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Newborns at Risk of Covid-19―Lessons from the Last Year

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Newborns at Risk of Covid-19―Lessons from the Last Year J. Perinat. Med. 2021; 49(6): 643–649 Review Malika D. Shah and Ola Didrik Saugstad* Newborns at risk of Covid-19 ― lessons from the last year https://doi.org/10.1515/jpm-2021-0258 recommendations from different communities related Received May 22, 2021; accepted May 27, 2021; to mothers and newborns with suspected or laboratory published online June 14, 2021 confirmed SARS-CoV-2 infection [1]. The Chinese employed a very strict regime, encouraging cesarean section, avoiding Abstract: After more than 1 year of the SARS-CoV-2 contact between mother and child, and withholding both pandemic, a great deal of knowledge on how this virus affects breastfeeding and expressed breast milk [2, 3]. The guidelines pregnant women, the fetus and the newborn has accumu- from the AAP and the USA Centers for Disease Control and lated. The gap between different guidelines how to handle Prevention (CDC) advocated routine delivery, separation be- newborn infants during this pandemic has been minimized, tween mother and child and encouraged use of expressed and the American Academy of Pediatrics (AAP)’srecom- breast milk fed by alternate caregiver [4, 5]. By contrast, WHO mendations are now more in accordance with those of the recommended keeping mothers and infants together, and WorldHealthOrganization(WHO).Inthisarticlewesum- allowing direct breastfeeding with careful breast hygiene [6]. marize present knowledge regarding transmission from Guidelines similar to the WHO were issued by European or- mother to the fetus/newborn. Although both vertical and ganizationsasUnionofEuropean Neonatal and Perinatal horizontal transmission are rare, SARS-CoV-2 positivity is Societies (UENPS) [7]. Guidelines from 17 countries were associated with an increased risk of premature delivery and recently summarized by Yeo et al. [8]. higher neonatal mortality and morbidity. Mode of delivery At that early stage of the pandemic, the possibility of and cord clamping routines should not be affected by the vertical or horizontal transmission was unknown, and it was mother’s SARS-CoV-2 status. Skin to skin contact, rooming in not fully known how newborns would be affected. However, and breastfeeding are recommended with necessary hygiene as knowledge accumulated over the last year, many studies precautions. Antibodies of infected or vaccinated women have reported on outcomes and approaches to handling of the seem to cross both the placenta and into breast milk and mother and newborn during the COVID-19 pandemic. Sub- likely provide protection for the newborn. sequently recommendations have been revised. Most notably, Keywords: COVID-19; guidelines; newborn. AAP has gradually changed their position to more closely resemble the WHO recommendations [4, 6]. In this article, we review the development in this field over this past year and Introduction summarize the evolution of guidelines for caring of new- borns and mothers with suspected or laboratory confirmed SARS-CoV-2 infection. While data on long term outcomes As the Covid-19 pandemic comes to age the medical continue to be lacking, there is greater consensus on delivery community has actively collected and gained informa- room practices and early management of newborns. tion regarding this disease. A year ago, we summarized *Corresponding author: Ola Didrik Saugstad, MD, PhD, Ann & Robert Transmission to the newborn H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; and Department of Although maternal morbidity can be severe, vertical trans- Pediatric Research, University of Oslo, 0424 Oslo, Norway, mission has been reported to be rare. Huntely et al. reviewed E-mail: [email protected] 99 articles and found no confirmed vertical transmission [9]. Malika D. Shah, Prentice Newborn Nursery, Northwestern Memorial Horizontal transmission of SARS-CoV-2 to the newborn Hospital, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA; and Ann & Robert H. Lurie Children’s Hospital of seems to occur primarily through respiratory droplets when Chicago, Northwestern University Feinberg School of Medicine, neonates are exposed to mothers or other caregivers with Chicago, IL, USA SARS-CoV-2 infection. Neonatal infection is uncommon, Open Access. © 2021 Malika D. Shah and Ola Didrik Saugstad, published by De Gruyter. This work is licensed under the Creative Commons Attribution 4.0 International License. 