who have a chronic medical condition placing them at increased risk for severe COVID-19, may not be optimal caretakers for the potentially infected infant. In some cases, the mother may be the most appropriate caregiver, provided she uses infection prevention practices such as using a face covering, remaining 6 or more feet away when possible, and practicing diligent hand hygiene and cough etiquette.

References:

1.      Sutton D, Fuchs K, D’Alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med. 2020 Apr 13: NEJMc2009316. Published online 2020 Apr 13. doi: 10.1056/NEJMc2009316

2.      Elshafeey F, Magdi R, Hindi N, et al. A systematic scoping review of COVID‐19 during pregnancy and childbirth. Int J of Gyn and Obstet 2020;150(1):47-52

3.      Centers for Disease Control and Prevention. Evaluation and management considerations for neonates at risk for COVID-19.https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html (accessed January 16, 2020)

4.      American Academy of Pediatrics. FAQs: Management of infants born to mothers with suspected or confirmed COVID-19. American Academy of Pediatrics, updated 01/19/20  https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/ (accessed 01/16/21)

5.       Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) Pandemic, updated 12/14/20. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html (accessed January 16,2021)

7.      Ronchi A, Pietrasanta C, Zavattoni M, et al. Evaluation of rooming-in practice for neonates born to mothers with severe acute respiratory syndrome coronavirus 2 infection in Italy. JAMA Pediatr. doi:10.1001/jamapediatrics.2020.5086, Published online December 7, 2020

8.      Davanzo R., Moro, G., Sandri, F., Agosti, M., Moretti, C., Mosca, F. Breastfeeding and coronavirus disease-2019: Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies. Maternal & Child Nutrition, 2020;49.doi:10.1111/mcn.13010.

9.      Puopolo KM, Hudak ML, Kimberlin DW, Cummings J. Initial guidance: management of infants born to mothers with COVID-19. Published April 2, 2020.  https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf.