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Rooming-in, with precautions, now OK in revised AAP newborn guidance :

July 22, 2020

Editor's note: This guidance was updated on Nov. 19, 2020. Please visit https://bit.ly/35c1O18. AAP interim guidance is based on current evidence and best data at the time of publication. Updates are provided to reflect changes in knowledge about the impact of the disease on children and adolescents.  For the latest news on COVID-19, visit https://www.aappublications.org/news/2020/01/28/coronavirus.

Mothers with suspected or confirmed COVID-19 can room-in with their newborns when precautions are taken to protect the infants from maternal infectious respiratory secretions, according to updated AAP interim guidance.

Revised from May 21, the recommendations are based on months of national and international experience with babies whose mothers tested positive for SARS-CoV-2. Guidance also changed on how to determine when individuals previously infected with COVID-19 can visit a neonatal intensive care unit (NICU).

The interim guidance is titled “FAQs Update: Management of Infants Born to Mothers With Confirmed or Suspected COVID-19.”  Since the initial neonatal recommendations came out April 2, health experts have been able to draw evidence from published case series, along with data provided to a national registry. The information has “better informed the risks of perinatal disease,” according to the report, and guidance will continue to be updated.

The Q&A also addresses newborn risk for COVID-19, precautions to take to attend a delivery from an infected mother, whether to continue delayed cord-clamping practices, procedures to follow if an infant needs intensive care, COVID-19 testing of babies and hospital discharge.

When the pandemic began, the only data available came from China, where the universal approach was to immediately separate all newborns from infected mothers and isolate them for 14 days, the AAP statement explains. Therefore, previous AAP guidance on rooming-in was based on the most cautious recommendation at the time, to minimize neonatal infection while the risk remained unknown.

New evidence for rooming-in

Initial guidance had recommended temporary separation of newborns from their infected mothers. But data gathered from more than 1,500 mother-infant dyads in the National Registry for Surveillance and Epidemiology of Perinatal COVID-19 Infection reveal the likelihood of a positive polymerase chain reaction (PCR) test result for SARS-CoV-2 was similar for infants who were separated from their mothers and those who roomed-in with mothers when infection prevention measures were used.

While it is not known whether any of the infants included in the registry became ill at home after hospital discharge, there are not currently a lot of reports on infants being re-admitted to the hospital due to COVID-19, said Karen M. Puopolo, M.D., Ph.D., FAAP, a lead author of the newborn guidance and a member of the AAP Committee on Fetus and Newborn.

About 2% to 5% of infants born to women with COVID-19 around the time of delivery have tested positive in the first 24-96 hours after birth.

“I think it’s very important for people to understand where we were when guidance was first provided at the end of March-beginning of April,” said Dr. Puopolo. “All we knew about this virus was that it was really contagious and was killing a lot of people. So it was important for us to be cautious. I’m super glad that it doesn’t seem to be a virus that is really dangerous to newborn babies, at least as far as we can currently tell.”

Rooming-in recommendations

The AAP offers the following guidance for rooming-in:

  • Follow the usual practice of the birth center.
  • Mothers with confirmed or suspected COVID-19 should maintain a reasonable distance from their infants when possible. While performing hands-on care, the mothers should wear a mask and use hand hygiene. An isolette may facilitate distancing and provide added protection; take care to properly latch isolette doors to prevent infant falls.
  • Health care workers should wear gowns, gloves, standard procedural masks and eye protection when providing care for well infants. When this care is provided in the same room as a mother with COVID-19, health care workers may opt to use N95 respirators instead of standard procedural masks, if available.
  • Mothers who are acutely ill may not feel up to providing all care for their babies. They might need to be temporarily separated or have the infant cared for by another, healthy caregiver in the room.
  • Noninfected partners or other family members present during the birth hospitalization should use masks and hand hygiene when delivering hands-on care to the baby.

 NICU visitation

The updated guidance also addresses how to determine if a former COVID-19 patient who wishes to visit a NICU is no longer contagious. Those who are fully recovered still can test positive by PCR testing for weeks and months, which Dr. Puopolo noted is a problem that can unnecessarily restrict visitation.

While previous recommendations suggested a choice of two strategies for determining when a potential NICU visitor is still contagious, the current version focuses on a symptom- and time-based approach in line with that of the Centers for Disease Control and Prevention (https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html). The test-based approach is reserved for rare circumstances.

Updated NICU visitor recommendations include the following:

  • People who are not immunocompromised may be considered noninfectious if their symptoms have improved; if they have been afebrile for 24 hours without use of antipyretics; and at least 10 days have passed since symptoms first appeared (or, for asymptomatic women identified only by obstetric screening tests, at least 10 days have passed since the positive test result).
  • For those who were severely or critically ill with COVID-19, and for immunocompromised people, the length of time since symptoms first appeared can be extended to 20 days.
  • Centers may choose to extend the amount of time needed to pass before parents with prior infection may safely enter the NICU.

Breastfeeding

Several studies have detected SARS-Co-V-2 nucleic acid in breast milk. It is not known whether viable, infectious virus is secreted in breast milk, nor has it been established whether the milk contains protective antibodies. The AAP continues to strongly support breast milk as the best choice for feeding infants.

 Registry

Clinicians are asked to participate in the National Registry for Surveillance and Epidemiology of Perinatal COVID-19 Infection, which will inform future guidance. Register at https://redcap.ctsi.ufl.edu/redcap/surveys/?s=FY44J48D9F.

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