Well-Newborn Unit Director Experiences During the COVID-19 Pandemic: A BORN Study Free

This study was conducted through the Better Outcomes through Research for Newborns (BORN) network, which includes newborn clinicians from 107 well-newborn units in 37 states in the United States; ∼400 000 newborns are cared for in these units annually (∼10% of nearly 4 million live births in the United States).⁸  The BORN network is a core activity of the Academic Pediatric Association. At each participating unit, there is a BORN representative. This individual is either the well-newborn director or another clinician who is knowledgeable about well-newborn policies at his or her institution and clinical practice at the site.

We sent a 40-item electronic survey about changes in newborn care in response to COVID-19 to the well-newborn medical director at each BORN site (see the Supplemental Information for the survey) in May 2020. Responses were collected until September 2020. We chose to survey well-newborn medical directors because we expected these individuals to be most knowledgeable about policy and protocol changes in response to COVID-19 in their unit. The survey was developed on the basis of published reports on the topic and consensus of the research team.^6,7,9  The survey was divided into the following sections: testing, infection prevention, breastfeeding, routine newborn care, rounding and teaching, discharge planning, and case estimates. Lastly, respondents were given the option to write free-text responses about their experiences during the pandemic not captured in the survey.

The survey was administered electronically (institutional Qualtrics), and up to 5 e-mail reminders were sent during the study period (May to September 2020). Of note, the AAP updated their recommendations on COVID-19 and newborns in July 2020 to support mother-infant rooming-in with appropriate infection prevention measures. For each site, we had data from the BORN network about site location (US state), number of annual deliveries, payer mix, hospital setting (community or academic medical center), breastfeeding rates, and involvement of trainees. These baseline data are obtained when sites enroll with the BORN network. The project was approved by the human investigation committee at our institution.

We report descriptive statistics of responses, including frequencies and percentages. We performed a content analysis on free-text responses and report major themes shared by respondents. Given the differences in SARS-CoV-2 testing capabilities across the United States and the conservative approach by most institutions to handle patients with suspected COVID-19 (the same as for patients with confirmed COVID-19), for this study, mothers positive for COVID-19 also included mothers with suspected COVID-19.

Representatives from 65 of the 107 BORN sites (61%) responded to the survey. Characteristics of responding sites are shown in Table 1. Sites in all regions of the country were represented. Regarding case estimates between January and May 2020, respondents estimated a total of 1207 COVID-19-positive mothers and 13 COVID-19-positive newborns, or 1% of 1198 newborns who were tested. Fifty-seven (88%) sites completed the survey before the updated AAP guidance on July 22, 2020.

Survey results are shown in Table 2. Most respondents performed universal testing of mothers at delivery (86%) and universal testing of all newborns of COVID-19-positive mothers (82%). Most infants were tested with a nasopharyngeal swab (88%) and the most common timing for testing was at 24 hours (75%).

Survey results are shown in Table 2. Of respondents, 46 (71%) reported that COVID-19-positive mothers were placed in a negative pressure room. Healthy and well-appearing newborns of COVID-19-positive mothers were admitted to the well-newborn unit at 56 (86%) hospitals; 35 (54%) recommended rooming-in. Of respondents that admitted newborns to the well-newborn unit, 50 (89%) recommended that a healthy caregiver be present to care for the newborn and 8 (14%) considered the mother’s partner a person under investigation, who was not permitted to provide care for the infant.

In sites that admitted newborns of COVID-19 positive mothers to the well-newborn unit, when rooming-in, 53 (95%) respondents asked the mother to wear an N95 mask, 51 (91%) placed the infant 6 ft away from the mother, 28 (50%) placed the newborn in an isolette, 21 (38%) separated the mother and newborn with a curtain, and 9 (16%) asked the mother to wear a surgical mask.

Survey results are shown in Table 3. The most common infection prevention strategies were hand hygiene before expressing breast milk (97%), requiring mother to don a surgical mask while pumping (91%), and recommending a healthy caregiver feed the breast milk to the newborn (77%). If a COVID-19-positive mother breastfed, recommendations included the mother donning a surgical mask during breastfeeding at all institutions (100%), performing hand hygiene (100%), and cleansing the breast before latching (74%). Virtual lactation visits were reported by 39 (60%) sites.

Survey results are shown in Table 3. For elective circumcisions, 25 (38%) respondents deferred circumcision at their institution altogether. For newborn baths, 48 (74%) respondents bathed newborns of COVID-19-positive mothers immediately after delivery. Routine newborn screening (state newborn screen, cyanotic congenital heart disease screen, and hearing screen) was reported to be performed per standard protocol by 44 (68%) respondents. Regarding discharge timing, 56 (86%) discharged newborns of COVID-19-positive mothers once they met routine discharge criteria, and 7 (11%) monitored newborns for a certain period of time before they could be discharged (of those, 4 monitored for at least 48 hours).

Respondents were asked whether discharge timing of all newborns was impacted at institutions. There was no change at 12 (18%) sites, but early discharges were accommodated (57%) or encouraged (25%) at other institutions. Criteria used by providers to screen for newborns appropriate for early discharge at 24 hours or sooner can be found in Table 4.