644 Shah and Saugstad: Newborn and Covid-19 although neonates born to newly infected symptomatic an air-purifying respirator that provides eye protection for women are more likely to be infected and some studies have personnel involved. The goal is to protect against both found correlations with other maternal characteristics. Out maternal virus and potential newborn virus aerosols dur- of 1,200 pregnant women from the USA, the PRIORITY study ing resuscitation procedures such as bag mask ventilation. prospectively followed 179 newborns of SARS-CoV-2 positive Delayed cord clamping should be practiced per usual and 84 newborns of SARS-CoV-2 negative pregnant mothers. center practice. The risk of transmission of COVID-19 During the follow-up period of 6–8 weeks an estimated through blood is likely to be minimal. There is no evidence incidence of a positive test for SARS-CoV-2 among infants of that delaying cord clamping increases the possibility of mothers with positive testing for SARS-CoV-2 was 1.1% (95% viral transmission from the mother to the newborn [14]. CI 0.1%, 4.0%). No infant required re-hospitalization in the Table 1 summarizes appropriate IPC (infection prevention follow-up period [10]. and control) measures needed. A more recent multicenter cohort from 11 institutions in Massachusetts included 255 neonates born to mothers with SARS-CoV-2 infection, and only five (2.2%) had positive re- Newborn resuscitation sults during the birth hospitalization. High maternal social vulnerability was associated with higher likelihood of Suspected or confirmed COVID-19 alone in an otherwise neonatal test result positivity (adjusted odds ratio, 4.95; 95% uncomplicated pregnancy is not an indication for the CI, 1.53–16.01; p=0.008), adjusted for maternal COVID-19 resuscitation team. However, delivery room preparation and symptoms, delivery mode, and rooming-in practice. Of the management should include consideration for prompt don- 151 newborns with follow-up data in the first month of life, ning of appropriate personal protective equipment (PPE). seven underwent SARS-CoV-2 testing, and only one had a It is unclear if a woman can disseminate the SARS-CoV-2 positive result [11]. virus through droplets, aerosols, body fluids, and fomites In an international multicenter study, a total of 706 during labor and delivery. Where respiratory support is pregnant women with COVID-19 diagnosis and 1,424 preg- required at delivery, spread through aerosolization may be nant women without COVID-19 diagnosis were enrolled. increased. Providers involved in aerosol generating proced- Among women who tested positive (98.1% by real-time po- ures (AGP) such as intubation, open airway suctioning, lymerase chain reaction), 54 (13%) of their neonates tested surfactant administration, and application of nasal cannula positive. Cesarean delivery (RR, 2.15; 95% CI, 1.18–3.91) but interface at flow of >2 L/min are at higher risk of exposure to not breastfeeding (RR, 1.10; 95% CI, 0.66–1.85) was associ- the SARS-CoV-2 virus. Hence, in many units, all personnel ated with increased risk for neonatal test positivity [12]. attending neonatal resuscitation should according to Perl- Flannery et al. showed that maternally derived IgG but man et al. don N95 particulate respirator masks, goggles or not IgM antibodies were detected in cord blood in 72 of 83 face shield, full-length water-resistant gowns and gloves [15]. pregnant women who were seropositive. Transfer ratios were Personnel assigned with AGP should consider wearing a associated with time elapsed from maternal infection to de- powered air purifying respirator (PAPR). All providers livery and not associated with severity of maternal infection should undergo training in donning and doffing of PPE, and [13]. Maternally derived antibodies to provide neonatal pro- tection from SARS-CoV-2 infection seems therefore possible. Table : Infection prevention and control (IPC). – Frequent hand hygiene with soap and water or alcohol-based hand rub. Delivery and cord clamping – Respiratory hygiene: sneeze or cough into a tissue and immedi- ately dispose of the tissue. Hands should immediately be washed with soap and water or alcohol-based hand rub. The first consensus guidelines from China recommended – Clean and disinfect surfaces with which the mother has been in cesarean delivery for SARS-CoV-2 affected mothers. We contact. now know that there is no indication to prefer one mode of – Wear a medical mask until symptom resolution and criteria for delivery over another. Induction of labor and caesarean release from isolation have been met. – If an infected mother chooses not to nurse her newborn, she may section should only be undertaken when medically justi- express breast milk after appropriate hand hygiene, and this may fied and based on maternal and fetal condition While be fed to the infant by other uninfected caregivers. symptomatic COVID in mother may necessitate early de- – Mothers of NICU infants may express breast milk for their infants livery of the infant, COVID-19 positive status alone is not an during any time that their infection status prohibits their pres- indication for caesarean section. AAP emphasizes the use ence in the NICU. Centers should make arrangements to receive this milk from mothers until they are able to enter the NICU. of gown, gloves, 95 respiratory mask, and eye protection or Shah and Saugstad: Newborn and Covid-19 645 simulation of code situations with full PPE to familiarize with source of anti-SARS-CoV-2 IgA and IgG and neutralizes the facility, access, special precautions and communication. SARS-CoV-2 activity. Of the 70 swabs tested, eight had Pre-assigned facility for delivery, functional equipment, evidence of SARS-CoV-2 RNA.
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