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Where Pediatricians Encounter COVID-19: It's Official

Managing Newborns of Mothers with COVID-19: New Guidelines

The American Academy of Pediatrics (AAP),1 “an organization of 67,000 pediatricians committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults,”2 released its initial clinical guidelines3 for managing infants of mothers with confirmed or suspected COVID-194 infection.

Definitions

According to the WHO:5

· COVID-19: the coronavirus disease.

· SARS-CoV-2: severe acute respiratory syndrome coronavirus 2—the actual virus that causes coronavirus disease. The designation, “2,” is because although related genetically to the coronavirus that causes SARS, it is distinctly different.

Why are the new AAP guidelines important?

The newborn patient represents an important demographic in the documentation of statistics (the epidemiology) relevant to this pandemic. Within the COVID-19 population are SARS-CoV-2-infected new mothers intimately associated with their uninfected infants in a physical and emotional mutual exchange, so it is prudent to create barriers between them to reduce the chance of spread from an infected mother to her uninfected newborn.

Special associations require special barriers

Blocking transmission requires barriers, and obstruction to contagion from mother to infant requires such barriers; but the physical and emotional bonding activities between mother and child or among family members and child are difficult to moderate without a price, i.e., weakening that bonding. Nevertheless, the balance between total isolation and prudent distancing has been attempted by the AAP in an effort to get the most distancing between SARS-C0V-2 and the uninfected newborn while recognizing the importance of the mother-newborn relationship.

What are the AAP’s recommendations?

It is assumed that the newborn in the birthing environment is not infected with SARS-CoV-2 since there has been no proof of “vertical” transmission in utero.6 Therefore, recommendations are made to prevent what is called “horizontal” transmission (from person-to-person outside of the fetal/maternal interaction of pregnancy):7

· Physical environment permitting, separate newborns at birth from any mothers with COVID-19.

· PPE (personal protective equipment, i.e., masks, face shields, gowns, gloves) should be mandatory for any staff or attendees to the birth, to prevent transmission via contact. (Just assigning a 1-minute and 5-minute APGAR is conducive to the type of contact that endangers unprotected health care providers and the infant for whom they are caring.)

· If family and/or mother choose(s) to “room in” with the infant, education to a level of “informed consent” about potential risks to them or the infant should be given.

· Infants of infected mothers should be tested at 48 hours postpartum, or if going home prior to 48 hours, at 24 hours postpartum. Any infant testing positive requires very close follow-up via telephone, telemedicine, or office visit until 14 days post-discharge. The same applies to a SARS-CoV-2-negative infant born of a mother with COVID-19.

How do these precautions extend throughout the postpartum period?

What you need to advise:

· A COVID-19 mother should stay at least 6 feet away from her newborn. This, of course, impacts breastfeeding. SARS-CoV-2 has not yet been identified in breastmilk, so feeding newborns maternal breastmilk is acceptable, under certain conditions, i.e., expressing breastmilk for collection and given by uninfected caregivers.

· Closer than 6 feet of distance requires mask and hand hygiene for newborn care.

Precautions with newborns—how long is long enough?

A healthcare provider managing the newborn should recommend these precautions until

· the mother goes 72 hours without a fever (without the use of antipyretics) AND

· it has been at least 7 days since the symptoms first began.

In the special case in which a COVID-19 mother’s newborn requires continued nursery in-hospital care after the mother’s discharge, she should

· stay separated from her baby until she goes 72 hours without a fever (without the use of antipyretics) AND

· her respiratory symptoms have improved, AND

· at least 2 consecutive SARS-CoV-2 nasopharyngeal swabs, 24 hours apart, come back negative.

Conclusion

There is no entity better qualified to give recommendations for caring for newborns and their mothers than the AAP. The uninfected newborn is a special demographic in COVID-19 disease epidemiology, and the recommendations use two well-established concepts to advantage, i.e., there is no evidence of vertical transmission from expectant mother to her unborn child, and pregnancy and delivery offer no further risk to a woman than to anyone else infected with SARS-CoV-2, simplifying care of this special demographic with the barrier methods effective elsewhere (with the additional consideration of breastmilk).

RESOURCES:

1. https://www.aap.org/en-us/Pages/Default.aspx

2. https://services.aap.org/en/about-the-aap/

3. https://reference.medscape.com/viewarticle/929115

4. https://emedicine.medscape.com/article/2500114-overview

5. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it

6. Chen, H., Guo, J., Wang, C., Luo, F., Yu, X., Zhang, W., ... & Liao, J. (2020). Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet, 395(10226), 809-815

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

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