Regarding follow-up care, for infants born to COVID-19-negative mothers, there was no change in practice reported by 59 (91%) respondents. For infants born to COVID-19-positive mothers, there was no change in practice reported by 29 (45%) respondents. Video visits (23%) and telephone visits (12%) were recommended more frequently than for newborns of COVID-19-negative mothers. Information provided to COVID-19-positive mothers regarding home isolation varied (Table 4).

Most respondents (75%) reported no change to rounding on the well-newborn unit, with rounds occurring in the room. Some reported changes to rounding practices: at 18 (28%) sites, infants were no longer placed in the nursery (and roomed-in with the mother), and 4 (6%) sites each reported performing a portion of rounds over the phone or bringing newborns to a centralized location for examinations.

Sixty-one sites worked with medical students before the pandemic, but medical students were no longer present at the time of survey completion at 25 (41%) of those sites. Of 36 respondents who had medical students present in the well-newborn unit at the time of survey completion, 36 (100%) did not have students see newborns of mothers with COVID-19.

Residents were not present at the time of survey completion at 4 (7%) of 58 sites that worked with residents before the pandemic. Of the 54 respondents who reported having a resident present in the well-newborn unit at the time of survey completion, 24 (44%) did not have residents see newborns of mothers with COVID-19 at some point during the pandemic.

The major themes and exemplar quotes from content analysis of free-text responses are shown in Table 5.

This survey of well-newborn unit directors in the BORN network illustrated both consistencies and variations regarding newborn care practices during the peak of the COVID-19 pandemic. Our study estimated a 1% positivity rate in newborns tested for COVID-19, which is similar to the 2% rate in the National Perinatal COVID-19 Registry¹⁰  (E.A., D.W., J.L., unpublished observations).

There was some consistency in testing, with ≥75% of respondents employing universal maternal testing, likely driven by early reports of high COVID-19 incidence rates among asymptomatic pregnant women in New York presenting for childbirth.¹¹  Newborn testing was also consistent, with most sites testing newborns of mothers positive for COVID-19 at 24 hours with a nasopharyngeal swab. This practice differed from the initial AAP guidelines that were current when most respondents answered the survey, which stated that newborns should be tested at 24 hours and again at 48 hours and that clinicians should consider testing using throat, nasopharyngeal, and rectal swabs.⁷  Deviation from the recommendations may have been driven by testing resources, a trend toward earlier newborn discharges, and experiences, because newborns of COVID-19-positive mothers were noted to clinically do well. Other responses aligned with initial AAP guidelines: >90% of respondent sites recommended hand hygiene and surgical masks to be worn while breastfeeding and pumping. Most sites allowed for only one visitor for COVID-19-negative mothers (>90% of sites); the effect of visitor restrictions on other outcomes, such as breastfeeding rates (given less interruptions) and maternal mental health, warrants investigation.

A major finding in our study was the variation in rooming-in practices in new mothers positive for COVID-19. Discrepancies in results, such as 54% of sites recommending rooming-in but 89% recommending that a healthy caregiver care for the newborn, may mean that healthy caregivers were in the room with COVID-19-positive mothers at some sites. The findings may also be due to respondents selecting multiple answers and may illustrate a lack of consistency in practices given uncertainty about the effects of SARS-CoV-2 infection in neonates, changing recommendations in support of rooming-in with infection prevention measures from the AAP released in July 2020, unpredictable hospital resources, and flexibility to practice shared decision-making. Maternal infant separation recommendations in the setting of COVID-19 were initially similar to those put forth by the CDC for influenza (although unlike COVID-19, influenza is associated with serious illness in young children) in that they encouraged temporary separation.^12,13  As of August 2020, the CDC now emphasizes maternal autonomy in rooming-in decisions in the setting of COVID-19.

Notably, literature and organizations have widely identified breast milk as safe for newborns of COVID-19-positive mothers since the early stages of the pandemic.^4,6,7  Although we did not query about breastfeeding rates, other researchers have identified a negative correlation between separation and exclusive breastfeeding at discharge in newborns of COVID-19-positive mothers.¹⁴  In addition to the positive effect on breastfeeding¹⁵  and the myriad of resultant benefits,¹⁶  rooming-in and skin-to-skin contact have maternal benefits,^17,18  improve infant homeostasis,^19,20  and aid in mother-infant bonding.²¹ 

Ultimately, decisions regarding newborn care during the COVID-19 pandemic reflect a risk/benefit analysis. There is now mounting evidence that rooming-in for newborns of mothers with COVID-19 is a safe practice,^22–26  and although there are emerging reports of infants with COVID-19,^27,28  most have mild symptoms and there are few reported severe cases. As captured by the qualitative comments in our study, navigating the initial AAP recommendation to separate COVID-19-positive mothers and their newborns was challenging for well-newborn unit directors because rooming-in is common practice.

We also found variation in bathing, elective circumcision practices, and routine newborn screening procedures for newborns of mothers with COVID-19. Many sites immediately bathed newborns of COVID-19-positive mothers. This unproven measure to decrease the risk of COVID-19 transmission differs from WHO recommendations for delayed well-newborn baths, which are associated with infant benefits of normothermia and increased breastfeeding rates.²⁹  Delayed circumcisions and newborn hearing screens can create challenges for families who need to return to the health care setting, and delayed circumcisions may also lead to anesthesia exposure, the effect of which is still being investigated, for some newborn boys. Finally, new mothers with COVID-19 are increasingly being offered alternative (and not face-to-face) methods for follow-up care with their newborn during a period of isolation that may be compounded by stress associated with a diagnosis of COVID-19. Inconsistencies among recommendations that health care providers are giving to new mothers with COVID-19 can prolong this period of isolation. This warrants further scrutiny given indications of increased anxiety, depression, and maternal distress related to lack of support systems in postpartum mothers during the pandemic as well as an increased burden of these issues on disadvantaged populations.^30–32 

Variations in practices are likely due to a variety of factors, including uncertainty regarding COVID-19 transmission, scarce data on neonates with COVID-19 and born to mothers with COVID-19, and the resultant variable recommendations from major organizations, such as the CDC, AAP, and WHO. Although evidence and experiences are mounting and informing more similar recommendations, there was initially fatigue in keeping up to date with and difficulty implementing variable recommendations, as evident in the qualitative comments. Another cause for variability in reported practices may be the differences in physician staffing, PPE, and negative pressure room availability by institution, which we did not ask about in the survey. It remains to be seen whether practices standardize as data around newborns of COVID-19-positive mothers accumulate.

The impact on the medical trainee experience during the COVID-19 pandemic was significant. In March 2020, the Association of American Medical Colleges recommended removing medical students from participation in patient care activities. Students were later able to return to individual sites as safety measures recommended by the Association of American Medical Colleges were met locally.³³  In our survey, we asked what the current state was at the time of survey completion and did not solicit details on how students were phased back in on the basis of guidance regarding availability of PPE and other safety protocols. Nonetheless, 41% of sites that previously worked with students still did not have students present at the time of survey completion. Furthermore, we found that many sites did not have medical students (100%) or residents (44%) examine newborns of mothers with COVID-19. Conservative practices limiting trainee exposure to patients with COVID-19 were practical in the early stages of the pandemic. There were major concerns about the impact of COVID-19 on the physician workforce and concerns about PPE availability. For these reasons, trimming down rounding teams to fewer clinicians in the early stages of the pandemic made sense. Although trainees have been reintroduced into clinical settings as the pandemic surges on, there is a need for ongoing vigilance around exposure, availability of PPE, and balancing educational needs with the potential for alternative experiences, such as through telehealth.

The survey responses revealed flexibility and innovation during a period of changes and uncertainty. Many sites witnessed changes in the timing of discharges for all newborns, with more early discharges (despite differences in discharge criteria). This trend should be further evaluated for unintended consequences, such as increased readmissions. Video and/or telephone newborn follow-up and lactation visits were increasingly used during the pandemic; again, outcomes should be monitored to evaluate the efficacy of this more convenient model. Some sites discharged newborns with scales to facilitate virtual visits; one site reassigned trainees to call newborn families interested in receiving more information regarding food, housing, and immigration questions during the pandemic; and one site used a mobile van to facilitate follow-up visits for high-risk families. Well-newborn unit directors should be encouraged to continuously exchange and study ideas and innovations that can improve the care for newborns and their families.

There are several limitations to our study. The 61% response rate does not fully represent our network. Although we expected the medical director at each site to have accurate knowledge of institutional policy changes, only 1 representative from each participating site was queried. Each survey response captured practices at only 1 point in time. As data and guidelines regarding SARS-CoV-2 and its effect on newborns continue to change, institutions are likely to modify procedures to best serve patients. Furthermore, both local COVID-19 rates and availability of PPE continue to change, likely leading to changes in institutional policies. We did not collect data on local COVID-19 rates during the study period, which may have affected survey responses. Although there was representation from across the country, BORN sites are generally academic centers, which may have approaches that are different from those of private community hospitals or birthing centers. Data on payer mix, number of deliveries, and breastfeeding rates are estimates provided by the BORN site representative at the time they enrolled in the BORN network. Although newborn COVID-19 case estimates are reassuring, the results should be interpreted with caution because they are reported numbers. Because of the variability in infection prevention practices (such as those related to mother-newborn dyad separation and breastfeeding recommendations), it is unclear whether current practices led to low numbers of positive newborn cases. We also provide no information regarding outcomes of newborns who tested positive for COVID-19 and no information regarding outcomes for those infants who were COVID-19-negative (and born to mothers who tested positive for COVID-19). Finally, qualitative analysis of open-ended survey responses yields less granular results than does provider interviews.

Variations in many aspects of COVID-19 care exist in the well-newborn unit and likely affect resource use and newborn outcomes. Research is needed to continue to assess for newborn outcomes as care evolves during the COVID-19 pandemic, and providers should continue to collaborate to develop and share innovations that can best serve newborns and their families during the COVID-19 pandemic. This survey highlights the opportunity for the identification of best newborn care practices related to COVID-19.

We thank well-newborn unit directors from the BORN network for their participation and the BORN network administrative staff for their support.